How a scleral lens treats the surface
A scleral lens vaults the cornea and limbus and lands on conjunctiva over the sclera. The reservoir behind it, filled with non-preserved saline, keeps the cornea continuously hydrated and protects it from lid shear and the environment.[1] For severely compromised or sensitive surfaces, a non-preserved, non-buffered filling solution is generally considered optimal.[1]
Ocular surface disease is a minority indication. A 2015 practitioner survey, cited in a 2018 review, found 16% of scleral lenses prescribed for ocular surface disease, 74% for corneal irregularity, and 10% for uncomplicated refractive error.[1]
Where it sits in the treatment sequence
Scleral lenses are generally not initial therapy for ocular surface disease.[1] The 2017 TFOS DEWS II report recommends therapeutic contact lenses, soft bandage or rigid scleral, at step 3.[1] They can be combined with lubricants, cyclosporine, topical steroids, punctal occlusion, autologous serum, amniotic membrane, and tarsorrhaphy to delay or prevent surgery.[1]
Bandage soft lenses are a reasonable earlier step in many cases. There is consistent evidence that bandage soft lenses, particularly silicone hydrogels, improve epithelial healing and reduce pain in persistent epithelial defects.[11]
Who to refer
A 2018 review describes three groups who may benefit:[1]
- Symptoms and signs of ocular surface disease that persist despite standard therapy.
- Signs without symptoms, typically neurotrophic eyes with reduced sensation and surface breakdown.
- Symptoms without signs, such as neuropathic pain. Some of these patients may benefit, though evidence is limited.
By condition, the review describes therapeutic use in:[1]
- Exposure keratopathy from lagophthalmos, lid malposition, facial nerve palsy, or proptosis, where it offers an alternative to tarsorrhaphy
- Neurotrophic keratopathy after herpetic disease, trigeminal surgery, or diabetes
- Limbal stem cell deficiency, with the lens vaulting and protecting the limbus
- Ocular GVHD, where keratoconjunctivitis sicca is common
- Sjögren’s syndrome with severe surface disease
- Stevens-Johnson syndrome and other cicatrizing conjunctivitis
- Persistent epithelial defects that resist conventional therapy
What the outcome data show
- Mixed OSD, tertiary center (212 patients): 115 patients completed fitting, and therapeutic goals (comfort, surface protection, or resolution of keratopathy) were met in all but 2. Acuity improved from 0.32 to 0.12 logMAR. The most common indications were undifferentiated ocular surface disease, exposure keratopathy, and neurotrophic keratopathy. Patients had tried an average of 3.2 other interventions first. Fitting averaged 3 visits and 1.4 lenses per eye.[2]
- Ocular GVHD, retrospective (62 eyes, 31 patients): median acuity improved from 20/40 in spectacles to 20/25 in mini-scleral lenses, median OSDI from 73 to 27, and median Oxford staining grade from 3 to 1. 22.6% of patients discontinued.[5]
- Intractable OSD, prospective single-arm trial (21 eyes): after 12 weeks, BCVA improved from 0.77 to 0.27 logMAR, OSDI from 67.89 to 34.69, and the share of eyes with high-grade corneal staining fell from 61.90% to 14.29%. No adverse effects were observed.[6] The cohort included persistent epithelial defects, GVHD, SJS, and severe dry eye.
- PROSE, five-year follow-up (121 patients): continued wear was 64% for ocular surface disease versus 84% for distorted cornea.[3]
- PROSE, Canadian center (78 patients, 126 eyes): in the ocular surface disease group, limbal stem cell deficiency and GVHD were the most common diagnoses. Mean acuity gain was 0.29 logMAR in that group versus 0.52 logMAR in distorted corneas.[4]
These are mostly single-center series without control groups, from experienced centers.
Dry eye without corneal involvement
A 2024 review found the evidence for scleral lenses in dry eye without corneal irregularity or other surface disease to be sparse.[7] It identifies increased midday fogging, poor wettability, and variable patient satisfaction as challenges in this group.[7] Lid disease is also common: in habitual scleral wearers, meibomian glands with no expressible meibum were more frequent in eyes with ocular surface disease than corneal irregularity (39% vs 11%).[10]
Because patients with surface disease are at increased risk of poor lens wetting and fogging later in the day, a review advises monitoring them closely for meibomian gland disease and treating it aggressively.[1]
PROSE
PROSE (BostonSight, Needham, MA) uses custom-designed, fluid-ventilated gas-permeable scleral devices; older literature calls the device the Boston Scleral Lens.[8][9] Much of the long-term outcome data for severe ocular surface disease comes from PROSE centers. Referral to a PROSE center or to an experienced scleral lens practice are both reasonable; what matters most is the fitter’s experience with severe surface disease and their ability to see the patient often in the early weeks.
Persistent epithelial defects and extended wear
Overnight or continuous wear is outside routine scleral lens use and requires close medical monitoring.[1] In one review’s summary, a series of seven patients with persistent epithelial defects was treated with 24-hour PROSE wear plus daily office visits to remove, disinfect, and refill the reservoir with preservative-free saline and a fourth-generation fluoroquinolone until re-epithelialization.[1] Diabetic and immunocompromised patients and those with non-healing defects should be monitored closely for complications.[1] A case series of microbial keratitis in post-PK scleral wearers found coexisting surface disease and immunosuppression in all three.[12]
What to include in an OSD referral
- Diagnosis and staging, with photos or staining scores if you have them
- Everything tried so far, with duration and response
- Current drops and their preservatives (benzalkonium chloride is cytotoxic to the surface epithelium)[13]
- Systemic disease and immunosuppression
- Corneal sensation testing for suspected neurotrophic disease
- Lid status: lagophthalmos, MGD, prior lid surgery
The full referral checklist covers the rest.
Common questions
What is the difference between PROSE and a scleral lens?
PROSE (prosthetic replacement of the ocular surface ecosystem) is BostonSight's treatment using custom-designed, fluid-ventilated gas-permeable scleral devices. Many therapeutic fits use commercially available scleral lens designs instead. For the referring doctor, the practical questions are the same: the fitter's experience with surface disease, access, and cost.
Should I stop my patient's topical therapy when they start lens wear?
Usually not. Scleral lenses are typically used alongside other therapy. Ask the fitter about drop timing and preservatives: drops go in before or after lens wear, and BAK-preserved drops are best replaced where alternatives exist.
Is a scleral lens appropriate for a persistent epithelial defect?
It can be, but it is specialist territory. Published protocols have used continuous wear with daily office visits and a preservative-free fourth-generation fluoroquinolone in the reservoir, and close medical monitoring is essential.
Can a scleral lens help a patient with neuropathic ocular pain and a normal-looking surface?
A review suggests some of these patients may benefit, but the evidence is limited. If you refer, describe the pain workup so far and set modest expectations.