According to TFOS DEWS III, “Dry eye is a multifactorial, symptomatic disease characterized by a loss of homeostasis of the tear film and/or ocular surface, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities are etiological factors.”1
Dry eye disease (DED) symptoms include ocular dryness, grittiness, foreign body sensation, debilitating pain, photophobia, visual fluctuation, and visual distortion. Scleral lenses have become instrumental in the management of ocular surface disease (OSD).
They are well tolerated, highly effective for DED, and have consistently demonstrated the ability to improve both symptoms and visual acuity with minimal complications.2 Additionally, patient-reported outcomes show a significant positive impact on ocular comfort and quality of life with scleral lens wear.3
An overview of scleral lenses for DED
Multiple studies have shown improvements in dry eye symptoms for many indications, demonstrated by reductions in Ocular Surface Disease Index (OSDI) scores.4-8 According to the TFOS DEWS III Management and Therapy report, “Scleral contact lens use is generally not linked to specific complications and effectively improves the signs and symptoms of dry eye disease.”9
Since scleral lenses bathe and protect the ocular surface, they may be considered an advantageous option for individuals with all severities of DED, from mild to severe.
Figure 1: Corneal staining in severe dry eye disease.
Figure 1: Courtesy of Jennifer Harthan, OD.
Figure 2: Scleral lens fit on an eye with severe dry eye.
Figure 2: Courtesy of Nathan Schramm, OD.
Therapeutic indications for scleral lenses for OSD include:10-12
- Dry eye disease syndrome
- Keratitis
- Exposure
- Neurotrophic
- Filamentary
- Graft-versus-host disease
- Stevens-Johnson syndrome
- Ocular cicatricial pemphigoid
- Chemical burns
- Limbal stem cell deficiency
- Sjögren’s disease
- Other systemic autoimmune diseases
- Persistent epithelial defects
- Neuropathic ocular pain
Figure 3: Filamentary keratitis before scleral lens fitting.
Figure 3: Courtesy of Caity Morrison, OD.
Figure 4: Filamentary keratitis after scleral lens management.
Figure 4: Courtesy of Caity Morrison, OD.
Benefits of scleral lenses
There are many unique advantages of fitting scleral lenses in dry eye disease, even in individuals with regular corneas. Scleral lenses may be especially beneficial for symptomatic soft contact lens wearers who struggle with dryness and discomfort. The post-lens fluid reservoir of scleral lenses creates a sealed, lubricating environment over the ocular surface, effectively eliminating tear film evaporation.13
Scleral lenses maintain a stable post-lens tear reservoir composed of preservative-free saline and components of the natural tears. This is unlike soft contact lenses, which can thin the lipid layer and increase evaporation.13
Dry eye is a multifactorial condition, and oftentimes aqueous-deficient and evaporative dry eye exist along a continuum. This continuous hydration makes scleral lenses potentially beneficial for all types of dry eye disease.15
Moreover, the scleral bowl can be utilized off-label as a delivery reservoir for therapeutic agents targeting OSD, such as cyclosporine, with the goal of increasing drug corneal contact time, increasing bioavailability, and potentially increasing efficacy compared to standard on-label application of topical ophthalmic drops.14
Research on using cyclosporine in the scleral lens reservoir
A pilot study evaluated the tolerability of scleral lens use as a delivery system for preservative-free cyclosporine 0.05% in individuals with dry eye disease.14 Fourteen established scleral lens wearers with a baseline OSDI of 13 or greater and a baseline corneal fluorescein staining of two or higher were enrolled.
One drop of cyclosporine 0.05% was placed in the lens reservoir along with preservative-free saline. Lenses were worn for 6 hours, removed, and the protocol was repeated for an additional 4 hours or more.
After 1 month, participants demonstrated improvements in ocular surface signs, including corneal and conjunctival staining and conjunctival hyperemia, along with a modest improvement in symptoms, while visual acuity remained unchanged.14
These findings suggest that scleral lens–based delivery of cyclosporine is well tolerated and potentially effective, though larger studies are needed to confirm efficacy and long-term outcomes.14
In addition, there is no contact lens dehydration related to scleral lens wear since scleral lenses are not hydrated.13 In contrast, soft contact lenses are prone to dehydration due to environmental factors, which may contribute to discomfort and dryness. By eliminating lens dehydration, scleral lenses remove a key contributor to contact lens–related dry eye symptoms.13
How scleral lenses provide improved comfort and stability of vision
Scleral lenses offer improved comfort and stability of vision since they avoid direct epithelial contact, vault the cornea, and reduce mechanical irritation associated with blinking.13 The stable optical surface can improve visual acuity and reduce fluctuations, which may enhance overall comfort and tolerance of lens wear compared to other lens modalities.
Corneal healing
Scleral lenses have the ability to support corneal healing by protecting the ocular surface and reducing epithelial stress. Studies and clinical surveys have demonstrated reductions in corneal staining after scleral lens wear, with particularly strong evidence in conditions such as neurotrophic keratitis and persistent epithelial defects.15,16
Figure 5: Scleral lens with lissamine green staining.
Figure 5: Courtesy of Nathan Schramm, OD.
Visual acuity
Scleral lenses can improve visual acuity and, in turn, improve overall contact lens comfort in individuals with dry eye disease. Soft contact lens research has shown that reduced visual acuity is associated with poorer perceived comfort.17,18
In contrast, scleral lenses have demonstrated improved best-corrected visual acuity compared to habitual correction (soft contact lenses or glasses), even in eyes with regular corneas.13
By creating a stable post-lens tear reservoir, scleral lenses can mask anterior corneal astigmatism and minor surface irregularities, resulting in a smoother refractive surface and thus more consistent vision. This improvement in visual quality may contribute to improved comfort during wear.
However, direct evidence linking improved visual acuity with enhanced comfort in scleral lens wear is limited. Additional scleral lens–specific research in dry eye populations is needed.13
Addressing midday fogging
Midday fogging (MDF) is one of the most frequent complications of scleral lens wear, affecting 26 to 46% of scleral lens wearers in general, and up to 75% of individuals with DED.19-21 MDF is when debris accumulates in the post-lens tear reservoir, causing blurred vision.22
Research suggests that inflammation plays a major role: inflammatory markers, including MMP-9, MMP-10, and neutrophils, are often elevated in the post-lens tear film of those with MDF.22 Since DED is inherently inflammatory, these individuals may be more prone to MDF and require proactive management of both ocular surface inflammation and lens parameters.20,23
Midday fogging is typically managed through a combination of strategies, including lens removal and reapplication once or twice daily, adjusting the scleral lens fit, including improving landing zone alignment or reducing fluid reservoir thickness, the use of more viscous application solutions, and treatment of underlying ocular surface disease, including allergies and dry eye disease.23
Pearls for filling solutions in scleral lenses
Additionally, a study demonstrated that using a filling solution designed to closely mimic the composition of natural tears resulted in statistically significant improvements in comfort and subjective visual quality compared with habitual filling solutions.23 Regularly reviewing filling and disinfection solutions at each visit is essential for successful scleral lens wear.
Preservative-free solutions are recommended for scleral lens filling. Different solutions vary in their properties, including buffered versus non-buffered formulations and the presence of electrolytes. Replacement after a single use is recommended. In some cases, combining these solutions with a more viscous agent in the lens reservoir may enhance comfort and visual stability, depending on the patient’s ocular surface needs.
A recent study evaluated the impact of using a high-viscosity sodium hyaluronate solution in the scleral lens fluid reservoir on post-lens fluid turbidity and lens settling.24 Scleral lenses were fitted in individuals with keratoconus, and visual performance and lens behavior were assessed.
The study concluded that high-viscosity sodium hyaluronate may improve low-contrast visual performance compared with saline, without adversely affecting post-lens fluid turbidity or scleral lens settling.24
When wettability is an issue
Individuals with DED often experience poor scleral lens surface wettability, likely due to meibomian gland dysfunction or excess lipid deposition.25
Figure 6: Significant surface debris on a scleral lens.
Figure 6: Courtesy of Melissa Barnett, OD.
Poor wettability results in unstable tear distribution on the lens surface, causing blurred vision, discomfort, and reduced lens tolerance.25 Clinically, the scleral lens surface may look “greasy” or irregular. Selecting appropriate lens materials, surface treatments (e.g., PEG coatings), and reviewing skincare or cosmetic products can help.
In a double-masked crossover study of 21 scleral lens wearers with dry eye and lens discomfort, polyethylene glycol (Hydra-PEG) surface-treated scleral lenses significantly improved comfort, dry eye symptoms, ocular surface signs, visual clarity, and comfortable wearing time compared with untreated lenses.26 Overall, PEG surface treatment reduced ocular surface compromise and enhanced the scleral lens wearing experience in individuals with dry eye disease.
Conventional management options for anterior scleral lens fogging are increased lubrication with preservative-free artificial tears throughout the day and removal, manual cleaning, rinsing, and reapplication of the lenses. Hydrogen peroxide-based solutions may offer additional benefits, especially for patients with dry eye or sensitivity to preservatives.
Managing patient expectations
Individuals with dry eye disease and regular corneas often report lower satisfaction with scleral lenses compared to those with corneal irregularities, due to factors such as more frequent midday fogging requiring lens removal, surface deposits that affect visual quality, conjunctival sensitivity not addressed by scleral lenses, and less dramatic visual improvement.15,25 These elements may reduce motivation to persist through the application and removal and adaptation periods.
Setting realistic expectations is essential for successful scleral lens wear. Numerous educational resources are available to support both practitioners and patients, including the Scleral Lens Education Society (SLS), Gas Permeable Lens Institute (GPLI), and Association of Contact Lens Educators (AOCLE), as well as manufacturer-provided brochures and digital educational materials.
Final thoughts
When fitting scleral lenses for dry eye disease, guidance from TFOS DEWS III reminds us that “multiple treatments used together are the likely and most appropriate management strategy, considering that DED has multiple pathogenic drivers.”9
Thus, it is essential to address all aspects of ocular surface disease concurrently. Within this multimodal approach, scleral lenses can provide significant benefits, including improved vision, enhanced comfort, and a significant improvement in quality of life.
Key takeaways
- Clearly explain the scleral lens fitting process.
- Establish realistic expectations regarding comfort, vision, and adaptation.
- Optimize the ocular surface prior to fitting to improve outcomes.
- Continue existing dry eye therapies when initiating scleral lens wear, with the potential to reduce treatments over time.
- Review proper lens application and disinfection solutions to support long-term success.
