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Contact Lens Spectrum

Article

Online Photo Diagnosis: Post-Graft Alternatives to Scleral Lenses 

Post-graft patients often present with irregular corneal topographies that differ from typical keratoconus.

By: LUCIANO BASTOS
Contact Lens Spectrum March 2, 2026 Vol 41, Issue March-April 2026 Page(s): 4

 

Figure 1.

Post-graft patients often present with irregular corneal topographies that differ from typical keratoconus. Many of these patients were corneal GP lens wearers before surgery. And, after cicatrization, require more advanced specialty lenses than previously worn to restore vision. Some are unwilling to try scleral lenses and wish to continue wearing corneal GPs.

Clinical Challenge

Scleral lenses often offer a more stable option by vaulting the cornea entirely, but fitting with GPs in these eyes presents several challenges. Post-graft corneas commonly show central flattening with steep midperipheral zones, and anterior elevations in nasal-temporal areas with a steeper vertical meridian.

Standard corneal GP designs often fail to center due to high eccentricity, irregular elevation, and steep periphery. The image shows a fitting with paracentral touch at 4 o’clock. Figure 2 shows localized keratitis beneath the GP bearing zone. 

Figure 2. Fluorescein staining at the inferior paracentral cornea at 4 o’clock position

Alternative Fitting Designs

Post-graft cases require vaulting over the graft and optimal peripheral alignment. An intralimbal corneal GP design (Figure 3) with a 12.5 mm diameter offered modest improvement but showed inferior decentration and persistent touch at 4 o’clock.

Figure 3. Intralimbal GP lens 12.5mm diameter with inferior decentration and persistent touch

Customized Corneoscleral Lens Design

A second attempt used a 14.5 mm corneoscleral lens (Figure 4), which improved centration and alignment. Although clearance could still be optimized, the patient was instructed to use nonpreserved lubricating drops in the bowl to avoid air bubbles. Post-graft patients previously using GPs often apply larger lenses incorrectly, leading to bubbles. Patient education and application training are crucial (Figure 5).

Figure 4. Corneoscleral lens (14.5 mm) that has improved centration and full corneal vaulting
Figure 5. Scheimpflug image (90°) illustrating post-graft corneal profile withcentral flattening and peripheral steepening. Note: this image is representative.

Conclusion

Customized, high-Dk intralimbal or corneoscleral GP lenses can offer viable alternatives for post-graft patients unwilling to wear scleral lenses.

References

1. Messer BM, Fosso T, Kuzniar J. Contact lens wear after corneal transplantation. Contact Lens Spectrum.2023;37(10):34-36,38,40,41. https://www.clspectrum.com/issues/2023/october/contact-lens-wear-after-corneal-transplantation

2. Resnick S. Contact Lenses: KCK: post-graft fitting. Optometric Management. 2024;59(8). https://optometricmanagement.com/issues/2024/october/contact-lenses-kcn-post-graft-fitting

3. Winkler TD. Case report of a corneo-scleral RGP lens. Contact Lens Spectrum. 1999; 13(9). https://www.clspectrum.com/issues/1999/september/case-report-of-a-corneo-scleral-rgp-lens

4. Driebe WT. Contact lenses after corneal transplant. Rev Ophthalmol. December 30, 2025. https://www.reviewofophthalmology.com/article/contact-lenses-after-corneal-transplant

5. Cutler SI. Help! I’ve Been Grafted:. Rev Optom. April 15, 2002. https://www.reviewofoptometry.com/article/help-ive-been-grafted

LUCIANO BASTOS is the director and clinical instructor of specialty contact lenses at the Instituto de Olhos Dr. Saul Bastos (IOSB), and is the director and specialty lens consultant of Ultralentes, a small laboratory specializing in GP and scleral lens designs in Porto Alegre, RS, Brazil.