The document discusses scleral lenses, which are large diameter rigid contact lenses that rest on the sclera and are used primarily to improve vision in patients with corneal diseases. It covers the design, fitting processes, indications for use, adverse events, and patient compliance, highlighting their advantages and challenges. Scleral lenses are particularly noted for their ability to protect the cornea, provide cosmetic solutions, and deliver medication, although their high cost and fitting difficulties limit their popularity.

1. BY:
NOORMUNIRAHBINTI AWANG ABU BAKAR
OPTOMETRIST
MOC: O-0869
SCLERAL LENS

2. OUTLINES
Scleral Lens
Terminology
Anatomy
History
Indications
Design
Lens fitting
Adverse events
Patient compliance
Future hope

3. Scleral Lens
Also known as: Haptic lens
‘haptic’ = se nse o f to uch
A large diameter rigid contact lens that cover the
entire surface & rest on sclera.
 Diameter: 15.0mm to 25.0mm
Minimum or no contact on the cornea

4. Terminology

5. Ocular Anterior Anatomy
• Average corneal diameter
is 11.8mm
•The maximum diameter a
scleral lens can have is
24mm

6. History

7. When it starts?
Scleral lens is used to fit on corneal diseases
(irregular corneas)
Two forms of manufacturing lens
(a) Spin cast - mold
(b) Lathe cut – custom made
Scleral lenses are lathe cut
 High cost making it unpopular

8. Why is Scleral Lens not popular?
 Expensive
 Large lens diameter
 Difficult to fit
 Fragile
 Lack of expertise to fit
 Complications when patient wear it overnight

9. Indications

10. Indications
1. Vision Improvement
 Mainly for corneal ectasia cases
 Primary : Keratoconus, keratoglobus, PMD
 Secondary : Post refractive surgery (LASIK,LASEK, PRK)
 Other conditions: post trauma, corneal scar due to
infection
 To restore and improve vision

11. Indications
2. Corneal protection
 In 2 conditions:
 Severe ocular disease (Sjogren, Steven Johnson, Graft versus
host dx)
 Incomplete lid closure (eyelid coloboma, ectropion,
exophthalmos, nerve palsies)
 Help by reducing corneal exposure to air (not to close the
eye)
 Benefits:
 To relieve symptoms of pain & discomfort
 Keep ocular surface moist in severe dry eyes by fluid reservoir
retention
 Slow the progression of corneal disease and delay the need for
surgery
 Decrease risk of scarring

12. Indications
3. Cosmetic
 In prosthetic eye (not widely use in Malaysia due to its cost)
 Full ocular prostheses
 Partially prostheses
 Use on: aniridia (reduce glaring), albinism,
trauma,nanophthalmos
4. Sport
 More secured – reduce risk of loss
 Provides stable vision and comfort

13. Indications
5. Drug delivery
 Scleral lens has tear reservoir
 Instill drug onto bowl of scleral lens
 RGP is not suitable for drug delivery, due to lens movement
5. Normal eyes
 Very common in other country
 Corneal lens cannot fit well
 It gives less complication

14. Design of scleral lens

15. Design of scleral lens
1. Optical zone
 Minimal/not contact with cornea (RGP: contact)
 Large size (RGP: smaller)
 Give optical effect
 Surface:
 Anterior surface: Aspheric design to reduce photophobia and aberration
 Posterior surface: Same shape as cornea
 Sagittal height of scleral lens is higher than RGP sagittal height
 Available in toric (but not available in Malaysia)

16. Design of scleral lens
2. Transitional zone
 Only scleral lens has transitional zone
 Connect sclera and sclera
 It set the sagittal height
 Changing sagittal height means change the transitional zone (flatter or
steeper)
 Depends on the shape of the sclera
 The transitional zone for small diameter ScCL may rest on limbal
area, not for larger diameter ScCL.
 Range of transition zone: 0.5mm to 2.0mm.

17. Design of scleral lens
2. Transitional zone
Scle ralshape
 Referring to cornea, limbus and sclera
 Affect the ScCL fitting
 Involve the transitional and landing zone
 The sclera can be evaluated using:
 Pentacam
 Anterior segment OCT
 Type of limbal profile:
1. Gradual convex
2. Gradual tangential (common)
3. Convex concave
4. Marked convex (common)
5. Marked tangential
1 2 3 4 5

18. Design of scleral lens
2. Transitional zone
Lim balang le and scle ralang le
 What: This is angle between iris & cornea
 Temporal angle larger than nasal angle (T≠N)
 ScCL easily decentred to the nasal
 However, it would not affect vision because the optical zone is large.

19. Design of scleral lens
3. Landing zone (Haptic zone)
 Area of ScCL that rest on the sclera
 Important to know:
 Size of landing zone
 Angle of landing zone
 Landing zone as back surface toric: change the thickness at one
side
 Can make peripheral toric by thinning the edge like prism ballast.
 Increase diameter of landing zone, make it more comfortable to wear
as less movement produced

20. Scleral lens fitting

21. Scleral lens fitting
4 steps approach

22. Scleral lens fitting
1. Optical/Clearance zone diameter
Optical zone important to provide good optical
outcome and corneal clearance
Clearance zone = optical zone + transition zone
Usually 0.2mm larger than HVID
Size depends on lens designs
Can be altered to improve corneal and limbal
clearance

23. Scleral lens fitting-Lens insertion

24. Scleral lens fitting
2. Central and limbal clearance
Up to 600 microns of corneal clearance can be easily
achieved if needed centrally.
Clearance of 200–300 microns is usually considered
sufficient, but this can easily go up to 500 microns if desired
with the end stage large diameter lenses.
The terms “flat” and “steep” are substituted with increase or
decrease in sagittal height instead.
 Increasing the sagittal height of the lens causes the lens to “lift” off the eye,
increasing the clearance or vault of the lens.
Sagittal depth differs with the condition:
 Ectasia needs larger than post-corneal grafts
 Ocular surface disease management requires large sagittal height

25. Scleral lens fitting
 Central and limbal clearance evaluation
 Start with low sagittal height and gradually increase height to desired clearance
 A green fluorescein pattern will be visible.
 Use a thin optical section with brightest illumination setting at a 45 degree angle
 If CCT known, compare corneal thickness to tear layer thickness to estimate clearance
 If CCT not know, assume a 530micron central cornea and 650 micron at periphery
(Doughty 2000) and compare to the slit.

26. Scleral lens fitting
Limbal clearance
 Complete and generous limbal clearance is necessary to
ensure tear circulation and prevent erosive damage to the
limbal epithelial cells.
 If very little fluorescein observed in the limbal area of the lens,
then the lens is too small and should select a larger diameter.
Scleral lens with inadequate limbal clearance
Scleral lens with complete limbal
clearance

27. Scleral lens fitting
3. Landing zone alignment
 The landing zone should rest evenly on the scleral conjunctiva with the
edge appearing just above the conjunctival epithelium.
 The lens should not move with blinking. Moving lens cause discomfort
to the patient. Can correct by tightening the landing zone.
 No fluorescein will be visible under a well-fit landing zone except at the
edge.
 A ring of bearing on the inner part of the landing zone indicates a flat landing
zone
 A ring of bearing on the outer part of the landing zone indicates a steep
landing zone
 Increasing the size of the landing zone relieves pressure if needed.

28. Scleral lens fitting
4. Lens edge lift
 Assess lens edge lift after 30 minutes of lens installation during fitting
process.
 Also assess lens edge after 3-4 hours of lens wear.
 Too much edge lift :
 Cause lens awareness and discomfort
 Action: Decrease the edge lift by changing the landing zone angle or by choosing
a smaller landing zone radius of curvature.
 Low edge lifts:
 Leave a full or partial impingement ring on the conjunctiva after lens removal
 Two easy methods
 Observe the edge lift with white light & how much it “sinks” into the
conjunctiva
 Push-in method -preferred if the lens showed some mobility
 Remove lens and evaluate surface with fluorescein staining

29. Adverse events

30. Adverse events

31. Adverse events

32. Patient compliance
Patient compliance:
1. Hygiene
 Cleaning kit same as RGP, must using protein cleaner.
 If deposit on lens present, first see Giant papillary
Conjunctivitis.
1. Sleeping with Scleral CL
 Pt love to wear lens overnight.
 Advice patient not to wear scleral lens extendedly to avoid
complications.

33. Future Scleral Lens
Would you consider scleral lens in future?
YES.
 Good alternative for irregular cornea
 Less complications
 Better corneal health

34. Future Scleral Lens

35. Thank You