Quality-of-Life Improvement After Scleral Lens Fitting in Patients With Keratoconus

Size Matters: A Comparative Study on Midday Fogging and Lens Settling in Patients With Keratoconus Wearing Mini-Scleral Lenses With Two Different Diameters

PURPOSE

The objective of this study was to compare the changes in postlens fluid optical density, timing and quantity of lens settling, and the clinical performance between two different mini-scleral lenses.

METHODS

Seventeen eyes of 10 patients with keratoconus were fitted with a 15-mm mini-scleral lens (AirKone Scleral Lenses; Laboratoire LCS, Normandy, France), and 15 eyes of 10 patients with keratoconus were fitted with 16.5-mm mini-scleral lenses (Misa Lenses; Microlens Contactlens Technology, Arnhem, The Netherlands). The lens fit was evaluated with biomicroscopy and anterior segment optical coherence tomography (AS-OCT). At 0, 2, and 4 hrs, corneal clearances were measured with AS-OCT, and optical density measurements were made by Scheimpflug tomography. High-contrast visual acuity (HCVA) and contrast sensitivity (CS) were assessed at each time point. At the end of the 4th hour, participants' comfort, visual quality, and general satisfaction were evaluated with a 5-point Likert scale and 100-mm Visual Analog Scale (VAS) scale.

RESULTS

The mean age (24.4 ± 5.4 vs. 21.7 ± 4.5, P = 0.145) and best spectacle-corrected HCVA (0.36 ± 0.15 vs. 0.35 ± 0.20, P = 0.984) were similar in both groups. The mean Snellen HCVA significantly improved with dispensing both mini-scleral lenses and remained stable at 4 hrs in both groups. In comparison, CS significantly decreased at 4 hrs in both groups ( P = 0.02). Both groups' optical density significantly increased over time ( P = 0.003). In the 15-mm mini-scleral lens group, the settling amount was 62.2 ± 11.9 μm (62.6%) and 99.5 ± 14.2 μm (100%) at 2 and 4 hrs, respectively; in the 16.5-mm mini-scleral lens group, it was 46.4 ± 22.3 μm (56.4%) and 82.1 ± 37.3 μm (100%) at 2 and 4 hrs, respectively. More than 50% of settling occurred in the first 2 hrs in both groups. No significant difference was observed between the two groups with regard to visual acuity, CS, optical density, and total settling amount at 4 hrs ( P > 0.05). Patient in the 15-mm mini-scleral lens group scored higher in comfort (4.65 ± 0.7 vs. 3.60 ± 0.9), visual quality (4.76 ± 0.4 vs. 3.73 ± 0.7), and overall satisfaction (95.7 ± 6.0 vs. 65.3 ± 20.3) ( P < 0.0001).

CONCLUSION

Patients reported a heightened level of contentment with the smaller-diameter lens; however, it is crucial to emphasize that both diameter scleral lenses showcase comparable clinical efficacy, midday fogging, and settling.

Scleral Contact Lens Benefits for Myopic Patients With Regular Corneas: A Prospective Randomized Study

OBJECTIVES

To evaluate the impact of scleral contact lens (SL) wear on the visual quality and the ocular surface wettability in myopic patients with regular corneas.

METHODS

This prospective, randomized, controlled study enrolled a total of 80 myopes with regular corneas. Subjects were randomly allocated to wear SL or rigid corneal lens (RCL) for 3 months. The objective optical quality parameters were detected using the Optical Quality Analysis System-II, and the ocular surface wettability was assessed using the Keratograph 5M noninvasive ocular surface analyzer. The National Eye Institute 25-Item Visual Function Questionnaire and Ocular Surface Disease Index questionnaire were performed.

RESULTS

Both SL and RCL wear could obtain good best-corrected visual acuity. Strehl ratio, modulation transfer function cutoff frequency, objective scattering index, and Optical Quality Analysis System values (Optical Quality Analysis System values at 100%, 20%, and 9% contrasts) in the SL group significantly improved from baseline to the third month (both P <0.05), but not in the RCL group. At the third month, tear meniscus height and noninvasive tear break-up time showed a significant increase in the SL wearers from baseline (both P <0.05), but exhibited no significant changes in the RCL group. At the third month, SL wearers had significantly higher noninvasive tear break-up time compared with RCL wearers ( P <0.05). Besides, after 3-month SL wear, the National Eye Institute 25-Item Visual Function Questionnaire score and the Ocular Surface Disease Index score both remarkably improved from baseline (both P <0.05).

CONCLUSION

Short-term SL wear could provide satisfactory visual quality, ocular comfort, and stable tear film for myopic patients.

Long-Term Effectiveness of Scleral Lens Treatment in the Management of Keratoconus: A Systematic Review

This systematic review evaluates the long-term effectiveness of scleral lenses in improving visual outcomes, patient satisfaction, and safety in patients with keratoconus. A systematic search of six databases (PubMed, Embase, Web of Science, Scopus, Cochrane Library, and MEDLINE) was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria included studies with more than or equal to three months of follow-up, included a minimum of 20 keratoconus patients, published after year 2020 and outcomes reporting visual acuity, comfort or quality of life. Methodological quality was assessed using the Newcastle-Ottawa Scale and Murad et al. case series tool. Five studies (463 eyes) met the inclusion criteria. Scleral lenses consistently improved best-corrected visual acuity (BCVA) across studies, with visual gains from baseline logMAR 0.50-0.53 to post-treatment logMAR 0.08-0.09. Significant improvements in vision-related quality of life (National Eye Institute Visual Function Questionnaire (NEI-VFQ) scores) were observed in validated assessments. Complications were infrequently reported but included lens handling issues (10.4%-63%), fogging (58%), and physiological events (e.g., corneal epitheliopathy). Long-term follow-up indicated that 14.6% of the patients experienced worsening visual acuity due to keratoconus progression. Methodological quality was variable, with limitations including variable outcome reporting and limited follow-up duration.  Scleral lenses provide substantial and sustained improvements in visual acuity and quality of life for keratoconus patients, particularly those with advanced disease. However, the evidence is limited by methodological shortcomings and a lack of long-term controlled studies. Future research should prioritise randomised trials with standardised reporting and longer follow-up to better assess complications and durability of outcomes.

Impact of Scleral Lenses on Visual Acuity and Ocular Aberrations in Corneal Ectasia: A Comprehensive Review

Corneal ectasias, including keratoconus (KC), pellucid marginal degeneration (PMD), and post-LASIK ectasia, poses significant visual rehabilitation challenges due to the resultant irregular astigmatism, myopia, and higher-order aberrations (HOAs). These conditions often resist traditional corrective methods, necessitating advanced optical solutions. Scleral lenses (SLs) have emerged as a primary non-surgical option for managing these complex corneal irregularities. SLs form a smooth optical interface by forming a tear-filled chamber between the lens and the cornea, effectively mitigating HOAs and improving both high-contrast and low-contrast visual acuity (VA). This review evaluates the efficacy of SLs in enhancing VA and reducing aberrations in patients with corneal ectasia. It also explores the technological advancements in SLs, such as profilometry and wavefront-guided systems, which enable more precise and customized lens fittings by accurately mapping the eye's surface and addressing specific visual aberrations. The current body of evidence demonstrates that custom SLs significantly improve visual outcomes across various ectatic conditions, offering superior performance compared to conventional correction methods. However, challenges such as the complexity of fitting and the need for precise alignment remain. Ongoing innovations in SL technology and customization are likely to further enhance their clinical utility, solidifying their role as an indispensable tool in the management of corneal ectasias.

[Effect of keratoplasty on the quality of life of keratoconus patients]

Corneal deformations caused by keratoconus produce high levels of optical aberration (OA). Despite appropriate optical correction, these alter the quality of vision and diminish the patient's quality of life, especially since the affected population is predominantly young and of working age. When thinning is too severe or corneal transparency too impaired, a corneal transplant may be considered. In this study, we compare the quality of life of patients with keratoconus in the early (stages 1 and 2) or advanced (stages 3 and 4) stages of the Krumeich classification, as well as patients who have had keratoconus treated by keratoplasty. Quality of life was assessed using the NEI-VFQ 25 questionnaire, the most widely used for keratoconus. An aberrometric examination (OQAS®; HD Analyser, Visiometrics, Terrassa, Spain) was also performed to assess patients' quality of vision. Our results show that keratoplasty provides an improvement in quality of life compared with advanced-stage keratoconus in the areas of distance (p=0.0083) and near vision (p=0.029) activities. This improvement also applies to Best-Corrected Visual Acuity (BCVA) (p=0.032) and transparency (OSI) (p=0.049). Our study shows that keratoplasty improves corneal transparency, and it is interesting to note that it improves patients' quality of life over the long term.

Evidence of Contact Lenses for Vision Rehabilitation in Corneal Diseases: A Review

OBJECTIVES

To evaluate the efficacy and safety of contact lenses (CL) as a therapeutic option for patients affected by a corneal disease and to determinate which is the best lens modality for each disease.

METHODS

A literature review using PubMed was performed. All relevant articles published during the last 15 years have been included.

RESULTS

Various studies point to CL as the best therapeutic option for some corneal diseases and even as an alternative to surgery in some cases. After fitting, patients show an improvement in their functional vision and quality of life, in some cases being able to drive or work again.

CONCLUSIONS

There is a lack of scientific evidence to determine which lens modality is suitable for each corneal pathology. Currently, according to this review, the reason for choosing between the different options depends on the severity of symptoms, and it is worth mentioning that scleral lenses seem to be the best option in advanced stages of disease. However, the expertise of professionals is also an important factor at the time of choosing a particular CL modality. Standardized criteria are still necessary for correct selection of lens modality for a correct management of the disease.

TFOS Lifestyle: Impact of contact lenses on the ocular surface

Several lifestyle choices made by contact lens wearers can have adverse consequences on ocular health. These include being non-adherent to contact lens care, sleeping in lenses, ill-advised purchasing options, not seeing an eyecare professional for regular aftercare visits, wearing lenses when feeling unwell, wearing lenses too soon after various forms of ophthalmic surgery, and wearing lenses when engaged in risky behaviors (e.g., when using tobacco, alcohol or recreational drugs). Those with a pre-existing compromised ocular surface may find that contact lens wear exacerbates ocular disease morbidity. Conversely, contact lenses may have various therapeutic benefits. The coronavirus disease-2019 (COVID-19) pandemic impinged upon the lifestyle of contact lens wearers, introducing challenges such as mask-associated dry eye, contact lens discomfort with increased use of digital devices, inadvertent exposure to hand sanitizers, and reduced use of lenses. Wearing contact lenses in challenging environments, such as in the presence of dust and noxious chemicals, or where there is the possibility of ocular trauma (e.g., sport or working with tools) can be problematic, although in some instances lenses can be protective. Contact lenses can be worn for sport, theatre, at high altitude, driving at night, in the military and in space, and special considerations are required when prescribing in such situations to ensure successful outcomes. A systematic review and meta-analysis, incorporated within the review, identified that the influence of lifestyle factors on soft contact lens dropout remains poorly understood, and is an area in need of further research. Overall, this report investigated lifestyle-related choices made by clinicians and contact lens wearers and discovered that when appropriate lifestyle choices are made, contact lens wear can enhance the quality of life of wearers.

Vision-Related Quality of Life in Patients With Keratoconus: A Nationwide Study in Saudi Arabia

PURPOSE

To evaluate the impact of keratoconus (KC) on quality of life and assess visual performance via the National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ-25) in the Saudi population.

PATIENTS AND METHODS

A descriptive cross-sectional study was conducted using the NEI-VFQ-25 to evaluate the vision-related quality of life among previously diagnosed KC patients. An online questionnaire was used to distribute the validated survey through various social media networks. The data were extracted, reviewed, coded, and then analyzed using the Statistical Package for Social Sciences (SPSS) version 26 (IBM Corp., Armonk, NY).

RESULTS

A total of 429 patients completed the questionnaire. The overall score of NEI-VFQ-25 was 58.6 (SD: 18.0). The visual performance was worse in females than males (with a score of 55.1), especially in patients aged less than 30 years. Visual function improved with the use of low-vision aids (spectacles and contact lenses) compared with those who did not use them.

CONCLUSION

Our study confirms the functional impairment in patients with KC, especially in females, patients aged less than 30 years, and those with no low-vision aids. Moreover, it suggests a significant role of these vision aids (spectacles and contact lenses) in improving the quality of life in patients with KC.

Current Trends in Scleral Lens Prescription, Management, and Evaluation

OBJECTIVES

To report current trends in scleral contact lens prescription and management, including lens designs prescribed, care products recommended, and procedures performed during routine scleral lens (SL) evaluation.

METHODS

An online survey was designed by the Scleral Lenses in Current Ophthalmic Practice Evaluation study team and administered to eye care practitioners attending a specialty contact lens meeting. The survey was available from November 8, 2019, through March 31, 2020. Participants' demographic data were collected, along with information on lens diameters, landing zone (LZ) designs, recommended care products, and components of routine SL evaluation.

RESULTS

In total, 715 participants responded to at least one of the survey items of interest. Most lenses prescribed (63%) were 16 mm or more in diameter. Lenses with toric LZs were the most frequently prescribed (48%), followed by spherical (40%), quadrant-specific (8%), and impression-based or image-based designs (3%). Most participants (61%) recommended hydrogen peroxide products for lens care. Nonpreserved saline in a single-use vial was most frequently recommended to fill the bowl of the lens before application. Intraocular pressure was measured during SL evaluation by 45% of participants; 38% of participants routinely measured corneal thickness.

CONCLUSIONS

Practitioners increasingly are prescribing SLs with advanced LZ designs. Most practitioners recommend hydrogen peroxide-based disinfection systems and single-use vials of nonpreserved saline for lens care and application. Because differences in components of routine SL evaluations were reported, clinicians may benefit from reaching a consensus on essential components of SL evaluation.

From bench to clinic: Emerging therapies for corneal scarring

Corneal diseases are one of the leading causes of moderate-to-severe visual impairment and blindness worldwide, after glaucoma, cataract, and retinal disease in overall importance. Given its tendency to affect people at a younger age than other blinding conditions such as cataract and glaucoma, corneal scarring poses a huge burden both on the individuals and society. Furthermore, corneal scarring and fibrosis disproportionately affects people in poorer and remote areas, making it a significant ophthalmic public health problem. Traditional medical strategies, such as topical corticosteroids, are not effective in preventing fibrosis or scars. Corneal transplantation, the only effective sight-restoring treatment for corneal scars, is curbed by challenges including a severe shortage of tissue, graft rejection, secondary conditions, cultural barriers, the lack of well-trained surgeons, operating rooms, and well-equipped infrastructures. Thanks to tremendous research efforts, emerging therapeutic options including gene therapy, protein therapy, cell therapy and novel molecules are in development to prevent the progression of corneal scarring and compliment the surgical options currently available for treating established corneal scars in clinics. In this article, we summarise the most relevant preclinical and clinical studies on emerging therapies for corneal scarring in recent years, showing how these approaches may prevent scarring in its early development.

Comparison of corneal tomography using a novel swept-source optical coherence tomographer and rotating Scheimpflug system in normal and keratoconus eyes: repeatability and agreement analysis

Background

To determine the repeatability and agreement using corneal tomography of a swept-source optical coherence tomographer (SS-OCT) compared to a rotating Scheimpflug camera (RSC) in normal eyes and keratoconus (KC) eyes.

Methods

This prospective repeatability analysis was performed at the Department of Ophthalmology of University Hospital Carl Gustav Carus, Dresden, Germany. Forty-three normal and 57 KC eyes were enrolled in the study. Three consecutive measurements were performed by the same operator on each device. Corneal parameters of anterior and posterior corneal surface, such as simulated keratometry (SimK), as well as central and thinnest corneal thickness were evaluated. Repeatability and agreement were assessed by using the coefficient of repeatability and Bland-Altman analysis.

Results

The repeatability of anterior corneal parameters was comparable between RSC and SS-OCT in normal eyes (repeatability < 0.5 D). Repeatability was increased in mild and moderate KC for all parameters using both devices. In moderate KC, repeatability of Kmax was 1.33 D and 0.78 D for RSC and SS-OCT, respectively. Repeatability of posterior corneal parameters was consistently better for SS-OCT. Significant offsets and wide ranges of limits of agreement were found between the devices for SimK and corneal thickness values.

Conclusions

SS-OCT showed highly repeatable measurements of anterior and posterior corneal parameters in normal and KC eyes. Compared to RSC, the SS-OCT had a better repeatability of anterior corneal parameters in mild and moderate KC as well as posterior corneal parameters in all groups. Both devices should not be used interchangeably in the diagnostic process of patients.

Trial registration NCT04251143 at Clinicaltrials.gov, registered on 12 March 2018, https://clinicaltrials.gov/ct2/show/NCT04251143?cond=Keratoconus&cntry=DE&city=Dresden&draw=2&rank=1

Benefits of Scleral Lens in the Management of Irregular Corneas and Dry Eye Syndrome After Refractive Surgery

OBJECTIVES

To evaluate the utility of the SPOT scleral lens (Oxygen Permeable Scleral Lens of Thonon; LAO, Thonon-les-Bains, France) in the management of the irregular cornea after refractive surgery.

METHOD

We included 19 patients (35 eyes) with irregular corneas after refractive surgery. Patients were fitted with scleral lenses after the failure of conventional contact lenses adaptation. The ophthalmologic examination included measurement of best-corrected visual acuity (BCVA), slitlamp examination, and evaluation of ocular aberrations (Objective Scattering Index [OSI] and higher-order aberration [HOA]).

RESULT

Scleral lens fitting increases significantly the BCVA from 0.33 (±0.25) to 0.08 (±0.13) LogMAR (P<0.001). There was also a significant decrease in Ocular Surface Disease Index from 66.2±22.8 to 42.4±18.9 (P<0.001). Ocular aberrations (OAs) are also significantly reduced by the scleral lenses, the mean OSI goes from 7.2 (±4.2) to 3.0 (±1.8) (P<0.001), OA from 2.58 (±1.34) to 1.98 μm (±2.31) (P=0.035), and HOA from 0.94 (±0.51) to 0.48 (±0.23) (P=0.0018).

CONCLUSION

Fitting with scleral lenses improves patients' optical and ocular surface problems. Scleral lens restores BCVA and the quality of life. Fitting with scleral lenses is an alternative to further surgery on these fragile eyes and is sometimes the only viable treatment option for the patient.

Role of therapeutic contact lenses in management of corneal disease

PURPOSE OF REVIEW

The current review highlights areas of innovation and research in the use of contact lenses in the treatment of corneal ectasia and ocular surface disease.

RECENT FINDINGS

A series of academic reports were published by a committee of experts reviewing evidence-based practice patterns of contact lens use. There continues to be active research in the use of contact lenses in the management of keratoconus, including mini-scleral lenses, custom impression-based scleral lenses and wavefront-guided scleral lenses. Recent reports on contact lenses for ocular surface disease were primarily reviews, retrospective case reports or case series, with publications on contact lens use in corneal epithelial defects, graft-vs.-host disease, limbal stem cell deficiency and neurotrophic keratitis. There are recent publications on advances in drug-eluting contact lenses.

SUMMARY

Corneal specialists should be aware of current advances in the field of contact lens expanding their use in corneal ectasia and ocular surface disease.

How Can We Best Measure the Performance of Scleral Lenses? Current Insights

Scleral lenses (SLs) present several unique advantageous characteristics for patients. As these lenses are mainly fitted in severely diseased eyes, a thorough evaluation of the ocular surface before and after SL fitting and the on-eye SL fitting evaluation are essential and help minimize potential physiological complications. This review will explore the current and emerging techniques and instrumentation to best measure SL performance ensuring optimal lens fitting, visual quality, comfort and physiological responses, highlighting some potential complications and follow-up recommendations. A single physician could perform the great majority of evaluations. Still, the authors consider that the assessment of SL fitting should be a collaborative and multidisciplinary job, involving contact lens practitioners, ophthalmologists and the industry. This publication has reviewed the most up-to-date work and listed the most used techniques; however, the authors encourage the development of more evidence-based recommendations for SL clinical practice.