Optometry AdvisorAn OD’s Guide to Managing Scleral Lens Wearers Who Have Dry Eye Disease

🎓 Expert Commentary / Peer Perspective

This expert review examines persistent visual complaints among scleral lens wearers, particularly patients with keratoconus and other corneal irregularities. The authors argue that clinicians often focus on lens fit, vault, haptic alignment, and refractive optimization while underrecognizing ocular surface disease as a contributor to reduced visual quality. Drawing on published studies and clinical experience, the review highlights the prevalence of meibomian gland dysfunction, tear-film instability, midday fogging, and surface wetting problems in scleral lens populations. Rather than presenting new clinical trial data, the article offers a practical framework for evaluating patients whose visual outcomes remain suboptimal despite apparently successful lens fitting.

Clinical Considerations

• Keratoconic patients demonstrate higher rates of meibomian gland dysfunction and gland loss than age-matched controls, potentially contributing to visual complaints independent of lens fit.
• Midday fogging reportedly affects 26% to 46% of scleral lens wearers and may result from a combination of fitting factors and ocular surface disease.
• Tear-film abnormalities can present as fluctuating vision despite appropriate lens alignment, limbal clearance, and over-refraction findings.
• The authors advocate routine use of objective ocular surface assessments, including meibography, gland expression, lid-margin evaluation, staining, and tear break-up testing.
• Polyethylene glycol surface treatments and appropriate lens-care systems may improve comfort and wettability in selected patients.
• Repeated lens modifications may fail if the underlying cause of visual symptoms is untreated dry eye disease rather than a fitting problem.

Practice Applications

• Evaluate ocular surface health routinely when assessing scleral lens wearers with persistent visual complaints.
• Recognize that poor visual quality may originate from tear-film instability even when lens fit appears satisfactory.
• Monitor for midday fogging, non-wetting surfaces, and meibomian gland dysfunction during follow-up visits.
• Discuss multimodal dry eye treatment strategies alongside lens management rather than relying solely on remakes or fit modifications.
• Review ocular surface findings longitudinally to determine whether treatment improves lens performance and patient satisfaction.