Scleral Lenses vs Corneal Transplant for Keratoconus

Keratoconus can cause significant vision loss, but today, patients have multiple treatment options that preserve sight and prevent surgery. Two major options often compared are Scleral Lenses vs Corneal Transplant for Keratoconus.

Both can dramatically improve vision, but they differ in approach, invasiveness, cost, and long-term outcomes. Understanding these differences helps patients and doctors choose the safest, most effective treatment plan.

What Is Keratoconus?

Keratoconus is a progressive eye condition where the cornea becomes thin and cone-shaped, distorting vision. It often begins in the late teens or early twenties and can worsen over time.

Common symptoms include:

• Blurred or double vision
• Increased sensitivity to light and glare
• Frequent changes in eyeglass prescription
• Difficulty wearing standard contact lenses

When the cornea becomes too irregular for glasses or soft contacts, doctors recommend specialized treatments such as scleral lenses or, in more severe cases, corneal transplantation.

Scleral Lenses for Keratoconus

How Scleral Lenses Work

Scleral lenses are large, rigid contact lenses designed to vault over the cornea and rest on the sclera (the white part of the eye).The space between the lens and cornea is filled with sterile saline, creating a smooth optical surface that corrects visual distortion while keeping the cornea hydrated.

Unlike smaller rigid lenses (RGPs), scleral lenses don’t touch the cornea directly, which makes them ideal for irregular or scarred corneas often seen in keratoconus.

Benefits of Scleral Lenses

1. Improved Vision
   Clinical data show that scleral lenses can restore vision to near 20/20 for many keratoconus patients, even in advanced stages.
2. Non-Surgical and Reversible
   Because scleral lenses are removable, patients can discontinue wear anytime. If lenses fail to improve vision, a corneal transplant remains an option.
3. Comfort and Protection
   The fluid reservoir cushions the cornea, reduces irritation, and protects against environmental damage and eye rubbing.
4. Delay or Prevent Surgery
   A 2021 study published in Contact Lens and Anterior Eye found that 77% of keratoconus patients successfully used scleral lenses for at least one year, avoiding the need for a corneal transplant.

Considerations

• Fitting requires expertise and multiple visits.
• Costs are higher than traditional contact lenses (typically $1500–$4000 per pair).
• Daily cleaning and filling with saline are necessary.

However, with proper training and follow-up, most patients report significant visual stability and comfort over years of use.

Corneal Transplant for Keratoconus

How a Corneal Transplant Works

A corneal transplant (keratoplasty) replaces damaged or scarred corneal tissue with a healthy donor cornea. It’s usually recommended for patients whose vision cannot be corrected with contact lenses due to severe scarring or thinning.

There are two main types:

• Penetrating Keratoplasty (PK): Full-thickness transplant.
• Deep Anterior Lamellar Keratoplasty (DALK): Partial transplant, preserving the inner corneal layers.

Benefits of Corneal Transplant

• Long-Term Vision Improvement:
  Many patients achieve 20/40 vision or better post-surgery, often with the help of corrective lenses.
• Permanent Tissue Replacement:
  A successful graft can last decades, providing structural and visual stability.

Considerations

• Invasive Surgery: Carries risks such as infection, graft rejection (occurring in up to 20% of cases), and long recovery times (6–12 months).
• Dependency on Donor Tissue: Success depends on donor quality and surgical precision.
• Post-Surgery Care: Patients may still need scleral or soft lenses for optimal vision even after surgery.

According to the American Academy of Ophthalmology, 10–20% of keratoconus patients eventually require a corneal transplant, typically after all other treatments fail.

Scleral Lenses vs Corneal Transplant 

Factor	Scleral Lenses	Corneal Transplant
Type of Treatment	Non-surgical, reversible	Surgical, permanent
Vision Improvement	20/20 is possible for many	20/40 or better typical
Invasiveness	None	High
Recovery Time	Days	6–12 months
Risks	Minimal	Infection, rejection, scarring
Longevity	Replaceable lenses	Long-term graft survival (~15–20 years)
Cost	$1500–$4000 (initial)	$13,000–$30,000 (surgery + follow-up)
Suitability	Mild to severe keratoconus	Advanced or scarred keratoconus

Clinical Evidence Supporting Scleral Lens Success

Several peer-reviewed studies confirm the high scleral lens success rate in keratoconus:

• A 2019 prospective study (Macedo-de-Araújo et al.) found a 73% overall success rate in scleral lens wear over 12 months.
• In the irregular cornea group (which includes keratoconus), 77% of patients continued to wear successfully, with discomfort and handling issues being the main reasons.
• Other research reports visual improvement of two or more Snellen lines in over 80% of keratoconus eyes after scleral lens fitting.

These findings emphasize that scleral lenses offer long-term stability, safety, and reversibility, making them the first-line recommendation before any surgical option.

When Corneal Transplant Becomes Necessary

While scleral lenses can often delay or prevent surgery, there are situations where a corneal transplant becomes unavoidable, such as:

• Severe Corneal Scarring or Hydrops: When the tissue is too damaged for lens fitting.
• Extremely Thin or Steep Corneas: Lenses can no longer vault safely.
• Intolerance to Lens Wear: Some patients may experience persistent discomfort or handling difficulty.

In such cases, corneal transplantation can restore optical clarity. However, even after surgery, patients often return to scleral lens wear for optimal vision correction once the cornea heals.

Long-Term Outlook and Success Rates

Living with keratoconus can feel uncertain, but modern lens technology has changed the game. Before diving into the comparison, let’s look at how long-term success rates reveal why scleral lenses are becoming the preferred solution for lasting vision stability.

Scleral Lenses

• Average daily wear: 10–12 hours
• One-year success rate: 73–90%, depending on study and patient training
• Common reasons for discontinuation: Handling difficulty (35%) and discomfort (19%)

Corneal Transplant

• Graft survival rate: 85–95% at 5 years, according to the Cornea Donor Study.
• Vision stabilization: Typically achieved within 6–12 months post-surgery.
• Risk of rejection: Up to 20%, with possible need for repeat surgery.

Statistically, scleral lenses help more than 70% of patients avoid corneal surgery, especially when fitted early in disease progression.

See How Patients With Keratoconus Improved Their Quality of Life Using Scleral Lenses 

Patients with keratoconus often describe scleral lenses as life-changing due to improved clarity, reduced glare, and comfort for long wear hours.

By contrast, corneal transplant patients experience longer downtime and dependence on ongoing medical care. However, successful grafts can bring years of stability when lenses are no longer an option.

In most cases, optometrists recommend trying scleral lenses before considering a transplant, as the majority of patients achieve excellent results without surgery.

Which Option Is Right for You?

The decision depends on disease severity, corneal condition, and lifestyle factors:

• Choose Scleral Lenses If
  
  • Your cornea is irregular but not severely scarred.
  • You want a non-surgical, reversible option.
  • You value comfort and hydration during wear.
    
• Consider Corneal Transplant
  
  • Vision cannot be corrected with scleral lenses.
  • Scarring or thinning prevents safe lens fitting.
  • You experience repeated lens intolerance.

In short: try scleral lenses first. They are safe, effective, and can postpone or completely prevent the need for corneal surgery in many keratoconus cases.

Final Thoughts

When comparing scleral lenses vs corneal transplant for keratoconus, the data is clear,  scleral lenses offer a high success rate, minimal risk, and improved comfort, making them the preferred first-line treatment.

Corneal transplants remain a valuable option for advanced cases, but for most patients, modern scleral lenses provide clear, stable vision without the risks of surgery.

If you’re in Michigan or nearby, schedule a consultation with Dr. Shira Kresch at Michigan Contact Lens to explore whether scleral lenses are right for your keratoconus. With expert fitting and care, you may never need a corneal transplant.

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