A recent study evaluated the role of contact lenses (CLs) in visual rehabilitation following keratoplasty.¹Studies published between January 2010 and July 2023 in 4 databases (PubMed, Scopus, Web of Science, and Embase) were systematically reviewed. The authors evaluated information about the wear of CLs, visual outcomes, subjective comfort, rate and etiology of CL discontinuation, corneal endothelial cell density, central corneal thickness, and complications.

In total, the analysis included 2 chart reviews and 13 case series, encompassing 464 eyes, 97% of which had undergone penetrating keratoplasty. Scleral lenses were the most frequently prescribed (285 eyes, 61%). All studies reported a significant improvement in visual acuity with CL correction. Most patients were able to wear their lenses comfortably for 8 to 12 hours per day following keratoplasty.

The rate of CL dropout ranged from 0% to 39%, primarily due to contact lens intolerance, discomfort, or graft rejection. The most reported complications included corneal graft rejection (18 eyes), conjunctival hyperemia (8 eyes), corneal epithelial trauma (5 eyes), graft edema (4 eyes), and microbial keratitis (3 eyes). Despite these potential issues, CLs, particularly scleral lenses, have proven effective in enhancing visual acuity after keratoplasty, with only minor complications depending on the type of lens used.

When fitting scleral lenses post corneal transplant, careful monitoring is essential to avoid minimize the risk of graft rejection. Close evaluation includes assessing the corneal endothelium using corneal tomography, monitoring global corneal thickness, and examining the limbus for signs of microcystic corneal edema.

Scleral lens wearers at higher risk include those who have vascularized corneas, a history of rejection, or herpetic/ocular surface disease. Non-vascularized corneas carry a lower risk, and endothelial rejection is most common. Corticosteroid drops should be used for at least 1 year.

Scleral lens wearers are at higher risk of graft rejection if they have vascularized corneas, a history of previous rejection, or underlying herpetic or ocular surface disease. In contrast, non-vascularized corneas are associated with a lower risk of graft rejection. Endothelial rejection is the most common type following corneal transplantation. To reduce the risk of rejection, corticosteroid eye drops should be used for at least 1 year postoperatively. However, the risk of rejection remains for the entire life of a patient. 

Scleral lens wearers after corneal transplantation require routine monitoring at least twice a year. It is critical to recognize signs of graft rejection and treat them as an emergency. Inflammation may present as ciliary redness, anterior chamber cells, keratic precipitates, or corneal edema. The CL fit and material should be reevaluated regularly to ensure they do not compromise corneal physiology or ocular surface health. Patients must be educated about urgent symptoms, redness, photophobia, pain, and decreased visual acuity, and instructed to seek immediate care if these occur. Since rejection can happen at any time, lifelong vigilance is necessary.

Reference

1. Khosravi Mirzaei S, Feizi S, Hatami F, Hatami F, Moshtaghion SM. Contact lenses for visual rehabilitation in post-keratoplasty eyes: A systematic review. Cont Lens Anterior Eye. 2025 Jun;48(3):102374. doi: 10.1016/j.clae.2025.102374

Melissa Barnett, OD, FAAO, FSLS, has received remuneration from ABB, Abbvie, Alcon, Azura, Bausch + Lomb, BCLA, Bruder, Cloudbreak Pharma, CooperVision, Dompé, Epion, JJVC Vistakon, Lentechs, Ocusoft, Orasis, ScienceBased Health, STAPLE Program, Tarsus, and Théa Pharma.

 This editorial content was supported via unrestricted sponsorship.