Eyeworld

WINTER 2026 | EYEWORLD | 65 C References 1. Koppen C, et al. Scleral lenses reduce the need for corneal transplants in severe keratoconus. Am J Ophthalmol. 2018;185:43–47. 2. Ling JL, et al. Impact of scleral contact lens use on the rate of corneal transplantation for kera- toconus. Cornea. 2021;40:39–42. about visual quality. In my experience, and I am a rare cornea specialist who does in-office trials myself, although I no longer fit lenses, if the response is equivocal in someone with symp- toms but very good vision, they are not a good candidate, and I don't refer them. Dr. Louie: I would consider scleral lens- es if frequent application of preservative-free artificial tears (>6x/day), warm compresses, and nighttime gels are not reducing signs and symptoms as much as the patient or doctor would like. If there is a specific underlying cause (MGD/rosacea) that can be addressed concurrently, that is also important, but I think scleral lenses can play a role earlier in disease management than many people think. How have scleral lenses changed the man- agement of patients who previously might have required surgery? Dr. Jacobs: There is published data on the phenomenon of reduced need for keratoplasty from the U.S. and abroad. 1, 2 In this latter report, scleral or rigid corneal lens use reduced risk of keratoplasty 80%. Dr. Louie: I would assume, although I haven't done a literature search lately to back this up, that there are significantly less surgical interventions for most diagnosis in the past 10+ years since scleral lenses have become more "mainstream" and accessible. How do therapeutic lenses fit into the treat- ment pathway for keratoconus in the era of corneal crosslinking (CXL)? Dr. Jacobs: CXL and scleral lenses have no bearing on each other and are complementary. CXL is to stop progression; there might be small improvement in refractive error, uncorrected or best corrected vision. Scleral lenses are for vision correction. The decision for each is inde- pendent and not part of a stepwise approach. It would be best if every patient with kerato- conus had both eyes crosslinked before ectasia progressed to the point that scleral lenses were necessary for their daily activities. But even with increased awareness of the importance of early diagnosis, there are patients who do not present for care until the "good" eye has begun to decline. Certainly, there is no reason to hold off fitting until both eyes have recovered from CXL. The shape of the cornea is irrelevant to the fit of scleral lens, which vaults the cornea and sit on the sclera. The effect of CXL on shape is minimal. It is reasonable to proceed with fitting one eye and training in insertion and removal while the fellow eye is undergoing CXL and recovering and to proceed with fitting the crosslinked eye once the patient is comfortable enough to participate in fitting. If it seems that the patient will see well enough with glasses or soft lenses in the better eye, it may make sense to wait until after recov- ery from CXL for both eyes before proceeding with referral for scleral lens fitting. For patients with asymmetric severity, it is my experience that refractive correction should be targeted to the less severely affected eye. It is rare that patient will accept scleral lens correction for the worse eye, if the better eye meets their needs in spectacles or soft lenses. If a patient was using scleral lenses prior to CXL, they will likely continue to need them after. Generally, daily wear of scleral lens can resume as soon as the bandage contact lens is discontinued. Typically, the power requirement and fit of a scleral lens do not change after CXL. Dr. Louie: I would always advocate for considering CXL first before scleral lenses, but patients can be fit in scleral lenses before CXL, and the shape of the lens isn't likely to change, with only a small change in prescription in some patients. If patients are caught early and their best spectacle correction is functional and continued from page 63 continued on page 66 Scleral lens for keratoconus with sodium fluorescein dye in chamber between cornea/contact lens. Note the clearance over limbus indicated by yellow/green appearance past limbal structures and the edge of the lens resting on conjunctiva/sclera without blanching of blood vessels. Source: Derek Louie, OD/Casey Eye Institute

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