What aphakia means
The natural lens inside your eye sits behind the iris and does a large share of the eye’s focusing. Aphakia is the absence of that lens. In adults it can happen after a cataract is removed without an implant, when a lens dislocates, or when a lens has to be removed after an injury. In injury cases, surgeons sometimes remove the lens first and wait for the eye to heal before deciding about an implant.[1]
Without the natural lens, vision is very blurred, the eye loses its ability to change focus, and colors can look faded.[1] The eye needs strong focusing power from another source.
For children, where vision is still developing, see scleral lenses for children with aphakia. For people who had cataract surgery with an implant, see scleral lenses after cataract surgery.
The options for adults
There are three broad ways to replace the missing focusing power:
- Glasses. They need very strong plus lenses. Because of the optical effects of these high-power lenses, people with aphakia may be offered contact lenses or an implant as a first-line option instead.[1]
- A lens implant placed later (a secondary intraocular lens), if the eye can support one. Your surgeon decides whether that’s possible.
- Contact lenses, soft, small rigid, or scleral, chosen to suit the eye.
Where scleral lenses come in
Contact lenses for aphakia are often soft or small rigid lenses. Scleral lenses tend to be considered when the eye has other problems too, especially a cornea that’s scarred or irregular after an injury, which a soft lens can’t correct and a small rigid lens may not fit. A scleral lens vaults over the cornea and holds a layer of fluid against it, which evens out an irregular front surface.
What small studies show:
- Injury with an irregular cornea. A case series of 8 eyes with aphakia after injury, plus severe damage to the iris and cornea, that couldn’t be corrected with standard rigid lenses were fitted with mini-scleral lenses. Average vision with the lens was far better than with glasses, comfortable wear averaged 11.6 hours a day, the only lens-related problem was mild redness and irritation in 2 patients, and all were comfortable handling their lenses.[2]
- After open-globe injury. At one hospital, 29 patients evaluated for contact lenses after an open-globe injury were reviewed; aphakia was the reason for fitting in 13 of them. Vision improved with contact lenses in 28 of 29, using several lens types, of which scleral lenses were a small share.[3]
- Contact lens versus implant. A review of 42 eyes that lost their lens to injury found that both contact lenses and implants significantly improved vision, with no significant difference between the groups.[4] That study didn’t single out scleral lenses.
These are small, single-center studies, mostly of injured eyes. They suggest scleral lenses can work well for some adults with aphakia, not that they’re the right choice for everyone.
What wearers say
Wearers with aphakia are a small group, but those who describe it say a single scleral lens gave them much better vision than glasses or soft lenses had, with reading glasses for close work. As with any scleral lens, the early weeks of learning to insert and remove the lens are the hardest part.
Paying for lenses
Coverage varies. Federal Medicare rules exclude most glasses and contact lenses, but list exceptions that include prosthetic lenses for beneficiaries who lack the natural lens and weren’t given an implant.[5] See Medicare and scleral lenses and medically necessary contact lenses, and ask your plan what it covers.
What to ask your surgeon and fitter
- Is a secondary lens implant possible for my eye, and what are the risks?
- Which kinds of contact lens could suit my cornea, and why?
- Will my scleral lens be set for distance, near, or something in between?
- What’s my backup if I can’t wear the lens for a few days?
- How often should my eye pressure and cornea be checked?
See also corneal trauma and corneal scarring.
Common questions
Will I still need reading glasses with a scleral lens?
Usually, yes. The natural lens is what lets the eye change focus between distance and near, and that ability is lost in aphakia. Most aphakic contact lens wearers have their lens set for distance and use reading glasses for close work. Ask your fitter what makes sense for you.
Is a scleral lens better than a soft or small rigid lens for aphakia?
Not in general. The choice depends on your cornea and your eye. Soft and small rigid lenses are commonly used for aphakia. Scleral lenses tend to come in when the cornea is irregular or scarred, or other lenses haven't worked.
Should I get a lens implant instead?
That's a question for your surgeon. A secondary implant may be possible, depending on the eye. A small study of eyes that lost their lens to injury found similar vision with contact lenses and with implants. Your surgeon can explain the risks and benefits for your eye.
Does Medicare cover contact lenses for aphakia?
Federal Medicare rules exclude most glasses and contact lenses but make an exception for prosthetic lenses for people who lack the natural lens and didn't receive an implant. What that means for scleral lenses in your case is something to confirm with Medicare and your fitter.