Managing patients who have ocular surface disease (OSD) can be challenging. At times, signs and symptoms don’t even seem to be related, and the timeline for obtaining significant improvement (from both the practitioner and patient perspectives) is often longer than either party would want.

Scleral lenses have proven to be well tolerated for the visual rehabilitation of damaged corneas for many decades (Shein et al, 1990), and have been used off-label to manage dry eye disease (DED) for years, with several studies citing improved visual acuity and symptoms and reduced ocular surface damage (Kok and Visser, 1992; Bavinger et al, 2015; Schornack et al, 2014).

Since 2017, several scleral lens companies have sought U.S. Food and Drug Administration (FDA) approval for the therapeutic management of various forms of OSD. This is likely a contributing factor to the extensive growth we’ve seen in scleral lens use for dry eye management, since cost continues to be one of the main deterrents of scleral lens prescribing (Johns et al, 2017). FDA-approved indications allow for medically necessary insurance coverage in many cases.

Scleral lenses have also found their way onto the Tear Film & Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) treatment ladder after lubrication, hygiene, topical medication, and punctum occlusion, and before the initiation of systemic medications, autologous serum, and surgery (Craig et al, 2017).

It’s important to remember that fitting these lenses on dry eyes does not come without its problems, however, and expectations need to be managed in advance.

If patients have difficulty wetting their own ocular surface, they will likely struggle to wet the surface of a contact lens. This can lead to variable vision, surface deposits, and discomfort.

I’ve learned over time not to shy away from recommending scleral lenses to anyone, as long as they are properly indicated. Below are a few of my more memorable success stories that could have turned out quite differently if I had allowed my preconceived notions to get in the way.

Case #1: Motivation Often Supersedes Age A 78-year-old female who had Sjögren’s heard about our clinic and drove four hours round trip to see whether we could improve her quality of life. She was on maximum medical therapy and was instilling preservative-free artificial tears more than 20 times per day.

Despite being almost 80 years old, she quickly became a successful wearer and one of our best word-of-mouth referring patients. Her ocular lubricant use decreased to t.i.d. Now, four years later, she still enjoys 12-plus hours per day of comfortable vision.

Case #2: Combine to Prolong Treatment Effect I was struggling to manage persistent keratitis in a 64-year-old female who had Sjögren’s, rheumatoid arthritis, and CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome. Although we achieved some success with serum tears and amniotic membranes, she always returned to baseline within weeks of membrane removal.

She was fit in scleral lenses so that wear could be immediately initiated after the next set of amniotic membranes improved the corneal surface. In her case, this proved wildly more successful and extended the longevity of the membrane benefits.

Case #3: Where There’s a Will, There’s a Way This case involves a wheelchair-bound gentleman who had dementia and who began sleeping during the day to avoid the discomfort associated with DED. This decrease in mental stimulation was detrimental to his condition.

With scleral lenses, he could stay awake and engaged for six to eight hours, but he struggled significantly with lens application due to neck immobility. He found success by lying across the bed on his stomach while his wife sat on the floor and applied his lenses for him. Where there is a will, there really is a way! CLS

References

1. Schein OD, Rosenthal P, Ducharme C. A gas-permeable scleral contact lens for visual rehabilitation. Am J Ophthalmol. 1990 Mar 15;109:318-322.
2. Kok JH, Visser R. Treatment of ocular surface disorders and dry eyes with high gas-permeable scleral lenses. Cornea, 1992 Nov;11:518-522.
3. Bavinger JC, DeLoss K, Mian SI. Scleral lens use in dry eye syndrome. Curr Opin Ophthalmol. 2015 Jul;26;4:319-324.
4. Schornack M, Pyle J, Patel SV. Scleral lenses in the management of ocular surface disease. Ophthalmology. 2014 Jul;121:1398-1405.
5. Johns LK, McMahon JA, Barnett M. Contemporary Scleral Lenses: Theory and Application. Vol 4. Bentham Science; 2017:201-241.
6. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017 Jul;15:276-283.