The Scleral Lens Vault
Scleral Lenses Are Not Just for Severe Dry Eye
BY GREGORY W. DENAEYER, OD, FAAO
In addition to managing reduced vision secondary to corneal irregularity, scleral lenses are also prescribed to manage dry eye. There are several ways to grade dry eye severity, including the Ocular Surface Disease Index (OSDI) questionnaire or the Dry Eye WorkShop (DEWS) grading table. For the purposes of this article, dry eye will be referenced as mild, moderate, or severe.
Historically, scleral lenses are utilized to manage severe dry eye; but, scleral lenses can also be considered for patients who have less severe forms of dry eye.
Severe Dry Eye
Ocular surface disease that is secondary to a primary medical condition can result in severe dry eye that is disabling. Common examples include patients who have ocular graft-versus-host disease (GVHD) or Sjögren’s syndrome. These patients’ dry eye condition would be categorized as level 3 or 4 in the DEWS grading table (Pflugfelder et al, 2007). Such patients often have lid disease and keratitis that chronically affects their comfort and vision to a level that limits their activities. Palliative and medical intervention is often not enough to successfully manage such patients.
It is well documented that scleral lenses can significantly improve both vision and comfort for patients who have severe dry eye (Schornack et al, 2014; Schornack, 2015; Visser et al, 2007). A scleral lens not only holds a liquid reservoir that continuously bathes the compromised anterior ocular surface, it also provides protection from exposure.
Moderate Dry Eye
Patients who have moderate dry eye, which may or may not be related to a primary systemic disease, often have signs and symptoms that would categorize them as level 2 in the DEWS classification system. These patients will experience moderate amounts of discomfort and may have corneal staining. Palliative and ophthalmic medical management will often improve such patients’ vision and comfort, but they may not be able to tolerate traditional soft or corneal GP lenses.
As mentioned earlier, while scleral contact lenses are historically reserved to manage patients who have severe dry eye, it is logical to conclude that patients who have moderate dry eye may benefit from the therapeutic characteristics of scleral lens wear. In particular, scleral lenses may help provide relief for those patients who have moderate dry eye but are still not satisfied with their comfort and vision with maximum traditional dry eye management strategies. Dimit et al (2013) reported outcomes for use of a scleral device for various ocular conditions, including moderate dry eye. The average OSDI score for patients who had dry eye was 30.59. Their Visual Function Questionnaire scores improved from 52.91 to 72.78 after fitting of the scleral device. Scleral lenses may not only successfully manage patients’ symptoms of moderate dry eye, they also may allow these patients to return to contact lens wear.
Patients who have moderate dry eye who have been unsuccessful in traditional contact lenses may benefit from scleral lenses. This may be especially the case in patients who also have high refractive error, especially astigmatism. Scleral lenses will not only continuously hydrate the eye, but they may also provide significantly sharper vision as compared to toric soft lenses. Trialing sclerals for these patients is the only way to determine success. CLS
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Dr. DeNaeyer is the clinical director for Arena Eye Surgeons in Columbus, Ohio and a consultant to Visionary Optics, Alcon, B+L, and Aciont. He is also a shareholder in Precision Ocular Metrology LLC. You can contact him at firstname.lastname@example.org.