Eyeworld

WINTER 2026 | EYEWORLD | 63 C by Liz Hillman Editorial Co-Director About the sources Deborah S. Jacobs, MD, MSc Associate Professor of Ophthalmology Massachusetts Eye and Ear Harvard Medical School Boston, Massachusetts Derek Louie, MSc, OD Professor of Ophthalmology Casey Eye Institute, School of Medicine Oregon Health & Science University Portland, Oregon patients do not all have close practice relation- ships with optometrists comfortable with fitting lenses on such patients. There remains some misunderstanding as well that eyes that are very "dry," such as in Stevens-Johnson syndrome or chronic graft-versus-host disease, are unable to support a contact lens or that risk of infection is too high. I think the option of scleral lens is also underutilized in cases of exposure keratitis after surgery (such as for tumor or cosmetic blepha- roplasty) or after trauma. Dr. Louie: Any time there is an unsteady endpoint or refractive complexity, therapeutic contact lenses can be utilized. I think they are still underutilized in ocular surface disease. When do you consider scleral lenses for pa- tients with severe dry eye or ocular surface disease? Dr. Jacobs: A scleral lens is a good option for patients with both signs and symptoms who don't achieve adequate comfort and vision with lubricants, punctal occlusion, topical immu- nomodulators, etc. It's my experience that if the patient is 20/20 without any correction or with spectacles, they will not be happy with the vision in scleral lenses due to issues with front surface wetting and debris in the reservoir. Patients with symptoms that are primarily neu- ropathic will also not tolerate scleral lens wear. In these groups, it is not worthwhile chasing a better fit. My approach is to recommend a scleral lens "trial," not a fitting, as a first step. Contemporary scleral lens trial sets usually have a lens that would offer adequate fit for an in-of- fice trial. Ideally, one looks for an "ahhh" effect with immediate relief from the lens, and once there is appropriate over refraction, no fussiness O nce reserved for complex cases, therapeutic contact lenses are mov- ing up in the treatment algorithm, reshaping how cornea specialists approach everything from kera- toconus to ocular surface disease. Deborah S. Jacobs, MD, MSc, and Derek Louie, MSc, OD, weighed in on how therapeutic contact lens use has shifted in recent years, when they consider them as a tool, and where they think their use is heading in the coming years. How has the role of therapeutic contact lens- es evolved in the past decade? Dr. Jacobs: There is increasing acceptance of scleral lenses among cornea specialists for vi- sual rehabilitation of patients with keratoconus, with other ectasias, and after penetrating kera- toplasty. There has also been increasing avail- ability of customizable lenses and an increased number of optometrists with interest and ability to fit scleral lenses and other "specialty lenses." For these reasons, it is more likely that patients will be referred for contact lenses instead of, or prior to, consideration of cornea transplantation or surgical procedures for astigmatism. Dr. Louie: I think there is increased aware- ness of their capabilities and ability to solve complicated problems to avoid/delay surgical intervention. At our institution, contact lenses have been first line [for] problem solving for at least this decade, sometimes even before or instead of topical therapies. How are therapeutic contact lenses effective- ly utilized? Where are they underutilized? Dr. Jacobs: I think there is underutiliza- tion in severe ocular surface disease because the subset of cornea specialists who see these Q&A: contact lenses as a treatment tool continued on page 65 Anterior segment OCT of scleral lens over cornea transplant Source: Derek Louie, MSc, OD/Casey Eye Institute

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