IN THE CONTACT LENS INDUSTRY, practitioners often celebrate the “20/Happy” patients but can sometimes be frustrated by “20/Unhappy” irregular cornea patients. They often report ghosting or shadowing around letters, as well as glare and halos in low light environments, even with the best-fitting scleral lenses. What many irregular cornea patients may be expressing is their perception of their higher-order aberrations (HOAs), such as coma, trefoil, and spherical aberration.
Both corneal GP and traditional scleral lenses use spherocylindrical optics, but only partially correct for HOAs induced at the anterior surface of the cornea. Additionally, internal HOAs induced by the posterior cornea and both surfaces of the crystalline lens are unaffected by traditional rigid lenses. This can be especially true for emergent and mild keratoconus, in which posterior corneal HOAs are greater than those in the anterior cornea (Marsack et al, 2007; Chen and Yoon, 2008). For some irregular cornea patients, it is possible to not only quantify but also correct for these frustrating visual symptoms.
To create HOA-correcting scleral lenses, the practitioner uses a wavefront aberrometer to make a unique profile of that patient’s HOAs. Once the scleral lens fit is stabilized, a new scleral lens with a series of dots is scanned to determine the exact location and pattern of wavefront-guided correction needed for optimal vision. Then, the wavefront-guided optics are applied to the front surface of the lens to create a truly customized scleral lens experience.
An example of successful use of this technology is a patient seen in our office this year, a 71-year-old male who had a history of keratoconus and mild nuclear sclerosis in both eyes. The patient had a starting best-corrected visual acuity (BCVA) of 20/40 OD and 20/60 OS with a standard scleral lens. Aberrometry measured a visually significant HOA root mean square (HOARMS) of 0.70 µm OD and 1.72 µm OS.
After fitting him with wavefront-guided scleral lenses, BCVA improved to 20/20 OD and 20/40 OS with a reduced HOARMS of 0.29 µm OD (Figure 1) and 0.34 µm OS (Figure 2), an improvement of 58% OD and 80% OS.
Some of the primary advantages of HOA-correcting scleral lenses is reduction of glare and halos, especially in low light situations in which the pupil size increases. Patients can have a measurable visual acuity improvement, but those who do not have a measurable improvement in office often see a subjective improvement in the real world.
In a recently published double-blind, randomized, crossover clinical trial, 93.3% of patients who had irregular astigmatism preferred their vision in wavefront-guided optics vs traditional optics on scleral lenses (Gelles et al, 2025).
Wavefront HOA scleral lenses are becoming more readily available from multiple specialty contact lens manufacturers, and they are resulting in life-changing visual improvements.
References
1. Marsack JD, Parker KE, Pesudovs K, Donnelly WJ 3rd, Applegate RA. Uncorrected wavefront error and visual performance during RGP wear in keratoconus. Optom Vis Sci. 2007;84(6):463-470. doi:10.1097/OPX.0b013e31802e64f0
2. Chen M, Yoon G. Posterior corneal aberrations and their compensation effects on anterior corneal aberrations in keratoconic eyes. Invest Ophthalmol Vis Sci. 2008;49(12):5645-5652. doi:10.1167/iovs.08-1874
3. Gelles JD, Su B, Kelly D, et al. Visual improvement with wavefront-guided scleral lenses for irregular corneal astigmatism. Eye Contact Lens. 2025;51(2):58-64. doi:10.1097/ICL.0000000000001152