GSLS 2026: Keratoconus lens fitting before and after surgery

Susan Gromacki, OD, MS, FAAO, FSLS, presented a case-based overview from her GSLS 2026 lecture, “Keratoconus Lens Fitting Before and After Surgery.” She emphasizes that specialty contact lenses—especially scleral and corneal GP lenses—are the cornerstone for managing irregular corneas in keratoconus, as many patients cannot achieve adequate vision with spectacles or soft lenses.

She describes a particularly challenging case: an ER physician with keratoconus who wore scleral lenses 12–24 hours straight due to long shifts. The patient had undergone corneal collagen cross-linking combined with conductive keratoplasty (CK). Gromacki notes that CK is not FDA-approved for keratoconus, and the cross-linking method used was also non–FDA-approved. Over time, the CK spots near the cone coalesced into a raised area of tissue, leading to significant scleral lens bearing on that area. This resulted in severe superficial punctate keratitis (SPK) and stromal streaming.

Her management was twofold: first, heal the cornea; second, refit the scleral lenses. She refit the patient into a different scleral lens design, changing the base curve from 8.44 to 6.7 and adjusting the mid-peripheral geometry to avoid focal bearing on the raised tissue while also preventing excessive central clearance, which could compromise corneal oxygenation. She also educated the patient about limiting scleral lens wear time when not on ER call and maintaining strict compliance with lens care and safe wear practices.

Gromacki highlights that successful care is multifactorial: fitting the lens, communicating effectively, promoting safe wear, and ensuring compliance. She stresses that keratoconus is highly variable—“not one size fits all” for corneas or lenses—citing the COLLECT study, which describes six levels of keratoconus severity, each with distinct corneal shapes, even before any surgery. Post-surgical topographies (ie, after PKP, DALK, cross-linking, CK, Intacs/ICRS) further diversify presentations.

Finally, she notes that while many younger doctors are now well trained in scleral lens fitting, corneal GP skills are underutilized and still crucial. As contact lens fitters, clinicians must be nimble, understand corneal topography and health, and choose appropriately between scleral and corneal GP lenses to achieve the best outcomes for irregular cornea patients.