We all have our annoyances—the landlord that only has your parking lot plowed at 1 PM in the middle of patient care, or the patient that requests you perform an optical miracle with their 15th multifocal contact lens trial. But nothing makes me want to jump off the proverbial cliff faster than dry eye disease (DED) ruining what would otherwise be a pristine specialty lens fitting.
One of the primary challenges is the compromised ocular surface itself. DED is frequently associated with inflammation, tear film instability, epithelial disruption, and lid margin disease. These factors can lead to fluctuating vision, reduced comfort, and variable lens performance. A lens fit on an unhealthy ocular surface may initially appear acceptable but will fail once the patient experiences worsening dryness or inflammation. For this reason, careful prefitting evaluation and ocular surface optimization are critical steps that cannot be overlooked.
Lens Fogging Associated With Scleral Lenses
Scleral lenses are the most common modality prescribed for dry eye due to their fluid reservoir and minimal corneal interaction. However, not all dry eye patients tolerate them equally. Lens fogging associated with scleral lenses is the most encountered complication in the dry eye population. The location of the fogging makes all the difference in how the practitioner proceeds. If fogging occurs in the postlens tear layer between the lens surface and the cornea, the practitioner would be best served to closely evaluate the fitting relationship of the lens and eye. However, if the lens surface is consistently fogging then the DED or lid margin disease must be aggressively treated.
Achieving and Maintaining a Stable Fit
Achieving and maintaining a stable fit can also be challenging. Dry eye patients often exhibit conjunctival irregularities, pingueculae, or subtle scleral asymmetry that complicates lens alignment. Even minor areas of localized compression or edge lift can result in discomfort, hyperemia, or lens intolerance over time. Advanced diagnostic tools such as scleral profilometry and anterior segment optical coherence tomography are invaluable but require additional time, expertise, and financial investment.
Educating Patients on the Fitting Process and Therapy
Patient expectations represent another hurdle. Many dry eye patients seek specialty lenses after years of discomfort and failed treatments, and they may expect immediate relief. Although specialty lenses can be transformative, they often require multiple visits, lens modifications, and ongoing management. Educating patients about the iterative nature of the fitting process and the need for concurrent dry eye therapy is essential to maintaining trust and adherence.
Finally, long-term management poses ongoing challenges. DED is chronic and often progressive, meaning that a successful fit today may need adjustments in the future. Changes in tear quality, eyelid health, or systemic medications can all affect lens performance. Regular follow-up, continued treatment of the underlying dry eye, and open communication are necessary to sustain long-term success.
Conclusion
Fitting specialty contact lenses in dry eye patients requires a thoughtful, comprehensive approach that extends beyond lens selection alone. If done well, specialty contact lenses can not only transform lives, but also provide numerous benefits to the practice itself. Dry eye will challenge you in ways you do not anticipate. There will be moments where you question how to proceed. But at some point down the road, you’ll be a better clinician for having learned to manage the challenge.OM
