GP Insights

Differential Diagnosis of Red Eye With Scleral Lenses

GP Insights

Differential Diagnosis of Red Eye With Scleral Lenses



Previously successful patients wearing scleral lenses may present to your office with redness, irritation, or pain as a primary complaint. Patients who have a more complicated ocular history and who are using advanced scleral designs need a thorough assessment to properly diagnose and manage the root cause of their symptoms.

Scleral Lens Fit

A lens that exhibits compression secondary to a tight-fitting haptic or excessive lens flexure will result in redness, irritation, and reduced wear time. Lens compression will cause vessel blanching beneath the lens haptic and paralimbal congestion. A lens that is sealed-off in this way will be extremely difficult to remove when using proper technique.

Compression of a scleral lens may worsen over time secondary to swelling of the bulbar conjunctiva (Visser, 2006). Lens impingement (when the edge of the scleral lens digs into the bulbar conjunctiva) can also result in reduced wear time and redness. Finally, a lens that is flat-fitting and bears excessively on the cornea can cause epithelial disruption that results in redness.


Patients wearing scleral contact lenses can have a toxic reaction or hypersensitivity to lens care solutions. Scleral lens patients are at risk for solution toxicity because preservatives or buffers can become trapped in the reservoir, which increases exposure time. Always ask patients what care solutions they are using because they may have switched to a non-prescribed solution that is the source of their toxicity.


Figure 1. A scleral lens patient who developed a delayed hypersensitivity to a multipurpose disinfecting solution.

Patients may also develop hypersensitivities to care solutions or prescribed eye drops (Figure 1). The onset of a reaction to any particular care solution may be immediate, but it also may be a delayed hypersensitivity, which can take months to manifest. A delayed reaction can make the diagnosis more difficult because the onset of symptoms does not correspond with the initiation of the offending care solution, and the patient will probably be using multiple products.


Patients may present with a red eye(s) secondary to infection. Bacterial conjunctivitis is relatively common and more easily diagnosed due to its strong association with mucus discharge. Viral conjunctivitis may be more difficult to diagnosis because the symptoms of redness and watering can mimic many other scleral lens-related complications. Although rare, scleral wearers can develop microbial keratitis (MK). Early diagnosis and prompt treatment of MK is critical to reduce secondary complications.

Other Complications

Patients who wear scleral lenses may have a corneal transplant or glaucoma. A corneal graft rejection or an acute increase in intraocular pressure (IOP) can present with redness that is unrelated to the lenses. It’s imperative to perform a careful slit lamp evaluation of the cornea and to measure IOP to rule out any medically related complications. CLS

For references, please visit and click on document #209.

Dr. DeNaeyer is the clinical director for Arena Eye Surgeons in Columbus, Ohio, and a consultant to Visionary Optics, B+L, and Aciont. You can contact him at