DEVELOPMENTS related to scleral lenses (SLs) are constantly progressing and improvements to ocular surface mapping, fitting methods, designs, materials, and surface treatments have all been detailed within the literature, with proven clinical impact. This article envisages some potential developments in SLs that are anticipated to have a major impact on the fitting process, comfort, vision, and quality of life for SL wearers.

To improve surface wettability while reducing depositions, a 90% water polyethylene glycol (PEG)-based polymer coating has already been used in SLs, resulting in enhanced comfort (Mickles et al, 2021). However, the durability of the coating is limited. A solution booster is available in the U.S., but even longer-lasting coatings are needed given the envisioned timeframe between SL replacements. Such advancements would enable patients to comfortably wear SLs for extended periods without frequent lens retreatments.

SL technology can also have a significant impact on the SL fitting process. A recent survey showed that 2.4 lenses per eye were needed to complete the SL fitting process (Schornack et al, 2023). Advances in ocular profilometry will allow the manufacture of more customizable SLs, minimizing lens remakes per eye to no more than one. This will make the fitting process more valuable and efficient, reduce chair time, and enhance the patient experience.

The Tear Film & Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) report proposed a management algorithm based on four steps for treating dry eye disease (DED) (Jones et al, 2017). Interestingly, the inclusion of SLs as part of the dry eye treatment paradigm is in step three, notably at a later step than goggles in step two.

This raises questions about the prioritization of goggle treatment over SLs and whether this will be revised with future study of the role of SLs in managing DED. Considering the convenience and continuous lubrication provided by SLs through a post-lens fluid reservoir and the greater number of practitioners fitting these lenses, there is hope that SLs can be considered and utilized earlier in the disease.

It is also envisioned that SLs can have a positive impact on CL dropout in the future. CL dropout patients want to enhance their wearing experience and are significantly more inclined to use artificial tears or rewetting drops than successful CL wearers (Pucker et al, 2019). However, these individuals are still more likely to reduce their CL wearing time and discontinue CL use due to unmanaged discomfort (Pucker et al, 2019).

CL use has been shown to improve quality of life; therefore, dropout may be detrimental in ways beyond ocular correction (Kandel, 2022). Prescribing SLs for marginally dry eyes could be beneficial in addressing end-of-day discomfort and reducing CL dropout rates. Patients who previously abandoned CL wear due to discomfort can now resume wear and benefit from improved comfort and quality of life if refit into SLs.

Despite the benefits of SLs in DED, practitioners need to be aware that DED patients are more susceptible to midday fogging (MDF) (McKinney et al, 2013; Walker et al, 2023). Increased levels of nonpolar lipids have been associated with higher fogging occurrences during SL wear (Walker et al, 2023). Future management strategies may incorporate lipid analysis to effectively manage MDF, improving vision, comfort, and overall satisfaction in these patients and preventing issues before they manifest.

The SL future is bright and offers exciting possibilities. From advancements in fitting techniques to the expansion of applications, the potential for enhanced effectiveness, comfort, and versatility is immense. Beyond the topics in this article, new technologies to manage the visual experience by addressing aberrations or to correct for presbyopia with accommodating optics are also in development and will provide further applicability of these lenses. CLS

References

1. Mickles CV, Harthan JS, Barnett M. Assessment of a Novel Lens Surface Treatment for Scleral Lens Wearers With Dry Eye. Eye Contact Lens. 2021 May 1;47:308-313.
2. Schornack MM, Fogt J, Nau A, et al. Scleral lens prescription and management practices: Emerging consensus. Cont Lens Anterior Eye. 2023 Feb;46:101501.
3. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017 Jul;15:575-628.
4. Pucker AD, Jones-Jordan LA, Marx S, et al. Clinical factors associated with contact lens dropout. Cont Lens Anterior Eye. 2019 Jun;42:318-324.
5. Kandel H. Quality-of-life outcomes of long-term contact lens wear: A systematic review. Cont Lens Anterior Eye. 2022 Feb;45:101521.
6. McKinney A, Miller W, Leach N, Polizzi C, van der Worp E, Bergmanson J. The Cause of Midday Visual Fogging in Scleral Gas Permeable Lens Wearers. Invest Ophthalmol Vis Sci. 2013 Jun;54:5483.
7. Walker MK, Bailey LS, Basso KB, Redfern RR. Nonpolar Lipids Contribute to Midday Fogging During Scleral Lens Wear. Invest Ophthalmol Vis Sci. 2023 Jan 3;64:7.