Most of us have encountered this question at least once if not multiple times from patients. For those of us who fit specialty lenses, the answer can be complicated in some cases. The key is to have a strategic approach for patients but also to know that the conversation may need to be uniquely tailored based on each patient’s condition.

Probably the most common situation for which we have this discussion is for patients who are classically characterized as contact lens dropouts. It is estimated that approximately 35% of patients discontinue soft lenses due to discomfort or dryness (Pritchard et al, 1999). Many of these patients simply stopped wearing contact lenses a few years or even a decade or more ago without even discussing options with their eyecare provider. For these patients, a simple history and discussing options—in addition to rehabilitating the ocular surface when necessary—may be all that is needed to get them back to successful lens wear.

When Patients Are Reluctant to Try Contact Lenses Again

For patients who are referred for a scleral lens due to ocular surface disease, scleral lenses are often a slam dunk if you are able to proceed. I commonly find that many of these patients want to discuss issues with their past contact lens experiences. Some are resistant to even trying a diagnostic fitting because of their poor experience in the past.

With these patients, it is helpful to switch gears and explain that these lenses are in a completely different category and are considered medically necessary. Start by describing the cooling and lubricating effect that scleral lenses are designed to have on the eye. Patients who have comorbidities may require a bit more time and a multimodal approach of fitting the lens in addition to managing and treating ocular allergies or meibomian gland dysfunction, to name a few.

When Even Scleral Lenses Are Uncomfortable

In some cases, despite the perfect fit, a patient may not tolerate a scleral lens. When the symptoms exceed the clinical signs, such patients may fall into the category of neuropathic pain or corneal neuralgia (Goyal and Hamrah, 2016). While some of these patients may obtain relief from a scleral, some may not, and it’s nice to offer another alternative. Consider a trial of soft lenses to see whether they mitigate the symptoms. I often use a daily disposable to avoid any other contact lens-related discomfort issues such as deposits. When I fit these patients, I describe the lens as a type of bandage; of course, practitioners know it as a bandage contact lens but not in the traditional sense.

A difficult encounter may come when patients had successfully worn scleral lenses but stopped or now limit wear due to discomfort. For these patients, rule out any fitting issues by asking them to wear their lenses to the exam, if feasible. This provides an opportunity to see whether the lens is touching the cornea, resulting in discomfort that may be described as dryness. Also rule out any other fitting issues such as suction, edge lift, or impingement. If you have still not found the culprit, patients may benefit from a different design or diameter due to lid interactions.

Finally, don’t rule out hybrid lenses for any of these patients. It’s possible that they offer the best of both worlds, with the comfort of the soft skirt, the optics of a GP lens, and perhaps some dry eye relief.

In any case, it is important to instruct patients that they may still need artificial tears as a supplement to help with successful wear. CLS

For references, please visit www.clspectrum.com/references and click on document #296.