LEARNING METHOD AND MEDIUM
This educational activity consists of a written article and 20 study questions. The participant should, in order, read the Activity Description at the beginning of this activity, read the material, answer all questions in the post test, and then complete the Activity Evaluation/Credit Request form. To receive credit for this activity, please follow the instructions provided below in the section titled To Obtain CE Credit. This educational activity should take a maximum of 2 hours to complete.
CONTENT SOURCE
This continuing education (CE) activity captures key statistics and insights from contributing faculty.
ACTIVITY DESCRIPTION
This article reviews the multiple factors that a practitioner should consider when fitting specialty contact lenses in order to optimize visual outcomes, patient comfort, and ocular health.
TARGET AUDIENCE
This educational activity is intended for optometrists, contact lens specialists, and other eyecare professionals.
ACCREDITATION DESIGNATION STATEMENT
This course is COPE accredited for 2 hours of CE credit. COPE Course ID: 103887-CL
DISCLOSURES
Hannah Yoon, OD, MS, reports no conflicts of interest.
Ellen Shorter, OD, has received grants from SynergEyes and Art Optical.
DISCLOSURE ATTESTATION
The contributing faculty members have attested to the following:
1. That the relationships/affiliations noted will not bias or otherwise influence their involvement in this activity;
2. That practice recommendations given relevant to the companies with whom they have relationships/affiliations will be supported by the best available evidence or, absent evidence, will be consistent with generally accepted medical practice;
3. That all reasonable clinical alternatives will be discussed when making practice recommendations.
TO OBTAIN CE CREDIT
To obtain COPE CE credit for this activity, read the material in its entirety and consult referenced sources as necessary. We offer instant certificate processing for COPE credit. Please complete the post test and evaluation online by using your OE tracker number and logging in to visioncarece.com.
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Disclaimer
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of Contact Lens Spectrum. This activity is copyrighted to Conexiant ©2026. All rights reserved.
This activity is supported by an unrestricted educational grant from Contamac.
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Release date: May 1, 2026
Expiration Date: March 24, 2029
SPECIALTY CONTACT LENS FITTING is often an art—one that asks the clinician to play matchmaker by pairing the right lens with the right patient. Today’s extensive catalog of specialty lens designs gives clinicians a wide range of options, increasing the likelihood of achieving a successful fit from both a visual and a physiologic standpoint. Sound clinical judgment and a clear understanding of the patient’s primary goals are essential to navigating this “matchmaking” process effectively.
The 2026 Toolkit
In 2026, the spectrum of specialty contact lenses includes custom soft lenses, hybrid lenses, corneal GP lenses, and scleral lenses.1
Custom soft contact lenses: Because these lenses are lathe-cut by specialty laboratories, clinicians can individualize key parameters (ie, base curve, diameter, optic zone, center thickness, lens power, lens material) as well as incorporate design features, such as decentered multifocal optics2 or reverse-geometry designs.3 For first-time wearers, patients accustomed to soft lenses, or those who have not done well with corneal GP lenses due to comfort issues, custom soft lenses may be less intimidating and require a shorter adjustment period while still optimizing the patient’s vision and comfort. Tinted or hand-painted soft lenses can be designed for patients who desire a cosmetic enhancement (Figure 1) or those who seek relief from photophobia and glare (see Case 1).
Hybrid contact lenses: Frequently described as the lens that offers the “best of both worlds,” a hybrid lens combines the comfort of a soft lens with the optics of a GP lens. These lenses can be an excellent option for patients who have high refractive errors, mild to moderate corneal irregularities (Figure 2), and even anatomically normal corneas. Patients with corneal irregularities who have been unsuccessful with corneal GP or scleral lenses previously may also benefit, as hybrid lenses can provide comparable visual performance in a modality that may be more comfortable or easier to handle. Hybrid lenses are also available with multifocal optics,4 making them suitable for presbyopic patients who have either regular or irregular corneas.
Successful fitting requires selecting an appropriate base curve to ensure central clearance and choosing the correct skirt curve for proper conjunctival alignment, as the soft skirt can tighten and create a sealing-off effect.5 At follow-up visits, clinicians should evaluate for corneal staining, particularly at the rigid-soft junction, as well as for conjunctival injection or staining.
Corneal GP lenses: Although small in diameter, corneal GP lenses are highly effective. They are fully customizable, easy to handle, and provide excellent visual quality. They have many indications, including refractive error and presbyopia correction, treatment of corneal irregularities, and myopia control. Corneal GP lenses are suitable for all age groups, from aphakic pediatric patients (see Case 2) to presbyopes with evolving visual needs.
Because they rest entirely on the cornea, corneal GP lenses are associated with initial lens awareness or discomfort, particularly in contact lens-naive patients. With time, most patients acclimate to the foreign body sensation, especially when the visual benefits are substantial.
Scleral lenses: These large-diameter lenses provide the visual advantages of a corneal GP lens with improved comfort and stability. The lens lands entirely on the conjunctival tissue overlying the sclera. Before application, the lens is filled with preservative-free saline, which creates a fluid reservoir that continuously bathes and protects the cornea during wear. This makes scleral lenses uniquely capable of both addressing optical needs and providing ocular surface protection in patients who have combined corneal and ocular surface disease (OSD) (see Case 3).
In a 2025 Contact Lens Spectrum reader survey, 27% of respondents reported that more than half of the GP lenses they fit were scleral lenses.6 Technological advances, including image-guided and impression-based lens designs that precisely capture an individual’s ocular anatomy7 (see Case 4), and higher-order aberration correction for patients who have residual aberrations with diagnostic fitting,8 have broadened the application of scleral lenses.
Considerations for Initial Lens Selection
With the expanding variety of contact lens designs and the multitude of indications for referral, selecting an initial specialty lens can be challenging. Many patients present with multiple comorbidities, adding further complexity. A thoughtful review of the patient’s clinical history, goals, and visual demands is essential for guiding lens selection.
Common chief complaints of patients needing specialty lenses include blurred or distorted vision, dryness, haloes, glare, photophobia, and cosmetic concerns. In corneal disease, the severity of the condition often directs the initial lens choice.
• Mild to moderate disease: Custom soft lenses, hybrids, or corneal GP lenses may be appropriate.
• Severe or advanced disease: Scleral lenses are often the preferred option.
• OSD or combined corneal disease and OSD: Scleral lenses are typically the most suitable first choice due to their protective fluid reservoir.
For brown-eyed patients who have photophobia (eg, from aniridia) or cosmetic concerns (eg, from an opacified cornea), an iris-tinted lens may provide adequate benefit. Patients who have lighter irises, however, may require a hand-painted cosmetic lens to achieve satisfactory cosmesis and light control.
Several additional factors may influence lens selection.
Previous contact lens history: Contact lens-naive patients may be more sensitive to initial lens discomfort or discouraged by application and removal. Even if a corneal GP lens offers the greatest visual or physiologic benefit, some patients may prefer a soft or hybrid lens for comfortability. For patients who have previously tried and been unsuccessful with certain modalities, understanding the specific challenges they encountered helps determine whether to pursue a new lens type or attempt a refined fit in the same lens modality.
Use of eye drops: Patients who require frequent instillation of topical medications (3 or more times daily) may need to remove their lenses midday. Clinicians should discuss whether this is practical given the patient’s work environment, schedule, and comfort with handling lenses throughout the day.
Age and dexterity: Older adults or those who have complex medical histories may have reduced hand dexterity, affecting their ability to safely apply and remove lenses. Caregivers or family members may need to assist, especially with pediatric patients who need parental involvement. Application tools, such as stands or lights, can also support safe lens handling.
Lifestyle/hobbies: Patients who participate in sports or other active hobbies often prefer more stable lens options, such as soft lenses, hybrids, or scleral lenses. Presbyopic patients with frequent shifts between near, intermediate, and distance demands may benefit from multifocal designs or monovision if they seek greater independence from glasses.
After considering the patient-specific factors discussed above, the clinician should select and fit a contact lens that supports the patient’s visual goals while ensuring a safe, physiologic fit that does not compromise ocular health. Because poorly fitting lenses can trigger inflammatory responses, careful monitoring at regular intervals is essential.
Proper contact lens hygiene should be reviewed during application and removal training and reinforced at subsequent visits. Clinicians should routinely ask patients which solutions they use and confirm that their cleaning regimen is appropriate and consistent with lens and material recommendations.
Contact Lens Matchmaking Success Stories
The following cases illustrate how specialty contact lenses can help patients with complex ocular conditions achieve their visual and comfort goals.
Case 1 – An iris-tinted therapeutic soft lens was designed for a patient with a KPro and a glaucoma drainage device: A 37-year-old male with complex left eye history, including a Boston type 1 keratoprosthesis (KPro), limbal stem cell deficiency, aniridia, and secondary glaucoma status post glaucoma drainage device, presented for contact lens evaluation. He arrived wearing a clear soft therapeutic lens (Figure 3A) and reported significant photophobia and glare.
A lens with an 11.5-mm light brown tinted iris, translucent sclera, and 4.0-mm clear pupil was ordered (Figure 3B). The lens was centered without edge fluting or bubbles. Because the glaucoma tube was positioned more posteriorly in the superotemporal quadrant, a 16.0-mm lens with an 8.6-mm base curve fit appropriately without impingement (Figure 3C). The tinted lens effectively reduced light sensitivity and improved cosmesis.
The KPro functions as a carrier for a donor corneal graft and is sutured to the host corneal rim. Extended-wear soft therapeutic lenses are the standard of care for KPro patients because they maintain hydration of the tissue surrounding the device and improve comfort by creating a smooth interface between the prosthesis and the eyelid.9,10
For patients who have a glaucoma drainage device, clinicians must carefully evaluate how the contact lens interacts with the tube and confirm that the lens does not impinge on the patch graft.10 After lens removal, instilling sodium fluorescein can help identify any staining that suggests tight or compressive fit. Lens diameter or base curve can then be modified to optimize the fitting relationship based on the tube’s location and profile.
Case 2 – A corneal GP lens was prescribed for a pediatric patient with traumatic aphakia and central corneal scarring: An 8-year-old male with a history of penetrating globe injury from a pencil, resulting in aphakia and central corneal scarring, presented for contact lens evaluation. Uncorrected visual acuity was counting fingers at 4 feet, with minimal improvement on manifest refraction. Corneal topography showed markedly distorted mires (Figure 4) and simulated keratometry of 52.23 D/34.50 D @149°, consistent with severe irregular astigmatism from central stromal scarring. After discussing optical correction options with the family, a diagnostic corneal GP lens was selected to offer the greatest potential for visual improvement, particularly given the patient’s young age and risk for amblyopia.
The diagnostic lens demonstrated appropriate upper-lid attachment, good centration, and adequate movement, supporting the decision to proceed with corneal GP lens correction. His best corrected visual acuity improved to 20/60. After successful application and removal training and a thorough review of lens hygiene and care, a final corneal GP lens (hexafocon A material, base curve 8.18 mm, +17.50 D) was dispensed (Figure 4). He adapted well to daily lens wear and maintained corneal GP lens use.
For pediatric patients who have aphakia, contact lens options include corneal GP lenses, silicone elastomer (SE) lenses, and soft hydrogel and silicone hydrogel lenses.11 SE lenses offer exceptionally high oxygen permeability and can be worn continuously for up to 30 days, making them a parent-friendly option for aphakic infants.11 Corneal GP lenses carry a higher risk of dislodgement, particularly in young patients who rub their eyes, but they provide superior vision when aphakia is combined with significant corneal irregularity. Regardless of lens type, frequent follow-up is essential, as lens power adjustments may be required to account for axial length growth and evolving changes in refractive error.12
Case 3 – A scleral lens was prescribed for a patient with a history of radial keratotomy and upper lid blepharoplasty: A 66-year-old female who had a history of radial keratotomy (RK) and astigmatic keratotomy (AK) in 1995, as well as bilateral upper lid blepharoplasty, presented for a contact lens evaluation with complaints of blurred and fluctuating vision, dryness, and light sensitivity. After initially achieving clear vision for 2 years post-RK, her vision had gradually declined.
Spectacle-corrected visual acuity measured 20/20- in the right eye and 20/30+ in the left eye. Central corneal thicknesses were 585 µm OD and 595 µm OS. The patient reported a preoperative refractive error of approximately –6.50 D. The current refraction was +2.25 +3.00 x 150 OD and +0.25 +5.75 x 024 OS. Pentacam imaging showed irregular astigmatism with central flattening and peripheral steepening. Slit lamp examination of the cornea revealed RK and AK incision scars with inferior punctate epithelial erosions in both eyes (Figure 5).
The patient had been fit previously with hybrid lenses by a different provider, but she reported difficulty with lens application and removal. Given her combination of visual symptoms related to prior refractive surgery and ocular surface discomfort, likely exacerbated by the upper lid blepharoplasty, scleral lenses were the most appropriate option.
An excellent fit was achieved with scleral lenses that had bitangential landing zones (roflufocon D, 8.4-mm base curve, 16.0 mm diameter).
• Right eye: –0.50 sphere, 3,600 sag, 36-42 landing zone
• Left eye: –1.25 –1.25 x 165, 3,800 sag, 36-42 landing zone
Although the patient’s scleral lens-corrected visual acuity (20/20 OD, 20/25 OS) was similar to her spectacle-corrected acuity, the lenses improved her visual quality and provided continuous hydration to the ocular surface.
RK is a surgical procedure during which corneal incisions are made in a radial pattern to flatten the central cornea and reduce myopia. It was a popular procedure in the late 1990s, prior to the introduction of laser-assisted in situ keratomileusis (LASIK).13 RK is associated with long-term complications, such as progressive hyperopic shift, irregular corneal topography, and tear film stability.14 Properly fitted scleral lenses can address both visual disturbance and dry eye symptoms in post-RK eyes.
Clinicians should be mindful that excessive central clearance in scleral lenses can induce corneal edema. Maintaining appropriate central clearance is essential for oxygen delivery, and recommending midday removal and reapplication may be beneficial for some RK patients.13 Additionally, because the corneal shape becomes more oblate after RK, reverse-geometry specialty lenses may also provide better fit and visual outcomes.
Case 4 – An impression-based scleral lens was designed for a patient with neurotrophic keratitis (NK) and advanced glaucoma: A 64-year-old male was referred for evaluation of poor vision in his right eye. His history included advanced open-angle glaucoma status post Ahmed valve implantation 3 months prior, varicella zoster virus-induced anterior uveitis, and NK. He was under the care of his cornea specialist for recurrent nonhealing corneal epithelial defects. Current medications included tafluprost 0.0015%, preservative-free dorzolamide-timolol 2%/0.5% twice daily, and valacyclovir 1 g 3 times daily.
Spectacle-corrected visual acuity in the right eye measured counting fingers at 5 feet. Slit lamp examination revealed meibomian gland inspissation, a well-covered superotemporal glaucoma drainage device, nasal pinguecula, and central corneal haze with 1+ punctate epithelial erosions. Corneal thickness measured 448 µm.
Given the patient’s corneal scarring from previous epithelial defects and significant dryness, scleral lens fitting was recommended. A diagnostic scleral lens with bitangential landing zones was ordered for the patient and successful application and removal training was completed prior to dispensing the lens.
At follow-up, he reported fogging with increasing wear time and difficultly removing the lens. Visual acuity measured 20/40. Central clearance was 200 µm after 6 hours of wear, with adequate limbal clearance 360°. However, upon lens removal, conjunctival staining was noted over the superotemporal Ahmed tube, indicating impingement of the lens (Figure 6). A second lens was ordered with flatter peripheral scleral landing zones, but his symptoms persisted.
A custom impression-based scleral lens was recommended due to the risk of conjunctival erosion over the glaucoma drainage device. The patient returned for ocular surface impression using polyvinyl siloxane material, and multiple impressions were obtained to ensure adequate coverage and centration. An impression-based lens was ordered (roflufocon E with a polyethylene glycol coating; base curve 8.279 mm, diameter 17.00 mm, +2.63 D). A digitized rendering of the patient’s corneoscleral shape is shown in Figure 7, highlighting 2 notable elevations: the glaucoma drainage device (GDD) and the nasal pinguecula.
The lens was positioned with the reference dot at 270° and demonstrated excellent corneal and conjunctival alignment. Central clearance was approximately 250 µm, with adequate limbal clearance and no compression over the glaucoma drainage device or pinguecula (Figure 7). The patient elected to wear progressive addition spectacles over the distance-corrected scleral lenses.
NK is a degenerative corneal disease caused by impaired trigeminal innervation and reduced corneal sensation. Management focuses on promoting epithelial healing and preventing further breakdown. A properly fitted scleral lens provides a valuable nonsurgical option by offering continuous corneal lubrication through the post-lens fluid reservoir while simultaneously improving vision.
Because scleral lenses are rigid and conform to the shape of the corneoscleral contour, improper fitting can lead to tissue irritation or trauma. Excessive haptic impingement may result in conjunctival redness, discomfort, and limited wear time, whereas edge lift can cause discomfort from eyelid-lens interaction and reduced visual quality if debris accumulates in the post-lens fluid reservoir.
An impression-based scleral device is created from a mold impression system combined with computerized 3D scanning. Because the posterior surface of the device is manufactured to precisely match the scanned impression, it provides an exceptionally accurate initial fit, particularly valuable in eyes that have highly irregular ocular surface profiles.
A multicenter review of 44 patients (70 eyes) fitted with impression-based scleral devices found that 68% had previously failed standard scleral lens fitting. On average, 1.3 impressions (range 1-3) were required per eye, and a mean 2.1 devices (range 1-5) were ordered to achieve final fit completion.15 Impression-based scleral lenses can, therefore, be an excellent and efficient option for patients who can’t wear diagnostic scleral lenses, especially when conjunctival elevations are present.
Takeaways
The wide spectrum of contact lens designs available today allows clinicians to fit contact lenses that support patients’ visual goals while ensuring a safe, physiologic fit that does not compromise ocular health. Because every patient has different goals and expectations, it is important to consider various factors during the initial lens selection process to find the most appropriate lens for the patient. At times, the initial lens selected may not be suitable and the clinician may need to alter course by choosing a lens that is more customized, easier to handle, or more comfortable, depending on the patient’s symptoms or ocular signs. While scleral lenses have gained significant popularity over the years,16 it is important to remember that custom soft lenses, hybrid lenses, and corneal GP lenses also remain valuable tools in optimizing vision and comfort for patients.
References
1. Jacobs DS, Carrasquillo KG, Cottrell PD, et al. CLEAR - Medical use of contact lenses. Cont Lens Anterior Eye. 2021;44(2):289-329. doi:10.1016/j.clae.2021.02.002
2. Davis RL, Schwartz M. Custom soft lenses: expand your fitting options. Contact Lens Spectrum. 2021;36:38-42. Accessed Jan 26, 2026. https://clspectrum.com/issues/2021/october/custom-soft-lenses-expand-your-fitting-options
3. Lampa M. Custom soft lenses for irregular astigmatism. Rev Optom. 2023. Accessed January 26, 2026. https://www.reviewofoptometry.com/article/custom-soft-lenses-for-irregular-astigmatism
4. Frogozo M, Harthan J, Sonsino J. Custom soft vs. hybrid vs. rigid lenses. Contact Lens Spectrum. 2022;37:32-34,36,37. Accessed January 26, 2026. https://clspectrum.com/issues/2022/october/custom-soft-vs-hybrid-vs-rigid-lenses
5. Davis R, Eiden B. Hybrid contact lens management. Contact Lens Spectrum. 2010;20. Accessed Jan 26, 2026. https://clspectrum.com/issues/2010/april/hybrid-contact-lens-management
6. Fogt JS. GP and Custom Soft Annual Report 2025. Contact Lens Spectrum. 2025;40:10-14,16,23. Accessed January 25, 2026. https://clspectrum.com/issues/2025/october/gp-annual-report
7. Fogt JS, Schornack M, Nau C, Harthan J, Nau A, Shorter E. Image- and impression-based technology in scleral lens fitting for keratoconus: availability and utilization. Eye Contact Lens. 2024;50(7):292-296. doi:10.1097/ICL.0000000000001100
8. 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
9. Harissi-Dagher M, Beyer J, Dohlman CH. The role of soft contact lenses as an adjunct to the Boston keratoprosthesis. Int Ophthalmol Clin. 2008;48(2):43-51. doi:10.1097/IIO.0b013e318169511f
10. Thomas M, Shorter E, Joslin CE, McMahon TJ, Cortina MS. Contact lens use in patients with Boston keratoprosthesis type 1: fitting, management, and complications. Eye Contact Lens. 2015;41(6):334. doi:10.1097/ICL.0000000000000154
11. Şengör T, Gençağa Atakan T. Management of contact lenses and visual development in pediatric aphakia. Turk J Ophthalmol. 2024;54(2):90-102. doi:10.4274/tjo.galenos.2023.56252
12. Shaikh N. Pediatric contact lenses: indications and management. Rev Cornea Contact Lens. 2025. Accessed January 26, 2026. https://www.reviewofcontactlenses.com/article/pediatric-contact-lenses-indications-and-management
13. Arnold TP, Vincent SJ. Scleral lens-induced corneal edema after radial keratotomy. Eye Contact Lens. 2021;47(10):575-577. doi:10.1097/ICL.0000000000000835
14. McAlinden C. Corneal refractive surgery: past to present. Clin Exp Optom. 2012;95(4):386–398. doi:10.1111/j.1444-0938.2012.00761.x
15. Nau A, Shorter ES, Harthan JS, Fogt JS, Nau CB, Schornack M. Multicenter review of impression-based scleral devices. Cont Lens Anterior Eye. 2021;44(5):101380. doi:10.1016/j.clae.2020.10.010
16. Nau CB, Harthan J, Shorter E, et al. Trends in scleral lens fitting practices: 2020 Scleral Lenses in Current Ophthalmic Practice Evaluation (SCOPE) survey. Eye Contact Lens. 2023;49(2):51-55. doi:10.1097/ICL.0000000000000960
