Traditionally scleral lenses have been utilized with tremendous success to correct irregular astigmatism and treat ocular surface disease. Fast forward to 2017. There are now scleral lens designs available for patients with normal, healthy eyes. Scleral lenses can be used for corneas with a regular, normal, prolate shape without disease, ectasia or irregularities. However, the patient may have coexisting conditions such as ocular surface disease including meibomian gland dysfunction, blepharitis or dry eye.
Why use a scleral lens for a normal eye? Consider someone who is not satisfied with their current soft, corneal gas permeable or hybrid contact lenses. Perhaps the vision is not clear enough. Maybe the lenses are not as comfortable at the end of the day. According to the Tear Film and Ocular Surface Society (TFOS), the reason for contact lens dropout is multifactorial.1 Contact lens discomfort, which eventually leads to contact lens dropout, may be due to either contact lens or environmental factors or both. Numerous publications have established that contact lens dropout ranges from 15% to more than 20%.2-5 Contact lens dropout increases around age 40 and significantly increases around age 42. In patients under the age of 45, comfort issues are the main reason for contact lens dropout.1 After age 45, vision and comfort were almost equally stated as the reason for contact lens dropout.6 Of interest in the soft contact lens population, 93% of patients were not wearing multifocal contact lenses at the time of dropout.
Consider patients with refractive errors such as myopia, regular astigmatism, hyperopia and presbyopia. Transitioning a patient from other contact lens modalities to scleral lenses is easily attainable and improves the contact lens experience. If vision, comfort or both are not optimal with the current contact lens modality, offer the option of scleral lenses. Scleral lenses can significantly improve the lens wearing experience for normal eyes. As with scleral lenses for compromised corneas, it is important to to discuss realistic expectations including scleral lens risks, benefits, handling, solutions and the scleral lens fitting process.
A patient who is intolerant to corneal gas permeable lenses is an ideal candidate for scleral lenses. It is an easy to transition to scleral lenses to improve lens comfort and avoid spontaneous lens dislodgement while maintaining crisp and clear vision.
Consider a patient with astigmatism who complains of fluctuating vision with soft toric lenses. Due to crisp gas permeable optics and exceptional lens stability, scleral lenses maintain clear and consistent vision all day long. According to a study in a population of asymptomatic contact lens wearers published in Eye & Contact Lens, large diameter rigid gas permeable lenses can be a good alternative to soft toric lenses for the correction of refractive astigmatism.7
If glare and hales are problematic with conventional contact lenses, scleral lenses offer the largest optic zone of any lens. Haloes and glare are reduced along with a corresponding improvement in vision with the larger optic zone that scleral lenses offer.
For athletes, scleral lenses are an excellent option where lens stability is essential. Scleral lenses remain stable without erupting with quick movements. The eye is also protected from dust or dirt. Practitioners utilize scleral lenses on regular corneas for sports including skiing, water skiing, bicycling, amongst others. Scleral lenses have been reported to protect the cornea during sports,8 although protective eyewear and safety glasses are still recommended.
Scleral lenses are also ideal for presbyopic patients who often have concomitant dry eye. There are numerous multifocal scleral lens options that provide exceptional vision at all distances. Since scleral lenses protect and bathe the ocular surface, scleral lenses are fantastic for patients with ocular surface disease including dry eye. For the patient in all of our practices that has dry eye, astigmatism and presbyopia, scleral lenses are the perfect choice. These patients are so appreciative and will surely grow your practice.
A study published in Contact Lens Anterior Eye assessed the performance of scleral lenses for a wide range of clinical indications.8 This prospective cross-sectional study evaluated 281 existing contact lens patients fit with lenses based on a lens selection algorithm. The authors determined that wearing lenses significantly improved change in corrected distance visual acuity compared to wearing spectacles. In addition, there was an improvement in satisfactory wearing time. Both the scleral lens and soft lens groups were generally effective and had high subjective scores with similar results. Additionally, overall satisfaction was high in the scleral lens group (≥70 for 81% of patients).9
If you are interested in expanding your scleral lens practice, look to your existing patients. You can offer this amazing technology to patients with astigmatism, dry eye, presbyopia, athletes or simply to improve vision and/or comfort compared to their habitual contact lenses. Scleral lenses can positively improve the lives of all of our patients!
Nichols JJ, Willcox MD, Bron AJ, Belmonte C, Ciolino JB, Craig JP, Dogru M, Foulks GN, Nelson JD, Nichols KK, Purslow C, Schaumberg DA, Stapleton F, Sullivan DA; members of the TFOS International Workshop on Contact Lens Discomfort. The TFOS International Workshop on Contact Lens Discomfort: executive summary. Invest Ophthalmol Vis Sci. 2013 Oct 18;54:TFOS7-TFOS13.
Pritchard N, Fonn D, Brazeau D. Discontinuation of contact lens wear: A survey. Int Contact Lens Clin. 1999 Nov;26:157-162.
Young G, Veys J, Pritchard N, Coleman S. A multi-centre study of lapsed contact lens wearers. Ophthalmic Physiol Opt. 2002 Nov;22:516-527.
Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007 Feb;26:168-174.
Rumpakis J. New Data on Contact Lens Dropouts: An International Perspective. Review Optom. 2010 Jan 15;147:37-42.
Brujic M, Miller, J. Minimizing Dropouts: What You Can Do. Rev Cornea Contact Lens. 2011 March 17.
Michaud L, Bennett ES, Woo SL, et al. Clinical Evaluation of Large Diameter Rigid-Gas Permeable Versus Soft Toric Contact Lenses for the Correction of Refractive Astigmatism. A MultiCenter Study. Eye Contact Lens. 2016 Nov 24.
Altman BA. Injury of a Mini-scleral Contact Lens Wearer. Contact Lens Spectrum. Jan 2013
Dumbleton K, Woods CA, Jones LW, Fonn D. The impact of contemporary contact lenses on contact lens discontinuation. Eye Contact Lens. 2013 Jan;39:93-99.
Dr. Barnett is a principal optometrist at the University of California Davis Eye Center in Sacramento, specializing in anterior segment disease and specialty contact lenses. She is the past president of the Scleral Lens Education Society. She is an advisor to and/or has received honoraria or travel expenses from AccuLens, Alcon, Alden Optical, Allergan, Bausch + Lomb, Bruder, Contamac, CooperVision, EveryDay Contacts, Johnson & Johnson Vision, Ocusoft, Paragon Bioteck, RaayonNova, ScienceBased Health, Shire, SynergEyes, and Visioneering Technologies.