Clinical Scorecard: Fenestrated Scleral Lenses: Research Review

At a Glance

Key Highlights

• Fenestrated scleral lenses were historically common but less used with modern GP materials; they may benefit compromised corneas by reducing edema.
• Fenestrations can relieve lens suction, ease removal, reduce midday fogging, and potentially influence intraocular pressure (IOP), though evidence is inconclusive.
• Proper fitting parameters include large lens diameter, 0.5–1.0 mm fenestrations in the limbal curve, central vault <150 µm, limbal vault ≥75 µm, and polished fenestrations to minimize discomfort.

Guideline-Based Recommendations

Diagnosis

• Assess corneal health and endothelial function, especially in post-keratoplasty or compromised corneas.
• Evaluate symptoms of corneal edema, lens suction, and midday fogging during scleral lens wear.

Management

• Consider fenestrated scleral lenses to reduce corneal edema and lens suction in selected patients.
• Use multiple fenestrations if needed to manage edema in modern high-Dk scleral lenses.
• Optimize lens fit with appropriate vault and fenestration size and location to prevent discomfort and air bubble formation.

Monitoring & Follow-up

• Monitor corneal edema signs and symptoms during lens wear.
• Regularly assess intraocular pressure, acknowledging current inconclusive evidence regarding fenestrations' impact on IOP.
• Observe for lens comfort and midday fogging, adjusting fenestrations as needed.

Risks

• Potential discomfort from fenestrations if not properly polished and fitted.
• Uncertain effects on intraocular pressure; some studies report small increases, others suggest reduction of suction forces.
• Risk of air bubble encroachment on visual axis if limbal clearance is inadequate.

Patient & Prescribing Data

Young healthy adults and patients with compromised corneas such as post-penetrating keratoplasty

Fenestrated lenses may reduce corneal edema by approximately 19% in compromised corneas and improve lens removal and comfort; however, no significant edema difference was found in healthy corneas after short-term wear.

Clinical Best Practices

• Fit scleral lenses with the largest possible diameter to optimize fit and comfort.
• Place fenestrations (0.5–1.0 mm) in the limbal curve to balance tear exchange and minimize visual axis interference.
• Maintain central vault less than 150 µm and limbal vault at least 75 µm to prevent air bubbles and corneal bearing.
• Ensure fenestrations are rounded and polished to reduce discomfort and debris accumulation.
• Consider fenestrated lenses in patients with scleral lens-induced edema, suction issues, or midday fogging.
• Monitor intraocular pressure regularly due to inconclusive evidence on fenestrations' effect.

References

• Bowden and Barnett, 2017
• Bier, 1957
• Dallos, 1946
• Fisher et al, 2024
• Fisher et al, 2022
• Harris et al, 1977
• Asghari, 2022
• Fadel, 2023
• Schornack et al, 2023
• McMonnies, 2016
• Cheung et al, 2020