Scleral contact lenses are a non-surgical treatment option for patients with advanced dry eye disease who have not achieved sufficient relief with conventional therapies. These lenses provide therapeutic and optical benefits by creating a fluid-filled environment over the ocular surface. Scleral lenses are typically reserved for patients with moderate to severe dry eye who continue to experience discomfort, visual disturbance, or ocular surface damage despite using lubricating drops, gels, anti-inflammatory medications, or punctal plugs.
Scleral lenses are custom-designed medical devices that differ significantly from standard soft contact lenses. These lenses rest on the sclera, which is the white part of the eye, and vault over the cornea. The space between the back surface of the lens and the front surface of the cornea is filled with sterile saline solution. This constant layer of fluid acts as a liquid reservoir, continuously hydrating the ocular surface and protecting it from environmental exposure and mechanical irritation.
The structure of a scleral lens provides a stable and smooth optical surface, which is particularly important in patients with irregular corneas or damaged epithelium. In dry eye disease, the natural tear film is often unstable or deficient, leading to inflammation, epithelial breakdown, and compromised visual quality. By maintaining a consistent interface between the eye and the outside world, scleral lenses help prevent further injury to the ocular surface while also improving vision.
Understanding Dry Eye Disease and the Need for Advanced Treatment
Dry eye disease is a chronic, multifactorial condition involving tear film instability, increased tear evaporation, inflammation, and ocular surface damage. It is commonly classified into aqueous-deficient and evaporative subtypes, though many patients exhibit features of both. Symptoms can include burning, stinging, grittiness, fluctuating vision, and a sensation of dryness or foreign body presence.
Standard treatments for dry eye often begin with artificial tears and environmental modifications. For mild to moderate cases, topical anti-inflammatory agents, punctal occlusion, and warm compresses may provide relief. However, in severe cases, the tear film is so compromised that topical drops alone cannot restore surface integrity or reduce symptoms effectively. These patients may continue to suffer from discomfort and functional visual impairment, even with maximum medical therapy.
Scleral lenses address the underlying mechanical and inflammatory contributors to advanced dry eye. They do so not by replacing tears but by creating a sealed, protected microenvironment that bypasses the need for a stable tear film. As such, they represent a significant shift from pharmacologic management to a device-based approach that targets both the symptoms and the structural deficits of the ocular surface.
Indications for Scleral Lenses in Dry Eye Management
Scleral lenses are not typically the first line of treatment for dry eye, but they become a valuable option when other therapies are insufficient. Patients who are often considered for scleral lens therapy include those with severe keratoconjunctivitis sicca due to Sjögren’s syndrome, graft-versus-host disease, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, or severe meibomian gland dysfunction. They are also indicated for those who develop neurotrophic keratopathy, exposure keratopathy, or persistent epithelial defects.
These lenses can also benefit patients who experience significant visual fluctuations due to tear film instability or ocular surface irregularities that are not well corrected by glasses or standard contact lenses. The protective function of scleral lenses reduces friction from blinking and environmental exposure, which is critical in patients with inflamed or damaged conjunctiva and corneal epithelium.
Design and Fitting of Scleral Contact Lenses
Scleral lenses are larger in diameter than soft or rigid gas permeable lenses. They range from 14.5 to over 20 millimeters in size. This large diameter allows the lens to rest entirely on the sclera without touching the cornea. The central vault of the lens covers the cornea completely, and the edges or haptics are designed to align with the shape of the scleral surface to ensure comfort and stability.
Fitting scleral lenses requires specialized equipment and clinical expertise. The process includes corneal topography or optical coherence tomography imaging to assess the curvature and elevation of the cornea and sclera. Trial lenses are used to determine the appropriate fit, including the central clearance, edge alignment, and overall comfort. Because these lenses are custom-designed, they often require multiple adjustments and follow-up visits to optimize fit and function.
Once fitted, patients are trained to insert the lenses using a plunger device. The lenses must be filled with preservative-free saline before insertion to ensure the post-lens fluid reservoir remains clean and effective. Daily cleaning with approved lens solutions and proper handling are essential to reduce the risk of infection or lens-related complications.
Therapeutic Benefits of Scleral Lenses for Severe Dry Eye
One of the primary benefits of scleral lenses is the immediate and continuous hydration of the ocular surface. This liquid barrier eliminates the friction caused by blinking over a dry or damaged epithelium. It also protects the eye from wind, allergens, and other environmental factors that may worsen dry eye symptoms.
The improvement in comfort is often significant. Patients with debilitating dryness may report immediate relief upon insertion of the lenses. The protected environment promotes epithelial healing, reduces surface staining, and decreases the frequency of corneal erosions or ulcerations.
Visual improvement is another important benefit. In dry eye disease, visual quality is often reduced due to tear film instability and surface irregularity. Scleral lenses provide a smooth, optically neutral surface that corrects refractive error and irregular astigmatism. This allows for more consistent and stable vision compared to glasses or standard lenses, which may be affected by the quality of the tear film.
Scleral lenses also support long-term ocular surface health by reducing chronic inflammation. By minimizing mechanical stress and exposure, the lenses help interrupt the cycle of inflammation and surface damage that perpetuates dry eye disease. Over time, patients may experience reduced need for topical drops and improved quality of life.
Challenges and Considerations
While scleral lenses offer substantial benefits, they are not without limitations. The fitting process can be time-consuming and may not be available in all eye care settings. Insertion and removal require patient dexterity and adherence to hygiene protocols. Some patients may initially struggle with lens handling or experience fogging due to debris accumulation in the fluid reservoir.
There is also a cost consideration, as scleral lenses are more expensive than standard contacts and may not be fully covered by insurance. However, in medically necessary cases, insurance plans may reimburse some or all of the cost when prescribed for severe dry eye or corneal disease.
Infection is a potential risk if proper hygiene is not maintained. Regular follow-up with an experienced provider is essential to monitor lens fit, ocular health, and compliance with care instructions. Patients must also be screened for conditions such as glaucoma, where increased intraocular pressure from lens wear may be a concern.
Overview of Sclerals for Dry Eye
Scleral contact lenses are an effective treatment option for patients with advanced dry eye who have not achieved sufficient relief with conventional therapies. By providing a continuous layer of hydration and protecting the ocular surface, these lenses address both the symptoms and the underlying mechanisms of severe dry eye.
The use of scleral lenses requires specialized fitting and ongoing management but offers significant benefits in terms of comfort, vision, and ocular surface healing. For appropriate candidates, scleral lenses can restore quality of life and reduce dependence on topical medications. As awareness and access continue to grow, these lenses are becoming a vital tool in the management of complex dry eye disease.
