Where do Scleral Lenses Fit into Your Dry Eye Treatment Protocol?
Melissa Barnett, OD, FAAO, FSLS, FBCLA
Dry eye disease is the number one reason that patients see their eye care practitioners.1 There is an increasing awareness for both practitioners and the public of the magnitude of this condition. Thirty million or more Americans have symptoms of dry eye disease, however only 16 million are diagnosed and only one million are treated.2 Needless to say, there is massive potential opportunity to address this highly prevalent condition.
Dry eye disease can negatively affect one’s quality of life3, with symptoms such as grittiness, foreign body sensation, debilitating ocular pain and photophobia. Visual fluctuation and distortion may also occur. It is well established that the signs and symptoms of dry eye do not correlate and may be attributed to the neurosensory component of dry eye disease, as emphasized by DEWS II.
A frequent question and topic of discussion is when to incorporate scleral lenses into a dry eye management protocol. There have been numerous reports, even preceding rigid gas permeable contact lenses, of scleral lens therapy for ocular surface disease.4 Scleral lenses continuously bathe, protect and restore the ocular surface via the post-lens tear reservoir. Many scleral lens practitioners have robust ocular surface disease scleral lens practices.
In the mild to moderate dry eye patient without systemic co-morbidities, scleral lenses should not be the primary therapy. Other conventional treatment options should be tried first including environment modifications, preservative free eyedrops, prescription dry eye medications, eyelid hygiene, nighttime lubrication or goggles and punctal occlusion. When conventional treatments are insufficient, scleral lenses are a viable management option for dry eye patients. In addition, scleral lenses have been indicated for the treatment of conditions that are associated with neuropathic ocular pain.5
According to DEWS II, scleral lenses are tertiary therapy, after prescription medications and overnight treatments such as ointment or moisture goggles, and before long term use of steroids, amniotic membrane grafts, surgical punctal occlusion or other surgical procedures such as tarsorrhapy or salivary gland transplantation.6 Other step three therapies along with scleral lenses include oral secretagogues, autologous/allogenic serum eye drops and soft bandage contact lenses.
There is an escalating interest amongst practitioners to diagnose and treat dry eye disease. Each year, more practitioners are embracing dry eye and are incorporating dry eye management strategies into their practices. There are multiple lectures at every meeting, hands-on workshops on dry eye treatments and technologies and standalone meetings about ocular surface disease and dry eye.
Yet, scleral lenses are rarely mentioned as a viable therapy in these dry eye lectures or workshops. Why? Fortunately, this was not the case at the inaugural Twin Cities Ocular Surface Disease Symposium in Minneapolis, MN last June. This collaborative meeting had joint panel discussions with optometrists and ophthalmologists discussing all aspects of dry eye, from mild to severe. Fortunately, scleral lenses were included in these discussions.
My aspiration is that all future dry eye lectures, meetings, workshops and practices embrace scleral lens technology.
Gayton JL. Etiology, prevalence, and treatment of dry eye disease. Clin Ophthalmol. 2009;3:405-412.
Farrand KF, Fridman M, Stillman IO. Prevalence of Diagnosed Dry Eye Disease in the United States Among Adults Aged 18 Years and Older. Am J Ophthlamol. 2017 Oct;182:90-98. doi: 10.1016/j.ajo.2017.06.033. Epub 2017 Jul 10.
Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014 Apr;157(4):799-806. doi: 10.1016/j.ajo.2013.12.023. Epub 2014 Jan 2.
Barnett M, Johns LK. Contemporary Scleral Lenses: Theory and Application. Bentham Science 2017. Volume 4 ISBN: 978-1-68108-567-8. 108-120.
Jones, L. Downie, LE. Korb, D, et al. TFOS DEWS II Management and Therapy Report. The Ocular Surface. 2017 Jul;15(3):575-628. doi: 10.1016/j.jtos.2017.05.006. Epub 2017 Jul 20.
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.