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Big Gains for Big Lenses

Though sclerals are widely used today, is there any peril to their growing popularity?
By Joseph P. Shovlin, OD

4/15/2016


The first contact lenses, produced by Adolf Fick nearly 130 years ago, were made from glass and fashioned in a scleral configuration.1 After waxing and waning in popularity since then, scleral lenses have lately experienced a remarkable resurgence among contact lens practitioners, with their use broadening significantly to cover more and more challenging cases.1-3 

Three decades ago, only a few pioneers were touting the merits and benefits of scleral lenses. Now, the marvelous attributes of these lenses, which can be worn by patients who are otherwise intolerant of contact lenses, are well accepted.1,3 

Through the Looking Glass
This month’s issue highlights scleral lenses—namely, their benefits and some of their complications. Pros to prescribing scleral lenses in a specialty practice are numerous and include increased comfort (due to their large diameter), crisper vision (due to their rigidity) and a seemingly low resultant infection rate. 

But, do we really have all the data necessary to proceed with vigor in fitting these lenses on non-diseased corneas, or should we proceed with caution? The jury, in my opinion, is still out. Though I rely heavily on these lens options for the corneas that need them most, many practitioners will argue that we still have thousands of patients and a few decades of observation left to judge. Thus, the current pressing question is: “Are we proceeding with some potential peril?” 

Much has been written about the problems unique to using scleral lenses. Experts have raised concerns regarding their potential effects on intraocular pressure (i.e., episcleral venous pressure), premature endothelial morbidity including cell loss, and mechanical changes related to compression and edge impingement of the lens periphery on vital goblet cells and limbal stem cells. Smaller issues also remain, including conjunctival bunching and prolapse, epithelial “bogging,” lens debris adherence, misting and fogging, conjunctival blanching and potential solution-related corneal toxicity.

Solutions to these problems and similar issues will only come with time.1,2 Specifically, what are the long-term effects of oxygen and tear exchange deprivation? What are the best care solutions for scleral lens use to minimize the dreaded disaster of corneal infection? 

Scleral lenses are certainly not new, but definitely have been revitalized over the last few years. Many will argue that enough time has passed with clinical observation to deem them both safe and effective. Additional research to examine certain problem areas and greater vigilance for unexpected or unanticipated complications is essential for any device or drug. Ongoing surveillance and scientific study to enhance outcomes and expand clinical indications for this wonderful lens modality is crucial.

For the most part, however, we remain excited about this revisited lens modality for managing severe dryness and ocular surface disease and for restoring adequate vision to those who can’t wear spectacles or other contact lenses. 

What do you think? Do you still have reservations or are you confident these lenses carry no excessive risk or potential for morbidity?  

1. Walker MK, Bergmanson JP, Miller WL, et al. Complications and fitting challenges associated with scleral contact lenses: A review. Cont Lens Anterior Eye. Sept., 2015.
2. Caroline PJ, Andre MP: The unknowns of scleral lenses. Contact Lens Spectrum. 2013 Oct.
3. Caceroes V. Taking a second look at scleral lenses. EyeWorld. 2009 Jun.



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