The SCOPE (Scleral Lenses in Current Ophthalmic Practice Evaluation) study estimated that 74% of sclerals are prescribed for corneal irregularity, while only 16% are used for those who have ocular surface disease (Nau et al, 2018). Often unmentioned, and maybe even unintentionally forgotten, are those who have lid abnormalities who may benefit from scleral lenses.

Types of Lid Abnormalities

Ptosis A 54-year-old Caucasian female presented to the clinic with a chief complaint of a permanently enlarged pupil secondary to a compressive oculomotor nerve palsy. Despite successfully removing the compressive lesion, the third cranial nerve appeared permanently weakened, and the patient’s symptoms never fully resolved. She continued to experience a moderate ptosis, enlarged pupil, and binocular diplopia in various fields of gaze secondary to extraocular muscle restrictions OS (Figure 1A). The patient did report clear single vision in primary gaze and was mainly concerned with her cosmetic appearance; her initial goal was to be fit in a tinted lens that would decrease the pupil asymmetry. When questioned about the ptosis, she was against surgical repair and was unaware of sclerals as a possible solution. A quick in-office trial demonstrated dramatic improvement, and the patient was elated (Figure 1B).

A scleral designed for ptosis improvement may need increased apical clearance to create a shelf upon which the upper eyelid can rest. This often equates to a thicker tear reservoir, which may be contraindicated for those who have a compromised endothelial cell layer. Monitor for signs of corneal hypoxia, such as edema and neovascularization.

Blepharospasm Benign essential blepharospasm (BEB) is a movement disorder that involves uncontrolled blinking or spasms of the eyelids. Initial presenting symptoms such as dry eyes, an increased blink rate, or ocular irritation in windy or dusty conditions may be easily overlooked. Typical treatment starts with botulinum toxin injections; if symptoms do not improve, an upper lid myectomy may be considered. Blepharospasm patients triggered by bright lights may experience symptomatic relief when wearing rose-tinted lenses (Adams et al, 2006; Blackburn et al, 2009). One case reports a successful temporary use of scleral lenses designed with ptosis props to prevent eyelid closure in a BEB patient who was unresponsive to botulinum toxin injections (Salam et al, 2004). This unconventional lens design was worn by the patient during an interim period prior to upper lid myectomy.

A more promising alternative was presented by a recent ARVO abstract that detailed the effects of scleral lens wear on blink rate in patients diagnosed with dry eye disease or BEB (Hemmati et al, 2020). On average, these patients blinked 31 times per minute when not wearing a scleral. With a preservative-free saline-filled scleral lens on eye, the average blink rate decreased to 15 blinks per minute. Some patients also reported further symptomatic relief when the lens fluid reservoir was tinted by mixing saline with sodium fluorescein; the average blink rate further decreased to 12 blinks per minute. The difference in blink rate between the two scleral lens groups was not statistically significant, although this may have been due to the small sample size (n = 8). Surprisingly, I have noticed a slight uptick in scleral lens consultations for BEB patients. CLS

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