IN PRIVATE PRACTICE, I have managed patients who have complex refractive and ocular conditions with scleral lenses for more than a decade. As part of this, I have been increasingly concentrated on helping patients sustain comfortable vision and wear in their scleral devices. Below are three guidelines for prescribing, managing, and maintaining happy and healthy scleral lens patients. 

1. DESIGN LENSES WITH TORIC PERIPHERAL CURVES

Blurry vision is a primary reason for scleral lens dissatisfaction, and this is often due to the lens periphery not fitting well. Misaligned conjunctival-scleral and limbal landing zones may cause lens decentration, resulting in unwanted residual astigmatism that blurs vision.

Additionally, inadequate alignment may also cause the edge to be excessively flat or steep with respect to its underlying structures. A flat landing zone may cause cloudy tear film debris to be drawn into the central lens vault thereby degrading vision.

Alternately, a steep landing may impinge the conjunctival vasculature of the limbus, or even the limbal cells themselves. Impingement of this area may cause limbal hypoxia and eventually, if left unmanaged, stem cell deficiency and scarring. Adding toric peripheral curves, either to the limbal and/or the conjunctival-scleral landing zones, can help lens centration and create alignment with the underlying eye (Fadel, 2019).

2. MANAGE THE HEALTH OF THE ANATOMY BEYOND THE SCLERA

According to a new international consensus statement regarding the TFOS International Workshop on Contact Lens Discomfort, evidence suggests conjunctival lid changes are linked with contact lens discomfort (Berta et al, 2018). I have also noticed this with my scleral lens patients who have keratoconus.

Keratoconus patients have a higher frequency of systemic and ocular atopy (Wheeler et al, 2012). Since keratoconic tear film contains upregulated immune cells (D’Souza et al, 2021), the response to and launch of a hypersensitivity reaction toward foreign antigens is swift. Left unmanaged, ocular allergy may lead to chronic conjunctival inflammation and secondary dry eye disease (Dartt and Masli, 2014). Subsequently, meibomian gland dysfunction can occur and may cause contact lens discomfort (Arita et al, 2017).

In those wearing scleral contact lenses, consider proactively managing conjunctival and lid inflammation. Prescribing topical medications that decrease and modulate inflammation related to ocular surface conditions such as ocular allergy has helped sustained healthy lens wear. In cases of recalcitrant disease, do not hesitate to provide advanced procedures, such as heated meibomian gland evacuation or intense pulsed light therapy for treatment of secondary meibomian gland dysfunction.

3. LISTEN TO YOUR PATIENTS

Collecting a careful and mindful history is helpful to deliver improved scleral lens care. Questionnaire tools such as the Ocular Surface Disease Index, Contact Lens Discomfort Index, and/or a Pain Scale Index allow for repeatable qualitative and quantitative measurements of how patients perceive their lens-related comfort and health. Resources such as these, as well as listening and communicating effectively with patients, enable understanding of how the practitioner may provide, and the patient to adhere to, best possible therapies.

REFERENCES

1. Fadel D. Scleral Lens Issues and Complications Related to a Non-optimal Fitting Relationship Between the Lens and Ocular Surface. Eye Contact Lens. 2019 May;45:152-163.

2. Berta A, Toth-Molnar E, Csutak A. [New international consensus statement about the definition, classification, ethiology, diagnostics and therapy of dry eye (TFOS DEWS II)]. Orv Hetil. 2018 May;159:775-785

3. Wheeler J, Hauser MA, Afshari NA, Allingham RR, Liu Y. The Genetics of Keratoconus: A Review. Reprod Syst Sex Disord. 2012 Jun 3;(Suppl 6):001.

4. D’Souza S, Nair AP, Sahu GR, et al. Keratoconus patients exhibit a distinct ocular surface immune cell and inflammatory profile.Sci Rep. 2021 Oct 22;11:20891.

5. Dartt DA, Masli S. Conjunctival epithelial and goblet cell function in chronic inflammation and ocular allergic inflammation. Curr Opin Allergy Clin Immunol. 2014 Oct;14:464-470.

6. Arita R, Fukuoka S, Morishige N. Meibomian Gland Dysfunction and Contact Lens Discomfort. Eye Contact Lens. 2017n Jan;43:17-22.

MELANIE FROGOZO, OD, is the owner of Alamo Eye Care in San Antonio, TX, where she directs the Contact Lens Institute. She has received remuneration from ABB Optical Group.