The most effective contact lens option for patients who have severe dry eye disease (DED) is scleral lenses, which create a fluid-filled vault over the cornea and the limbus and provide them with constant lubrication. Several studies using scleral lenses have shown improved comfort, decreased dry eye symptoms, and improved visual acuity with a good safety profile in patients who have severe ocular surface disease (Weber et al, 2016; Harthan and Shorter, 2018).

Scleral lenses have been demonstrated to be safe for the healthy cornea and evoke less physiologic hypoxic swelling than a normal closed eye state (Barnett et al, 2021). In a recent personal correspondence, one scleral lens fitter shared that the fluid cushion layer of scleral lenses can be a life-changing tool for severe ocular surface disease, and that same principle can improve the contact lens-wearing experience for patients who have even mild or moderate dry eye symptoms.

Newer scleral lenses are easier to fit and readily available commercially, making them more accessible to patients. With increased availability of these scleral lens designs, we are now able to consider sclerals earlier in the management of DED (Thulasi and Djalilian, 2017; Jackson, 2009).

Scleral lenses not only provide vision correction, but they also protect and lubricate the ocular surface. Other perks to scleral lens wear can include improved vision quality, decreased photophobia, and, anecdotally, a wider, more open appearance to the eyes (Rosenthal and Cotter, 2003). They can be more comfortable because the conjunctival tissue on which scleral lenses rest is less sensitive than corneal tissue. Additionally, pesky presbyopic symptoms can be addressed with a multifocal scleral lens fit.

In recent years, the U.S. Food and Drug Administration has included keratoconjunctivitis sicca as a therapeutic indication in the labeling of scleral lenses (Art Optical, 2017). Considering these new standards, scleral contact lenses are now more commonly used by specialty contact lens fitters and dry eye specialists.

Scleral lens manufacturers provide tools to guide the practitioner to successful scleral lens fitting and adjustments to achieve the best patient lens fit. Special lens treatments and coating make lens wear more comfortable and increase lens wettability. Scleral lens bowl solutions also can be customized to the patient’s needs.

Perhaps lowering your threshold for a scleral contact lens fit and fitting the more regular, albeit drier, eye surface is a way to acquire expertise for the more complex fitting cases. CLS

References

1. Weber SLP, de Souza RB, Gomes JAP, Hofling-Lima AL. The Use of the Esclera Scleral Contact Lens in the Treatment of Moderate to Severe Dry Eye Disease. Am J Ophthalmol. 2016 Mar;163:167-173.e1.
2. Harthan JS, Shorter E. Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations. Clin Optom (Auckl). 2018 Jul 11;10:65-74.
3. Barnett M, Courey C, Fadel D, et al. CLEAR – Scleral lenses. Cont Lens Anterior Eye. 2021 Apr;44:270-288.
4. Thulasi P, Djalilian AR. Update in Current Diagnostics and Therapeutics of Dry Eye Disease. Ophthalmology. 2017 Nov;124:S27-S33.
5. Jackson WB. Management of dysfunctional tear syndrome: a Canadian consensus. Can J Ophthalmol. 2009 Aug;44:385-394.
6. Rosenthal P, Cotter J. The Boston Scleral Lens in the management of severe ocular surface disease. Ophthalmol Clin North Am. 2003 Mar;16:89-93.
7. Art Optical Contact Lens. Ampleye™ Scleral Now FDA Approved for Ocular Surface & Dry Eye Disease Management. [Press Release] 2017 Sep 20. Available at https://www.artoptical.com/news-events/ampleye-scleral-now-fda-approved-for-ocular-surface-dry-eye-disease-managem?msclkid=208bb7f0afac11ecb138e3a38ffd36d9 . Accessed April 29, 2022.