Co-managing scleral lens patients

A workable division of care

Co-management goes best when roles are written down at the start. A common split:

For graft patients, add the corneal surgeon. For PROSE or tertiary therapeutic fits, the fitting center may also handle surface disease. Settle that explicitly.

What to look for at your own visits

The patient will usually arrive wearing their lenses. A practical sequence:

1. Acuity in the lens, and with spectacles if the patient has a backup pair.
2. Lens on eye at the slit lamp, briefly: centration, debris in the reservoir, front-surface wetting, conjunctival blanching or redness at the landing zone. You don’t need to grade the fit, but note anything new.
3. Remove the lens (or have the patient do it) and examine the cornea with fluorescein: staining, edema, infiltrates, neovascularization.
4. Conjunctiva: look for staining, hyperemia, blanching marks, or tissue changes, especially if concentrated in one quadrant. Poorly fitted lenses can cause complications that may resolve with design changes, and both fit and underlying disease should be reassessed at regular intervals.^[11]
5. Lids: in a study of 49 habitual scleral wearers, upper lid wiper epitheliopathy was found in 43% of eyes, and lid margin telangiectasia was more common in ocular surface disease than corneal irregularity (61% vs 19%).^[10]
6. IOP with the lens out, and the optic nerve as indicated.

Send the fitter a short note if anything changes. The complications page lists signs and their usual causes.

Intraocular pressure: what the studies show

The concern is mechanistic. A scleral lens lands on conjunctiva overlying the sclera and may compress episcleral veins and structures around the limbus. A 2026 review summarizes this hypothesis and evidence of anterior chamber and angle changes during wear.^[6]

The measurements so far fall into two groups that should not be conflated.

IOP measured after lens removal (on the cornea, standard tonometry):

• A meta-analysis of 22 studies (830 eyes) found no significant IOP change after removal (mean difference 0.38 mmHg, p = 0.27), with high heterogeneity (I² = 78%).^[1]
• In a prospective 12-month study of 91 eyes in 16.4 mm lenses, IOP fluctuations measured after removal stayed below 1 mmHg on average.^[2]
• In 60 Chinese participants followed for three months, mean IOP varied by less than 0.3 mmHg. But 10% of eyes showed a rise of 2 mmHg or more from baseline on two consecutive visits, including the last.^[3]

IOP estimated during wear (indirect methods):

• In a randomized study of healthy adults, scleral pneumotonometry showed mean increases of 1.16 and 1.37 mmHg at 2.5 hours for 15.6 mm and 18.0 mm lenses; corneal IOP after removal was unchanged.^[4]
• In a crossover study of 31 healthy young adults (mean age 26), IOP measured with a transpalpebral tonometer through the lid rose from 11 to 16 mmHg after 16.5 mm lens application, stayed there through 8 hours, and returned to baseline after removal. A small reversible RNFL thinning was also measured. The two tonometers used agreed poorly.^[5]
• The 2026 review reads the in-wear evidence as a moderate increase, under 5 mmHg. It concludes this is unlikely to affect a healthy optic nerve but that glaucoma patients or those at risk could be adversely affected long term, and that it is too early to know.^[6]

What that means in practice: a normal post-removal IOP is reassuring about the eye without the lens, not about the eye during 12 hours of wear. For patients with glaucoma, ocular hypertension, or a suspicious nerve, structural and functional monitoring (OCT, fields) is the more informative check. The meta-analysis authors suggest daytime wear of high-Dk lenses appears physiologically safe while advising selective monitoring in high-risk patients.^[1] Glaucoma also appears over-represented in some therapeutic scleral populations: at one PROSE center, 8.5% of patients fitted had a glaucoma diagnosis.^[9]

Drops and preservatives

• Use topical medications before or after lens wear, with at least 10 minutes between drops and lens application.^[7]
• Preservative-free artificial tears can be used over the lens through the day.^[7]
• In ocular surface disease, consider eliminating benzalkonium chloride-preserved medications, particularly for glaucoma, given the available alternatives.^[7] BAK is cytotoxic to corneal and conjunctival epithelial cells, and its adverse effects are more problematic with chronic exposure.^[8]
• Tell the fitter about new drops. A preservative change can look like a lens problem, and vice versa.

Graft and surgical patients

For keratoplasty, the fitter should know the steroid regimen and any rejection history, and you or the surgeon should know the lens design and wear schedule. Monitoring for edema and rejection is the shared job. See scleral lenses and corneal transplants.

For eyes with trabeculectomy or tubes, coordinate with the glaucoma surgeon. In one PROSE center, 2 of 5 eyes with prior incisional glaucoma surgery could not be fitted successfully.^[9]

When the patient needs to be seen today

Microbial keratitis is uncommon but serious: 0.6% of eyes in a keratoconus series of 157 eyes over at least a year of wear.^[12] Risk rises with immunosuppression and coexisting surface disease, as a post-PK case series showed.^[13]

Make sure the patient knows whether to call you or the fitter first. Either is fine as long as it is agreed in advance and the other is told the same day.