A scleral lens is a large diameter lens made from an oxygen permeable polymer that is designed to vault over the front surface of the eye. A scleral lens is not considered a contact lens as there is no contact with the front surface of the eye, the cornea. Instead a scleral lens is designed to vault over the cornea and come to rest on the white portion of the eye, known as the sclera.
A scleral lens is intended to restore vision to patients who have lost quality vision and comfort due to ocular diseases, chronic dry eyes, ocular trauma and unanticipated ocular surgery complications. When treating an eye with a damaged cornea, eyeglasses will not provide functional vision. Almost all of the eyes that we see with damaged ocular surfaces cannot tolerate a conventional contact lens. This is because conventional contact lenses, both soft and rigid, rest on the corneal surface. While vision improvement may be achieved upon inserting these lenses, comfort readily decreases after a very short wearing time. In addition, conventional contact lenses can cause further damage to the highly compromised ocular surfaces of these eyes. We have to appreciate the fact that a preservative free saline reservoir exists between the back surface of the scleral lens and the front surface of the eye. This preservative from the liquid reservoir helps to provide nutrients to the cornea and allows a healing process to take effect. In other words, in addition to providing our patients with quality vision, we are helping the damaged ocular surfaces to heal.
The primary indications for scleral lenses are corneal irregularities due to cornea diseases and conditions such as keratoconus, corneal ectasia, chronic dry eyes, complications resulting from refractive surgery such as LASIK, a variety of corneal degenerations and dystrophies, ocular trauma, corneal transplant surgeries and many other conditions. In effect, a well designed and fit scleral lens replaces the cornea as an optical surface. The resulting improvement in vision and comfort is almost always dramatic and can be very emotional for the patient. Over the years we have had many patients break down in tears upon receiving their scleral lenses and experiencing the dramatic improvement in vision.
I have been using scleral lenses for over 25 years to treat some of the most complicated and challenging ocular conditions. One example would be a patient who we treated who lost the upper eyelid of one eye due to flying glass from a car accident. Because he could not close this eye, the cornea soon began to degenerate due to prolonged exposure to the atmosphere. We fit this eye with a very thin, highly oxygen permeable scleral lens designed to both protect the ocular surface and to provide vision during a 12 month long eyelid reconstruction period where multiple eyelid surgeries were performed. There are also diseases and conditions of the inner lining of the eyelids that can create a painful eye. Many of these eyelids will scratch the cornea every time a patient blinks. The scleral lens will protect the ocular surface from the blinking action of these eyelids and also allow the ocular surface to heal.
Scleral lenses have dramatically changed the way we treat and manage patients who have lost vision due to corneal disease, surgery and ocular trauma. Scleral lenses have helped to reduce the need for surgical intervention and have significantly improved the quality of life for hundreds of thousands of patients especially those suffering from severe ocular surface such as Stevens-Johnson Syndrome, grafts host disease, neurotrophic keratitis, exposure keratitis and neuropathic pain. Because of the exciting and innovative improvements in scleral lens designs, the number of patients undergoing corneal transplant surgery in the United States has declined dramatically over the last 10 years.
The main benefit of scleral lenses is that they can be designed to accommodate any degree of corneal steepness or shape. Scleral lenses provide better centration and stability than conventional contact lenses and they are more comfortable because the conjunctival tissue on which the scleral lenses rest is less sensitive (has fewer sensory nerves) than corneal tissue.
Furthermore, in patients who have experienced damage to corneal tissue, scleral lenses do not touch the cornea but rather bathe it continuously in preservative free saline so that scar formation is not encouraged and a healing process can take place.
When our specialty practice introduced scleral lens technology to Florida in the early 1990’s, there was only one scleral lens design and only one scleral lens laboratory in the United States. Since then there has been an “explosion” of scleral lens materials and designs. It would be best to consider these different scleral lens designs as treatment options instead of pieces of plastic. Sophisticated computers using proprietary software are now used in both the manufacture of scleral lenses and in the designing and fitting of these lenses in the doctors’ office. Certain lens designs, materials, shapes and diameters may work well with one eye but not with the other eye. We have many patients using a scleral lens made by one laboratory on one eye and another scleral lens design made by a different laboratory on the other eye. It is definitely not one size and one design fits all.
What must be appreciated is that every patient is different and unique. Some ocular conditions are extremely complicated and may require a great deal of time to arrive at a successful conclusion. In addition, the laboratory costs of scleral lenses can vary widely due to materials and technology used in manufacturing these lenses. Therefore, the cost of the scleral lenses and the professional fees charged can vary for these reasons. What is most important is to find a doctor willing to spend whatever time is required to make sure that a successful outcome is achieved. Scleral lenses are a life changing technology that has positively affected the lives of hundreds of thousands of patients.