Specialized contact lens fitting continues to evolve, and today’s clinicians are increasingly confronted with unique scenarios that push the limits of traditional scleral lens design. In "Call-In Conundrums," Jason Jedlicka, OD, and Brooke Messer, OD, explored several of the most challenging cases encountered in modern specialty lens practice.

One recurring question centers on megalocornea, which presents a unique fitting challenge that often leaves clinicians asking whether conventional scleral approaches are sufficient. Defined by a horizontal visible iris diameter greater than 13 mm, megalocornea typically features normal pachymetry and intraocular pressure, a deep anterior chamber, and may be associated with findings such as central mosaic dystrophy. These eyes are rare and atypical and demand a thoughtful return to fundamentals.

The core principle is simple: A large cornea requires a large lens. Standard scleral diameters may fail to provide adequate sagittal depth or landing zone alignment, which leads to instability or compromised comfort. In these cases, increasing overall lens diameter and chamber size is often essential to achieve proper vault and scleral alignment.

Lens depth becomes a critical variable, particularly in eyes that have deep anterior chambers. While advanced imaging and tech-driven designs can be helpful, their accuracy may be limited in atypical ocular shapes. Diagnostic fitting sets remain valuable, allowing clinicians to directly assess real-world lens behavior and usability on uncommon anatomy.

Ultimately, success with megalocornea requires confidence, flexibility, and a willingness to “go big.” By grounding decisions in basic scleral principles and adapting tools thoughtfully, clinicians can successfully manage even the most uncommon corneal presentations.

According to Dr. Jedlicka, "Call in Conundrums are cases that we all encounter from time to time that we just wish we could get another opinion on how to handle.  In our podcast, listeners are able to submit questions and cases that we talk through, not necessarily giving the correct answer because there may not be one, but giving thoughts and considerations based on our clinical experiences.  It was our hope that in this type of presentation, we would get some audience participation and be able to weigh various opinions on how to manage interesting cases.”