In 1970, Herbert Gould, MD, wrote the following: “Well-designed moist chambers are useful in moderately dry eyes and medial and lateral canthoplasties may be helpful...The use of minimal clearance, or flushfitting lenses, as originally advocated by Ridley in England, and advanced by Girard and Gould in the United States, offers an effective and conservative method of management.”

Almost 50 years later, the U.S. Food and Drug Administration (FDA) recognized the first scleral lens indicated for the management of ocular surface disease, specifically identifying dry eye disease (DED) as one of them (Norman, 2017). The same year, the Tear Film & Ocular Surface Society (TFOS) Dry Eye Workshop II (DEWS II) panel also recognized the use of sclerals in the treatment of DED.

They placed this intervention at stage 3 of the DED treatment algorithm, a step following tear substitutes, environmental control, lid hygiene, Demodex treatment, punctal occlusion, and even the use of moisture chamber devices (Jones et al, 2017). This means keeping scleral lenses for the most severe cases, when other therapies have proved ineffective or when signs and/or symptoms persist at a significant level.

This largely reflects practitioner behavior, surveys of which rank scleral lenses fifth in the DED treatment algorithm, after lubricants, lacrimal point occlusion, cyclosporine prescription, and topical corticosteroids (Shorter et al, 2018). More positively, in that report, sclerals are ahead of moisture chamber glasses, amniotic membrane, and tarsorraphy.

Current Recommendations

Since these publications, and two years after the pandemic, is the situation the same? Are scleral lenses still considered a last resort or is the trend to consider them earlier in the treatment of DED? What about the trade-off between burden of handling and improved comfort?

Studies are ongoing, but preliminary insights indicate that there would indeed be an advantage—particularly in terms of participants’ quality of life—in using scleral therapy earlier in the treatment algorithm.

However, it is important that patients perceive sufficient improvement in their condition to overcome the problems of applying, removing, and cleaning scleral lenses. In other words, patients must see a significant difference between living with and without lenses.

Studies addressing these questions are needed to document the suitability of scleral lenses in mild to moderate DED cases. Indeed, the literature on this subject is sparse. However, to move scleral lenses ahead on the DEWS II treatment algorithm, many more evidence-based studies are needed to justify it.

Additional Studies

Another issue with the use of sclerals is their fit on normal profile corneas. Here again the evidence-based literature is sorely lacking. Several proactive practitioners are already using this modality for the correction of common refractive errors (Achong-Coan, 2020). However, to become standard of care, this trend needs to be recognized by clinical guidelines or professional groups and associations.

There are also issues surrounding the use of sclerals for soft lens wearers who remain symptomatic at the end of the day for contact lens discomfort (CLD) despite all the changes in materials or care solutions or even the use of daily disposable lenses (Jones et al, 2013). In these cases, scleral lenses are considered to be the saving grace to avoid contact lens dropout.

The argument is simple: by keeping the corneal surface consistently moist and isolating this highly innervated tissue behind a protective shield, it is then possible to reduce patients’ symptoms while optimizing their visual quality. Some will argue that treatment of marginal dryness with scleral lenses is less invasive and less risky than refractive surgery, which is often the next step after contact lenses are discontinued.

There is no clear indication yet whether the benefit-to-risk ratio is favorable to scleral lenses to treat mild to moderate DED, including CLD. In the meantime, there is nothing to stop practitioners from building this scientific evidence, one patient at a time. In this way, it may be possible to move the needle on the next DEWS III. CLS

References

1. Gould HL. The dry eye and scleral contact lenses. Am J Ophthalmol. 1970 Jul;70:37-41.
2. Norman C. Scleral lenses for dry eye syndrome and presbyopia. Contact Lens Spectrum. 2017 Jul;32:15.
3. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017 Jul;15:575-628.
4. Shorter E, Harthan J, Nau CB, et al. Scleral Lenses in the Management of Corneal Irregularity and Ocular Surface Disease. Eye Contact Lens. 2018 Nov;44:372-378.
5. Achong-Coan R. Scleral Lenses for Regular Corneas. Contact Lens Spectrum. 2020 Aug;35:28-34.
6. Jones L, Brennan NA, González-Méijome J, et al; members of the TFOS International Workshop on Contact Lens Discomfort. The TFOS International Workshop on Contact Lens Discomfort: report of the contact lens materials, design, and care subcommittee. Invest Ophthalmol Vis Sci. 2013 Oct 18;54:TFOS37-TFOS70.