Selecting a contact lens for a patient who has keratoconus should begin with the patient rather than the lens, according to Jennifer Liao, OD, FAAO, FSLS, and Clark Chang, OD, MSc, FAAO, FSLS, who reviewed soft, corneal GP, hybrid, piggyback, and scleral options during their Academy 2026 presentation, titled “Growing Your Keratoconus Contact Lens Toolbox.”
The presenters emphasized that keratoconus severity is not the only factor in lens selection. Cone location and elevation, baseline visual function, previous contact lens experience, ocular anatomy and health, lifestyle, environment, and the patient's visual goals should also guide the decision.
For patients who have mild to moderate keratoconus, a specialty soft lens may provide a combination of familiar handling and comfort while improving vision by masking some corneal irregularity. These lenses may be particularly useful for patients who cannot tolerate a GP lens or whose activities make a corneal GP less desirable.
Corneal GP lenses also remain an option for mild to moderate disease, particularly for those who have centrally located, smaller cones. Their ability to optically correct the irregular corneal surface can provide better visual acuity and quality than soft lenses in appropriate patients. Proper fitting is critical, however; the presenters stressed avoiding flat fits and apical bearing because of the associated risk of corneal scarring.
When GP optics are desirable but comfort is a problem, they noted that other tools can bridge the gap. Hybrid lenses combine a rigid center for vision with a soft skirt for comfort and may be used across a range of keratoconus severity. A piggyback system, in which a GP is worn over a soft carrier lens, can improve comfort and stability while reducing mechanical trauma from the rigid lens.
Scleral lenses provide another option, particularly for patients who have moderate to severe disease, highly decentered cones, GP intolerance, and those who have greater comfort or stability needs. Because the lens vaults the irregular cornea and rests on the sclera, it avoids corneal contact while maintaining a fluid reservoir. Modern scleral designs also offer considerable customization, including quadrant-specific peripheral curves, channels, vaults, notches, and higher-order aberration (HOA) correction.
The latter can become important when good high-contrast acuity does not translate into satisfactory real-world vision. “By combining HOA correcting optics with scleral lenses, our latest published findings from Cornea Service at Wills Eye1 revealed significant reductions of mean HORMS and individual Zernike terms (Z7, Z8, Z11, Z17, and Z18) for all pupil sizes in a keratoconus patient cohort,” noted Dr. Chang.
In one highlighted case, a longtime scleral lens wearer continued to report shadows and difficulty driving at night. The presenters ultimately incorporated HOA correction to address the patient's visual quality rather than relying on Snellen acuity alone.
Regardless of lens type, fitting does not end when acceptable vision and comfort are achieved. The presenters recommended evaluating the ocular surface without the lens at follow-up visits and managing both the lens and the health of the eye. “An optimized contact lens fitting outcome goes beyond improving quality of vision, it ultimately allows your keratoconus patients to reclaim their lives!” said Dr. Chang.
The overarching takeaway was straightforward: one size does not fit all in keratoconus. Understanding the available lens designs—and how they can be customized—allows practitioners to match the lens to each patient’s ocular anatomy, ocular health, visual requirements, and everyday needs. “Advancements in contact lens technology expands what's possible our patients with keratoconus,” added Dr. Liao. “It empowers us to deliver personalized care to help them achieve their greatest potential for success.” OM
References
- Masoud OH, Chang CY, Meghpara BB, Syed ZA. Outcomes of wavefront-guided scleral lenses in keratoconus patients. Optom Vis Sci. 2026;103(8):e70092. doi:10.1002/ovs2.70092