Why the records matter
Scleral lens fitting is iterative. In a multinational practitioner survey, fits took a mean of 2.4 lenses per eye over 3.8 visits, with ranges up to 16 lenses and 18 visits.[1] Good referral data won’t remove that process, but it prevents repeat testing, avoids designing around unknown pathology, and gives the fitter a baseline to measure against.
The checklist
1. Reason for referral and goal
- The question you want answered: visual rehabilitation, surface protection, or both
- The patient’s own functional goal (driving, work, reading, comfort)
- Any time pressure (licensing, upcoming surgery, occupational requirements)
2. Diagnosis and laterality
- Primary diagnosis with ICD-10 codes, per eye
- Secondary ocular diagnoses (glaucoma or suspect, AMD, diabetic retinopathy, amblyopia)
3. Refraction and acuity
- Current manifest refraction and spectacle BCVA, per eye, dated
- BCVA in the patient’s current contact lens, if any
- Pinhole or potential acuity if you measured it
4. Topography or tomography, with dates
- The most recent scan, plus earlier scans if you have them
- Whether progression has been documented, and on what criteria
- Cross-linking status: done (date, protocol, eye), planned, declined, or not evaluated
Serial imaging matters for two reasons. First, a scleral lens does not stop ectasia: in a retrospective series of 157 keratoconic eyes, 14.6% lost best-corrected scleral lens acuity, all from progression.[2] Second, tomography before and after lens wear can help distinguish lens-induced swelling from intrinsic endothelial dysfunction in a graft, which decides whether the answer is a refit or surgery.[3] In children, reliable imaging can be harder to obtain, so send whatever you have.[11]
5. Contact lens history
- Every lens type tried (soft, toric, corneal GP, piggyback, hybrid, prior scleral) with approximate dates
- Why each was stopped: decentration, discomfort, poor vision, handling, cost
- Current care products, if the patient wears lenses now
The failure mode of a corneal GP lens tells the fitter a lot about cone position, lid interaction, and tolerance.
6. Surgical history and reports
- Keratoplasty: type (PK, DALK, EK), date, surgeon, indication, suture status, rejection episodes and their treatment
- Graft data: specular microscopy and pachymetry, if available. Baseline and follow-up pachymetry and specular microscopy may be considered in post-PK scleral lens wearers.[4]
- Refractive surgery: RK, PRK, LASIK, SMILE, with dates
- Intracorneal ring segments and cross-linking
- Glaucoma surgery: trabeculectomy, tube shunt, or MIGS, with the quadrant. At one PROSE center, fitting was described as challenging in eyes with incisional glaucoma surgery.[9]
- Cataract surgery, retinal surgery, scleral buckle, strabismus surgery, and any conjunctival surgery that changes the landing zone
The age of a graft matters as well. In a long-term series of scleral lenses after PK, grafts 20 years or older showed a higher refit rate due to recurrent ectasia.[5]
7. IOP and glaucoma status
- IOP history and the tonometer used
- Glaucoma diagnosis or suspect status, and current treatment
- Baseline optic nerve documentation (OCT RNFL, disc photos, visual fields) if the patient is at risk
Whether scleral lenses raise IOP during wear is not settled. A 2026 review concluded it is too early to determine the actual impact, and that glaucoma patients or those at risk could be adversely affected in the long term.[10] Baseline nerve documentation gives everyone something to compare against. See co-managing scleral lens patients for the study details.
8. Medications
- All topical ocular medications, with the preservative in each
- Steroid regimens (especially for graft patients)
- Systemic immunosuppression and biologics
- Medications that affect tear production
Topical medications should be used before or after lens wear, and patients told to wait at least 10 minutes after drops before applying a lens.[4] In ocular surface disease, the same review recommends eliminating benzalkonium chloride-preserved drops where alternatives exist, particularly glaucoma medications.[4] Benzalkonium chloride is used in about 70% of ophthalmic formulations and is cytotoxic to corneal and conjunctival epithelium.[6] If the fitter knows the drop list, they can raise preservative-free alternatives with you.
9. Systemic history
- Neurologic disease, tremor, arthritis, or other limits on dexterity. Comorbid neurologic disease was associated with discontinuation in a veteran cohort (OR 4.6).[7]
- Diabetes and immunosuppression. These patients should be monitored closely for complications.[4] All three patients in a case series of microbial keratitis after PK in scleral lens wearers were on topical or systemic immunosuppression.[8]
- Autoimmune disease (Sjögren’s, rheumatoid arthritis), atopy, and history of SJS/TEN or GVHD
- Who can help with lens handling at home, if needed
10. Logistics
- Your preferred channel for reports (fax, secure email, EHR)
- Who manages what: for example, you continue glaucoma care; the fitter handles lens care
- Insurance details and any prior authorization you have started
A one-glance version
| Send | Why the fitter needs it |
|---|---|
| Referral question and patient goal | Sets the endpoint for the fit |
| Refraction and BCVA, dated | Baseline for visual outcome |
| Serial tomography, CXL status | Progression vs lens effect; CXL timing |
| Lens history and failure reasons | Predicts fit challenges |
| Surgical reports (graft, glaucoma, refractive) | Changes lens design and monitoring |
| Graft specular microscopy and pachymetry | Baseline for edema risk |
| IOP, glaucoma status, nerve baseline | Monitoring plan for at-risk patients |
| Medications and preservatives | Drop timing and BAK exposure |
| Neurologic, dexterity, immune status | Training plan and infection risk |
A ready-to-adapt template is on the sample referral letter page.
Common questions
Do I need to send raw tomography files, or are printouts enough?
Printouts or PDFs of the standard maps with dates are usually enough. If the fitter uses the same device platform, ask whether they prefer the exported exam so they can run their own comparison.
Should the patient stop wearing their current lenses before the consult?
Ask the fitter. Many want baseline corneal measurements without recent rigid lens wear, and their instructions differ by practice and lens type.
What if the patient has never had tomography?
Refer anyway and say so. The fitter or a cornea service can obtain it. For a suspected ectasia, a baseline scan before lens wear begins is valuable for later progression decisions.
Should I include insurance information?
Yes, if you have it. Coverage rules vary by plan, and the fitter's office will need the diagnosis codes and plan details to check what applies.