Scleral Lenses & Epitheliopathy
cause or solution?
Gregory W. DeNaeyer OD FAAO FSLS
Scleral contact lenses have become a popular lens of choice for managing corneal irregularity and ocular surface disease. Even though there has been a flurry of studies and papers that have looked at the use of scleral lenses, there is still much that we don’t know. In fact, one of the most intriguing questions that remain regarding scleral lens use is: What affects (short-term and long-term) do using these devices have on the cornea? And more specifically: What affect does wearing scleral lenses have on the corneal epithelium and topography? The examples described below are documented cases of secondary epitheliopathy from wear of a scleral contact lens.
A 56-year-old male with keratoglobus and previous penetrating keratoplasty of his right eye was refit into an 18.4mm scleral contact lens because of inadequate centration of his corneal (R)GP lens. The patient’s right eye had a steep but clear graft (figure 1). The dispensed scleral lens was noted to have central clearance and overall haptic alignment, providing the patient with 20/25 vision. Corneal epitheliopathy was observed in his right cornea after 5 weeks of wear (figure 2). The patient continues to be successful with his scleral lens, and his epitheliopathy has remained unchanged.
Figure 1 + 2
A 67-year-old male with keratoconus and previous penetrating keratoplasty of his left eye was refit into 18mm scleral contact lens secondary to a poor fitting corneal (R)GP (figure 3). The patient’s cornea had mild central fibrosis and epitheliopathy before using the scleral lens (figure 4). The final scleral lens was noted to have 200 microns of central vault, although there was mid-peripheral alignment nasally. The lens haptic fit without excessive compression. At a five-month follow-up appointment, his vision with the scleral contact lens was 20/40. Slit lamp exam revealed increased central fibrosis and epitheliopathy (figures 5 and 6).
Figure 3 + 4
Figure 5 + 6
A 53-year-old female keratoconus patient was fit with scleral contact lenses. She was previously uncorrected, having been unsuccessful with corneal (R)GP lenses 15 years earlier. The patient was successfully fit with 18mm scleral lenses (figure 7). Epitheliopathy of the right eye was noted approximately 6 weeks after the initial dispense and has remained unchanged (figure 8).
Figure 7 + 8
Scleral lenses are typically used to manage severe epitheliopathy, but in some cases scleral lenses can actually cause mild-to-moderate epithelial changes weeks after wear despite having a successful fit. Scleral lens-induced epitheliopathy appears to be a relatively benign event that doesn’t improve during active scleral lens wear. Patients that develop it are typically asymptomatic and maintain good vision1. Superficial corneal fibrosis may accompany scleral lens-induced epitheliopathy in patients with a corneal graft.
Why does this happen? It may result from the negative pressure that the epithelium is exposed to during lens wear and lens removal. Hopefully, future studies will help us better understand this secondary complication.
Greg DeNaeyer is a graduate of The Ohio State University College of Optometry. He completed a hospital based residency at the Columbus VA Medical Center. Dr. DeNaeyer practices at Arena Eye Surgeons with an emphasis on specialty contact lenses.
Dr. DeNaeyer was a co-founder and is the past president of the Scleral Lens Education Society and is a Fellow of the American Academy of Optometry. He is a contributing editor for Contact Lens Spectrum and a contributor to Review of Cornea and Contact Lenses and Optometric Management. Dr. DeNaeyer has lectured internationally on specialty contact lenses and was the 2012 GPLI practitioner of the year.
Currently his primary research is focused on scleral lens design.