GSLS 2025: Scleral lens fitting in a keratoconus patient with a complex history

Abby Gillogly Harsch, OD, FAAO, FSLS, presented a poster at the Global Scleral Lens Symposium (GSLS) in Las Vegas on fitting scleral lenses in a keratoconus patient with a history of cataract, corneal transplant, and glaucoma surgery. Despite the complex surgical history, including a bleb, the patient was successfully fitted with Bausch + Lomb's ZenLens featuring a MicroVault. Adjustments were necessary to ensure the lens landed correctly over the bleb. Harsch emphasized the importance of consulting the Bausch + Lomb team for lens fitting advice and highlighted the need to balance surgical requirements with patient quality of life. The key takeaway is to explore lens add-ons to maintain patient satisfaction.

Video transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Emily Kaiser Maharjan:

Hi everyone. I'm here with Dr Abby Harsch, who is presenting a poster on scleral lens fitting in a keratoconus patient with a history of cataract, corneal transplant, and blood-forming glaucoma surgery at the Global Scleral Lens Symposium in Las Vegas, Nevada. So thanks for being here, Dr Harsch.
Thanks for having me.

Abby Gillogly Harsch, OD, FAAO, FSLS:

Of course. So first, can you give me a brief summary of this poster?
Yes, so you basically said it all in the title. We were able to successfully fit a patient who had been years in scleral lenses and really happy with her scleral lens experience. We were able to keep her in scleral lenses, despite her long surgical ocular history, including her bleb that the glaucoma surgeon had really intentionally requested that we switch to a [gas permeable, or] GP design so that we wouldn't be putting mechanical pressure on that bleb. We were able to add in the Bausch + Lomb Zenlens; [it] has a MicroVault, a unique feature of that lens that we were able to add in to the landing zone so that we could vault over that bleb and adjust it so that we have a happy glaucoma surgeon and a happy patient at the end of the fitting.

Kaiser Maharjan:

Fantastic. Did you have any surprises when you were trying to find the right fit for this patient, or anything that changed your perspective?

Harsch:

Absolutely. During the fitting process, when we added in the MicroVault to the edge of the lens, it kind of rotated where the scleral lens landed on the eye, and then the MicroVault was not over the area of the bleb where we were aiming for it to be. So we had to make an adjustment and a change to get that to land right where we wanted it, so that we would have the appropriate little bump right at the edge where the bleb is on the conjunctiva.

Kaiser Maharjan:

Perfect. You know, you mentioned making adjustments to make sure that the MicroVault fits right over the bleb where you want it. Do you have any tips and tricks for making sure that the lens lands exactly where you want it?

Harsch:

Yes, taking pictures and sending them to the Bausch + Lomb consultation team makes all the difference. There are markings on the lens that help them identify, and help us as practitioners, identify where do we want the MicroVault to go, and where is the bleb in relation to where the contact lens already sits. But pictures make it way easier for both parties to know exactly what we're aiming for.

Kaiser Maharjan:

Fantastic. And did you uncover anything in this experience that'll change how you fit scleral lenses in the future?

Harsch:

You know, I think a really helpful takeaway from this experience for me, and hopefully for others, is that the glaucoma surgeon had really asked for a small diameter GP, but the patient's quality of life really matters too, and she had lived life in small diameter GPs before, and inconsistent vision and lenses falling out really decreased that quality of life for her. So being able to work with the surgeon and make some adjustments to the lens, because surgeons don't fit the lenses that they may or maybe didn't know that we could make these unique add ons, will help this patient, but hopefully will help some other patients in the future, too.

Kaiser Maharjan:

Fantastic. And if you could give one nugget of wisdom to any practitioner who's facing a challenging scleral lens fit, what would it be?

Harsch:

I think in this discussion, I've shared a couple of things that I thought really made this case unique and worth sharing at GSLS this week. One thing I didn't mention that I absolutely think is worth discussing is that this patient still had her stitches from her most recent corneal graft and as her other surgeon, as her cornea surgeon, removes those stitches, that's going to work really well underneath the scleral lens, because of the space between the lens and the cornea. If we had done a corneal GP design, we would probably have to alter the fit a few times as that graft heals and the stitches are removed. So I think that that is 1 nugget that I hadn't shared that is definitely worth talking about in this patient's case.

Kaiser Maharjan:

Yeah, that's super helpful. And do you have any general key takeaways from this poster that you really want to drive home?

Harsch:

I think biggest takeaway, before we refit somebody out of the sclera lens who has done really well in the scleral lens, I think it's worth contacting the consultation team and saying, "Are there any add ons to this lens? Anything that we can do to keep this patient in the lens that they love?" Because I was aware of the MicroVault, but had I not been, consultation would have told me, and I would have been able to do something new and help the patient.

Kaiser Maharjan:

Thank you so much for taking the time to chat today, Dr Harsch. It's been a pleasure to learn more about fitting scleral lenses in challenging cases, and it's been really lovely to learn more. So thank you so much.

Harsch:

Thank you, Emily. I appreciate the chance to share with my colleagues.