Understanding Severe Dry Eye Disease
Dry eye disease occurs when the eyes do not produce enough tears or when tears evaporate too quickly, leaving the ocular surface unprotected. In its severe form, dry eye causes persistent discomfort, blurred vision, and damage to the corneal surface that can significantly affect daily life. Dry eye disease affects more than 16 million diagnosed adults in the United States, according to the National Eye Institute (2023). While many patients manage mild to moderate symptoms with drops and lifestyle changes, severe dry eye often requires more advanced interventions to protect the cornea and restore meaningful comfort.
Patients with severe dry eye may find that standard treatments such as artificial tears, warm compresses, and prescription eye drops provide only partial or temporary relief. The corneal surface in these patients is frequently compromised, with punctate erosions, filamentary keratitis, or persistent epithelial defects that resist healing. When the tear film is severely inadequate, the eye needs a more sustained form of protection and hydration. Scleral lenses offer a unique therapeutic approach because they create a stable fluid environment directly over the cornea, addressing the root problem of inadequate tear protection rather than simply supplementing tears from the outside.
A healthy tear film consists of three layers that work together to keep the cornea smooth, nourished, and protected. The outer lipid layer prevents evaporation, the middle aqueous layer provides hydration and nutrients, and the inner mucin layer helps tears adhere to the corneal surface. Severe dry eye can involve dysfunction in one or more of these layers. When the lipid layer is deficient, tears evaporate rapidly. When aqueous production is reduced, the eye lacks sufficient moisture. When the mucin layer is compromised, tears slide off the cornea instead of spreading evenly. Understanding which components are affected helps guide treatment decisions at Washington Eye Institute.
What Are Scleral Lenses
Scleral lenses are large-diameter gas-permeable contact lenses that rest on the sclera, the white outer shell of the eye, rather than on the cornea itself. Their diameter typically ranges from 14.5 to 24 millimeters, which is considerably larger than standard contact lenses. The rigid gas-permeable material allows oxygen to pass through to the cornea while maintaining a precise optical surface. Unlike soft contact lenses that drape directly over the cornea and conform to its shape, scleral lenses maintain a vaulted architecture that bridges entirely over the corneal surface without touching it.
The most important feature of scleral lenses for dry eye patients is the fluid reservoir that forms between the back surface of the lens and the front surface of the cornea. Before inserting the lens, the patient fills the bowl of the lens with preservative-free saline solution. Once the lens is placed on the eye, this pool of fluid remains trapped beneath the lens throughout the wearing period. The fluid reservoir continuously bathes the cornea in moisture, providing sustained hydration that no eye drop can replicate. This liquid cushion also protects damaged or fragile corneal tissue from the mechanical effects of blinking and from exposure to the external environment.
Standard soft contact lenses sit directly on the cornea and rely on the natural tear film for comfort. For patients with severe dry eye, soft lenses often worsen symptoms because they absorb the already limited tear film and increase evaporation from the ocular surface. Standard gas-permeable lenses are smaller and also rest on the cornea, which can cause irritation on a compromised corneal surface. Scleral lenses avoid both of these problems. Key differences include:
- Scleral lenses vault completely over the cornea without any corneal contact
- The fluid reservoir provides continuous hydration independent of the natural tear film
- The larger diameter and scleral landing zone provide greater stability on the eye
- Gas-permeable material resists deposit buildup better than soft lens materials
- Scleral lenses do not absorb or wick away moisture from the ocular surface
Who Benefits from Scleral Lenses
Patients who produce very little aqueous tear volume often experience the most dramatic improvement with scleral lenses. When the lacrimal glands cannot supply adequate tears, the cornea is left vulnerable to desiccation throughout the day. The scleral lens fluid reservoir essentially replaces what the lacrimal glands cannot provide, maintaining a stable layer of hydration over the cornea for the entire wearing period. Patients who previously relied on applying artificial tears every 15 to 30 minutes may find that scleral lenses reduce or eliminate the need for supplemental drops during wearing hours.
Sjogren syndrome is an autoimmune condition that attacks moisture-producing glands throughout the body, including the lacrimal glands responsible for tear production. Dry eye associated with Sjogren syndrome tends to be chronic, progressive, and resistant to conventional therapies. Scleral lenses are particularly well suited for these patients because the fluid reservoir compensates for the reduced tear production that defines the condition. Many patients with Sjogren syndrome report that scleral lenses provide the most consistent and sustained relief they have experienced.
Ocular graft-versus-host disease (GVHD) develops in some patients who have undergone bone marrow or stem cell transplantation. The donor immune cells can attack the recipient's tear glands and ocular surface, causing severe dry eye that may be accompanied by corneal scarring and chronic inflammation. The protective environment created by scleral lenses shields the cornea from further damage while providing continuous moisture. For GVHD patients, scleral lenses serve both a therapeutic role in promoting corneal healing and a functional role in improving vision and comfort.
Stevens-Johnson syndrome (SJS) and related conditions can cause severe scarring of the conjunctiva and cornea, leading to chronic dry eye, irregular corneal surfaces, and vision impairment. The scarred ocular surface in these patients makes standard contact lens fitting extremely challenging. Scleral lenses are often the only contact lens option that can be successfully fitted because they vault over the irregular corneal terrain and rest on the less affected scleral tissue. The fluid reservoir protects fragile epithelium, and the optical correction provided by the rigid lens surface can improve vision that is reduced by corneal irregularity.
Exposure keratopathy occurs when the eyelids cannot fully close during blinking or sleep, leaving portions of the cornea exposed and unprotected. This can result from facial nerve palsy, thyroid eye disease, or eyelid surgery complications. The exposed corneal areas dry out rapidly, leading to pain, erosions, and potential infection. Scleral lenses provide a sealed environment that protects the cornea from exposure even when lid closure is incomplete. The fluid reservoir maintains hydration over areas that would otherwise be left uncovered between blinks.
Some patients with severe dry eye have tried multiple treatments, including prescription anti-inflammatory drops, punctal plugs, autologous serum tears, and meibomian gland therapies, without achieving adequate relief. Scleral lenses may be recommended when these approaches have been insufficient on their own. Because scleral lenses work through a fundamentally different mechanism, providing direct physical protection and continuous hydration, they can succeed where other therapies have not provided enough improvement. At Washington Eye Institute, the dry eye team evaluates each patient's treatment history to determine whether scleral lenses represent an appropriate next step.
The Fitting Process for Dry Eye Patients
The scleral lens fitting process at Washington Eye Institute begins with a comprehensive evaluation of the ocular surface and dry eye severity. This assessment typically includes measurement of tear production, evaluation of the corneal and conjunctival surfaces using specialized dyes, mapping of the corneal topography to document surface irregularities, and imaging of the meibomian glands. The team also reviews the patient's complete dry eye treatment history to understand what has been tried and how the eyes have responded. This information guides decisions about lens design, size, and fluid reservoir depth.
Fitting scleral lenses is a more involved process than fitting standard contact lenses. The practitioner selects an initial diagnostic lens based on the patient's measurements and places it on the eye with saline solution. Using a slit lamp microscope, the practitioner evaluates how the lens sits on the sclera, whether it vaults adequately over the cornea, and whether the fluid reservoir is an appropriate depth. Several diagnostic lenses may be tried during a single visit to optimize the fit. Patients with severe dry eye or irregular corneal surfaces may require additional fitting visits to achieve the best possible result.
Scleral lenses for dry eye patients may be customized differently than lenses fitted primarily for vision correction. Considerations specific to dry eye fitting include:
- Increased vault clearance to create a deeper fluid reservoir for greater hydration
- Optimized edge design to maintain a proper seal and prevent fluid leakage
- Selection of lens material with high oxygen permeability to support corneal health
- Fenestration or channel features in some designs to allow fluid exchange beneath the lens
- Adjustment of lens diameter based on scleral shape and lid anatomy
After the patient receives their custom lenses, follow-up appointments are scheduled to monitor the fit and the corneal response. The practitioner checks for adequate corneal clearance, evaluates the health of the underlying corneal tissue, and asks about comfort and wearing time. Adjustments to the lens parameters may be needed, particularly in the first few months. The ocular surface in severe dry eye patients can change over time as the cornea heals under the protective lens environment, which may allow further optimization of the fit at subsequent visits.
Daily Care and Handling
Inserting scleral lenses requires a different technique than standard contact lenses because of their larger size and the need to fill the lens with solution before placement. Patients typically use a specialized plunger or stand to hold the lens while filling the bowl with preservative-free saline. The patient then leans forward, looks down into the lens, and brings the lens up to the eye, allowing it to settle onto the sclera. New scleral lens wearers usually need several practice sessions to become comfortable with the insertion process. The team at Washington Eye Institute provides hands-on training during the dispensing appointment and is available for additional coaching as needed.
Removal is accomplished using a small suction cup plunger designed specifically for scleral lenses. The patient looks down, applies the plunger to the lower edge of the lens, and gently rocks the lens to break the suction seal before lifting it away from the eye. It is important not to pull the lens straight off, as this can create excessive suction against the cornea. Patients are taught the proper angle and pressure to use during removal training.
Proper lens care is essential for maintaining both the lenses and ocular health. After removal, scleral lenses should be cleaned with an approved cleaning solution by rubbing the lens surfaces gently between the fingertips. The lenses are then placed in a disinfecting solution overnight. Key care practices include:
- Washing and drying hands thoroughly before handling lenses
- Using only solutions recommended by the prescribing practitioner
- Replacing the lens case regularly to prevent bacterial contamination
- Rinsing lenses with preservative-free saline before filling and inserting
- Avoiding tap water, saliva, or non-approved solutions for any step of lens care
New scleral lens wearers typically begin with a gradual wearing schedule, starting with four to six hours per day and increasing by one to two hours each day as comfort allows. Most patients work up to a full-day wearing schedule of 12 to 16 hours within one to three weeks. The practitioner at Washington Eye Institute provides individualized guidance on wearing time based on the patient's corneal health and response to the lenses. Some patients with very fragile corneal surfaces may be advised to limit wearing time or to remove and reapply the lenses midday with fresh saline to refresh the fluid reservoir.
Combining Scleral Lenses with Other Dry Eye Treatments
Scleral lenses can be used alongside many prescription dry eye medications. Anti-inflammatory drops such as cyclosporine or lifitegrast are typically applied at times when the lenses are not being worn, such as before insertion in the morning and after removal in the evening. Some practitioners recommend instilling certain drops before lens insertion to maximize their contact time with the ocular surface. Patients should discuss the timing and compatibility of all prescribed drops with their dry eye specialist to develop an effective combined regimen.
Punctal plugs, which block the tear drainage channels to help retain moisture on the eye, can complement scleral lens wear. Some patients benefit from having punctal plugs in place during hours when they are not wearing their scleral lenses, such as in the evening and overnight. The combination helps maintain ocular surface hydration around the clock. Washington Eye Institute offers punctal plug placement as part of a comprehensive dry eye management plan that may include scleral lens fitting.
Many patients with severe dry eye also have meibomian gland dysfunction (MGD), which compromises the lipid layer of the tear film. Treating MGD with therapies such as warm compresses, lid hygiene, or in-office procedures like intense pulsed light (IPL) therapy can improve the quality of the tear film during hours when scleral lenses are not being worn. Addressing MGD may also improve scleral lens comfort by reducing lid margin inflammation that can affect the lens-to-lid interaction. Washington Eye Institute provides IPL therapy and other meibomian gland treatments that can be coordinated with scleral lens care.
Severe dry eye often benefits from a multifaceted approach rather than relying on a single treatment. Scleral lenses address hydration and corneal protection during waking hours, while other therapies can target underlying inflammation, meibomian gland function, and overnight dryness. The multidisciplinary team at Washington Eye Institute works with each patient to build a treatment plan that addresses all contributing factors. This plan is reassessed over time as the patient's condition responds to treatment and as needs change.
What to Expect with Scleral Lenses
Most patients with severe dry eye notice a significant improvement in comfort within the first few days of scleral lens wear. The constant hydration provided by the fluid reservoir eliminates the scratching, burning, and foreign body sensation that characterize severe dryness. Many patients describe the sensation of wearing a well-fitted scleral lens as soothing, particularly compared to the discomfort they experience without the lens. While the adaptation period varies from patient to patient, the majority of dry eye patients report that scleral lenses provide the most consistent comfort they have achieved.
In addition to comfort, scleral lenses frequently improve visual clarity for dry eye patients. Severe dry eye disrupts the smooth optical surface of the cornea, causing fluctuating or blurred vision that worsens between blinks. The rigid front surface of a scleral lens creates a new, uniform refractive surface, and the fluid reservoir fills in corneal surface irregularities. Patients often notice that their vision is more stable and less dependent on blinking frequency. For patients with corneal scarring from conditions such as Stevens-Johnson syndrome or GVHD, the optical improvement can be substantial.
One of the most meaningful benefits of scleral lenses for severe dry eye is the potential for corneal surface healing. When the cornea is continuously bathed in fluid and protected from mechanical trauma and environmental exposure, existing epithelial defects, punctate erosions, and filamentary changes have the opportunity to resolve. Practitioners at Washington Eye Institute monitor corneal healing at follow-up visits using slit lamp examination and surface staining. Improvement in corneal surface integrity may become apparent within weeks to months of consistent lens wear.
Scleral lenses are a long-term management tool for severe dry eye rather than a temporary measure. Patients who benefit from scleral lenses typically continue wearing them on an ongoing basis. The lenses themselves are durable and, with proper care, generally last one to two years before replacement is needed. Over time, the dry eye team may adjust the lens parameters or the broader treatment plan based on how the condition evolves. Patients are encouraged to maintain regular follow-up visits to ensure the lenses continue to provide optimal fit, comfort, and corneal protection.
Frequently Asked Questions
Despite their larger diameter, most patients find scleral lenses more comfortable than smaller contact lenses, especially when dry eye is present. Because the lens rests on the sclera rather than the more sensitive cornea, initial awareness of the lens tends to be minimal. The fluid reservoir adds a cushioning effect that many patients describe as soothing. Most new wearers adapt to the sensation of scleral lenses within the first week of wear.
The fitting process for scleral lenses typically involves two to four office visits over several weeks. The initial evaluation and diagnostic lens trial may take 60 to 90 minutes. After the custom lenses are manufactured, a dispensing visit includes lens insertion and removal training. One or more follow-up visits are scheduled to evaluate the fit and make any necessary adjustments. Patients with more complex corneal conditions may require additional visits to optimize the lens design.
Many patients with prior eye surgery are successful scleral lens wearers. Previous corneal transplant, LASIK, PRK, or cataract surgery does not automatically disqualify someone from scleral lens wear. In fact, scleral lenses are often recommended after corneal surgery when the resulting corneal shape causes dry eye symptoms or visual irregularities. The practitioner will evaluate the post-surgical eye to determine whether scleral lenses are appropriate and to design a lens that accommodates the altered anatomy.
Scleral lenses should be filled with preservative-free sterile saline solution before each insertion. Preserved saline, multipurpose contact lens solutions, and tap water should not be used for filling because preservatives and contaminants can become trapped against the cornea under the lens. Some practitioners may recommend adding a small amount of preservative-free artificial tear to the saline for additional viscosity. The dry eye team at Washington Eye Institute provides specific solution recommendations based on each patient's needs.
Some scleral lens wearers experience midday fogging, which appears as a gradual haze or cloudiness in vision during extended wear. This occurs when debris, mucus, or inflammatory cells accumulate in the fluid reservoir beneath the lens. The most common remedy is to remove the lens, rinse it, refill with fresh saline, and reinsert. Persistent fogging may indicate the need for a lens design adjustment, a change in filling solution, or additional treatment for underlying ocular surface inflammation. Patients should report recurring fogging to their practitioner so the cause can be addressed.
Scleral lenses are generally considered when other dry eye treatments have not provided sufficient relief or when the severity of the condition warrants direct corneal protection. Patients with mild to moderate dry eye typically begin with artificial tears, lifestyle modifications, and prescription anti-inflammatory drops. If symptoms remain poorly controlled, punctal plugs, autologous serum tears, or meibomian gland therapies may be added. Scleral lenses become a strong consideration when corneal surface damage is present despite these treatments, when an underlying systemic condition causes persistent severe dryness, or when fluctuating vision from tear film instability significantly affects daily function. The dry eye specialists at Washington Eye Institute can help determine the right time to explore scleral lenses within an overall treatment strategy.