Karen R. Hoffman, OD, is a corneal specialist who is seeing an increasing number of patients with irregular astigmatism and complex corneal conditions seeking clearer vision and improved comfort. In this case series, I explore how customizable toric peripheral curves in scleral lenses—specifically using the Zenlens (Bausch + Lomb)—significantly improve fit, vision, and wearability in patients with challenging ocular anatomy. By leveraging the advanced customization of scleral lenses in 3 distinct zones (optical zone, vaulting chamber, and peripheral haptic), optometrists can achieve precise alignment even in asymmetric scleral shapes. Here are three illustrative cases that highlight the power and flexibility of toric and quadrant-specific peripheral adjustments. Case 1: Salzmann nodular degeneration Patient: 51-year-old female Condition: Left eye with Salzmann nodular degeneration and irregular astigmatism Pre-Lens VA: 20/80 in spectacles Findings: 4.00 D corneal and 5.00 D refractive astigmatism Lens Design: APS (Advanced Peripheral System): Flat Meridian = Steep 1; Steep Meridian = Steep 5 4 steps of toricity in the peripheral haptic Outcome: 2 revisions Final VA: 20/20 12 hours of comfortable wear Case 2: Post-globe rupture scarring Patient: 38-year-old male Condition: Left eye with irregular astigmatism and corneal/scleral scarring post-globe rupture Pre-Lens VA: 20/80 in spectacles Findings: 2.00 D corneal and 2.00 D refractive astigmatism Lens Design: APS: Flat 2, Steep 2 (3 steps of toricity) Additional vault near lens edge to accommodate peripheral scarring Outcome: 3 revisions Final VA: 20/20 14 hours of wear with high satisfaction Case 3: Keratoconus suspect with high astigmatism Patient: 38-year-old female Condition: Bilateral high astigmatism, suspected keratoconus Pre-Lens VA: 20/20 in spectacles, but poor comfort and satisfaction Findings: OD: 3.50 D corneal / 3.25 D refractive astigmatism OS: 4.75 D corneal / 3.50 D refractive astigmatism Lens Design: OD APS: Flat 3 / Steep 11 (8 steps of toricity) OS: Toricity distributed between APS and mid-peripheral vaulting chamber Added microvault for peripheral elevation in OS Outcome: 1 revision (OD), 2 revisions (OS) Final VA: 20/20 OU 8 hours daily wear, high patient satisfaction Conclusion These cases demonstrate that fitting scleral lenses for irregular corneas and scleras doesn't have to be overly complex. With tools like Zenlens and an understanding of toric and quadrant-specific customization, optometrists can reliably deliver excellent visual and comfort outcomes — even for the most complex patients.
