What is the treatment for small scleral aberrations?

Treatment of Small Scleral Aberrations

For small scleral aberrations, rigid gas-permeable scleral lenses are the most effective first-line treatment, as they can mask surface irregularities and improve visual quality by reducing higher-order aberrations. 1, 2

Diagnostic Considerations

• Small scleral aberrations can cause visual symptoms despite good Snellen visual acuity (20/20 vision but unhappy patients) 3
• Assessment should include:
  • Measurement of higher-order aberrations (HOAs) using wavefront aberrometry 4
  • Evaluation of visual quality beyond standard visual acuity testing 3
  • Determination of the extent of surface irregularity using keratometry 1

Treatment Options

Non-Surgical Management

1. Rigid Gas-Permeable (RGP) Scleral Lenses

   • First-line treatment for small scleral aberrations 1
   • Benefits:
     • Vault over the irregular surface to create a smooth optical interface 2
     • Significantly reduce higher-order aberrations 2, 5
     • Improve visual acuity and quality even in patients with good baseline acuity 3
   • Special considerations:
     • Mini-scleral lenses may affect accommodation response at higher accommodative demands 4
     • Regular follow-up needed to monitor for complications 1

2. Wavefront-Guided Scleral Lenses

   • Consider for patients who remain symptomatic despite good visual acuity with standard scleral lenses 3
   • Can further reduce residual higher-order aberrations 3
   • Particularly beneficial for patients reporting halos, glare, or perceptual smearing 3

3. Prism Correction

   • May be helpful for small vertical deviations 1
   • Limited usefulness if lateral incomitance is present 1

Surgical Options

For cases unresponsive to contact lens management:

1. Phototherapeutic Keratectomy (PTK)

   • Useful for anterior stromal scarring and surface irregularities 1
   • May be combined with mitomycin-C to prevent recurrence of scarring 1

2. Epithelial Debridement

   • Most helpful for lesions anterior to Bowman layer 1
   • Can be performed at slit-lamp or with operating microscope 1
   • Often combined with bandage contact lens and prophylactic antibiotics 1

Monitoring and Follow-up

• Regular assessment of visual acuity and symptoms 1
• Evaluation for complications of contact lens wear 1
• For scleral lens wearers, follow-up every 1-2 years to monitor for adverse effects 1

Potential Complications and Management

• Contact lens intolerance may develop in patients with severe dry eye 1
• Conjunctival prolapse can occur with scleral lens wear 5
• Risk of infection with prolonged contact lens use requires proper hygiene education 1
• Patients should have backup spectacles when using contact lenses as primary correction 1

Special Considerations

• Patients considering keratorefractive surgery should be cautioned that these procedures may worsen dry eye conditions 1
• Uncontrolled dry eye is a contraindication for keratorefractive surgery 1
• Patients with higher refractive errors benefit from high-index lenses to reduce thickness and weight 1