Challenges of Scleral Lens Practice in Yemen: Insights from a Tertiary Referral Eye Center in Sana’a

Abstract

While scleral lenses provide effective visual rehabilitation and excellent wearing comfort for patients with complex ocular surface diseases and irregular corneas, evidence regarding their delivery in resource-limited settings remains scarce. This narrative commentary highlights the major challenges of establishing and maintaining scleral lens services in Yemen, based primarily on clinical experience at a tertiary eye center in Sana’a. In our setting, healthcare infrastructure, supply chains, and access to specialized eye care are compromised. Here, we discuss the impact of financial constraints, restricted access to advanced fitting technologies, interrupted supply chains, misconceptions, and lack of patient awareness, as well as the difficulties in ensuring continuity of care and long-term follow-up. To address these challenges, we describe flexible, context-specific strategies, including individualized patient management and comprehensive patient education, to facilitate scleral lens care despite significant resource limitations. Ultimately, we delineate practical recommendations tailored to enhancing practitioner training, improving patient education, expanding access to scleral lens services through regional and international collaboration, and developing clinical frameworks and context-appropriate referral pathways. Although grounded in the experience of Yemen, the perspectives conveyed can inform policymakers, eye care providers, and clinicians operating under similar challenges in other resource-limited settings.

Introduction

Scleral lenses are large-diameter, rigid gas-permeable contact lenses that are designed to entirely vault over the cornea and land on the sclera, creating a fluid reservoir between the anterior corneal surface and the posterior lens surface.¹ Scleral contact lenses have become an increasingly essential modality for managing patients with irregular corneas and complicated ocular surface diseases because of their ability to provide excellent visual rehabilitation and superior comfort.² As scleral lens technology continues to advance, equitable access to these benefits remains limited across healthcare systems worldwide, particularly in conflict-affected and resource-limited settings.³ Much of the published evidence regarding scleral lens practice comes from high-income countries, where well-established supply chains, targeted training programs, advanced diagnostic instrumentation, and insurance-funded healthcare systems are readily available.^2,4 Accordingly, reports describing the provision of scleral lens services in low-income and conflict-affected countries remain limited in the literature.^3,4 Yemen presents a particularly important context for discussing these challenges. For more than a decade, the country has experienced ongoing conflict, a declining economy, and progressive deterioration of its healthcare system.^5,6 Based on our clinical experience and available published information, specialized ophthalmic and optometric services are still available in a few centers in Sana’a, the capital, and a small number of other major cities across Yemen. However, access to specialty visual rehabilitation remains restricted. Specialty contact lens services, including scleral lens fitting, remain limited and are primarily available through specialized eye-care settings in major urban centers. Reliable nationwide information regarding the availability and geographic distribution of scleral lens services in Yemen is currently lacking. In this context, the delivery of scleral lens services is affected not just by clinical considerations but also by wider logistical, systemic, and economic factors.⁷ Published literature provides limited description of the practical challenges involved in delivering scleral lens services within conflict-affected and resource-limited healthcare systems. Our commentary, therefore, addresses this gap by describing practice-based challenges and context-specific approaches observed in a tertiary eye-care setting in Sana’a, Yemen.

This commentary aims to highlight the major challenges associated with scleral lens practice in Yemen, using this experience to illustrate the broader barriers to providing scleral lens care in resource-limited and conflict-affected environments.

Commentary Approach and Sources of Evidence

This commentary draws primarily on the author’s clinical experience with scleral lens care at a specialty contact lens clinic within Noor Alyemen Eye and ENT Consulting Center in Sana’a, Yemen, along with relevant published literature and information from routine clinical records. The discussion reflects the practical challenges observed during the assessment, fitting, patient training, and follow-up of scleral lens patients in a resource-limited and conflict-affected healthcare setting. Routine clinical records were reviewed to illustrate specific practice-based observations; however, the information derived from these records was not collected or analyzed according to a predefined research protocol and was used to provide practice-based context rather than to constitute a systematic quantitative assessment. Published literature was used to support the clinical and contextual aspects of the discussion and to relate observations from our setting to the broader literature on scleral lens practice across diverse clinical contexts.

Scleral Lens Practice within a Conflict-Affected Healthcare System

Following years of armed conflict, Yemen’s healthcare system has collapsed.^8,9 This has fundamentally reshaped the delivery of specialized eye services.⁷ Practices that demand customized medical devices and high-level clinical expertise, such as scleral lens fitting, may be particularly prone to disruptions in healthcare infrastructure, supply chains, workforce capacity, and continuity of care.¹⁰ Our clinical experience suggests that scleral lens practice in a conflict-affected healthcare system may extend beyond standard clinical expertise alone. In our setting, logistical considerations can become as important as clinical findings when planning scleral lens care. Decisions concerning lens fitting and follow-up must balance optimal clinical management with the practical realities of limited access to replacement lenses, travel constraints, financial burdens, and the unpredictability of future follow-up. Disruptions in the supply of customized lenses and lens care products, combined with resource constraints, may require more flexible clinical decision-making, individualized patient management, and comprehensive patient education. Despite these challenges, our experience suggests that scleral lens care can be provided in resource-limited settings through context-specific clinical approaches and careful resource utilization. In our setting, adapting scleral lens practice to available resources may also present potential clinical management challenges. Limited access to advanced fitting technologies may make precise assessment and optimization of lens fit more difficult, while delays in obtaining replacement lenses may prolong the use of lenses that require replacement. Limited availability of appropriate preservative-free filling solutions may also complicate routine lens care. In addition, irregular follow-up may delay the identification of fit-related problems or ocular surface complications. These considerations highlight the importance of individualized risk assessment and careful patient counseling when adapting scleral lens care to resource-limited circumstances.

Economic Barriers and Affordability

Based on our clinical experience over several years, we consider financial affordability to be one of the most significant barriers to scleral lens practice in our setting. While scleral lenses can provide substantial visual rehabilitation for patients with advanced corneal disease, the cost of treatment frequently places them beyond the financial means of many patients.^1,11 In our setting, a pair of scleral lenses costs around US$1000, though prices can differ slightly among eye care centers. This amount represents a substantial financial burden for many Yemeni families, making scleral lenses unaffordable despite their potential to offer meaningful visual rehabilitation.^7,12,13 This financial challenge is also reflected in our clinical records. During the six-month period from January to June 2026, 87 patients were clinically assessed and considered suitable candidates for scleral lens rehabilitation; however, only 32 (36.8%) were able to purchase the lenses, while the remaining 55 reported financial limitations as the main barrier during clinical discussions. In our daily clinical practice, financial constraints influence patient management. Patients and their families commonly spend substantial time discussing whether treatment is affordable before any clinical decision can be made. Some delay scleral lens fitting while seeking to obtain the necessary funds, whereas others forgo treatment completely despite being suitable candidates. These challenges are further exacerbated by the predominantly out-of-pocket financing of healthcare in Yemen and the severe economic consequences of the prolonged conflict.^7,14 Consequently, our clinical experience suggests that affordability can substantially influence management decisions, sometimes leading optometrists to rely on spectacles or conventional corneal RGP lenses when scleral lenses may otherwise offer a suitable option for visual rehabilitation.

Supply Chain Challenges and Limited Availability

Another important challenge is the limited local availability of scleral lenses and the resources needed for their fitting. In high-income countries, where manufacturing and distribution networks are well established, scleral lenses and related supplies can usually be obtained within a relatively short time.¹⁵ In Yemen, however, obtaining these materials is rarely straightforward, and prolonged delays in acquiring lenses and accessories are common.⁵ In our practice, we primarily rely on suppliers in Saudi Arabia and Oman, with cross-border land transport serving as the most practical route for obtaining scleral lenses and fitting materials due to the restricted availability of regular air transport into Sana’a. Based on our experience, orders typically take approximately two months to arrive, which may negatively affect patient satisfaction and delay visual rehabilitation. In our clinical setting, contact lens practitioners mainly rely on their clinical experience and basic assessment tools rather than on sophisticated scleral topography or profilometry systems that are used in specialized centers in high-resource settings.¹⁶ Therefore, the limited availability of advanced fitting technologies can make scleral lens fitting more challenging.

Limited Patient Awareness and Misconceptions About Scleral Lenses

In our clinical setting, poor patient awareness and misconceptions about scleral lenses represent significant barriers to successful scleral lens practice in Yemen. Many patients attending our contact lens clinic have little or no prior knowledge of scleral lenses and commonly lack awareness of their efficacy in the visual rehabilitation of irregular corneas. During initial consultation, we frequently encounter confusion between scleral lenses and implantable collamer lenses (ICLs). Some patients also expect scleral lenses to permanently correct their underlying condition, rather than understanding that they are a non-surgical modality for visual rehabilitation.^17–19 Moreover, patients confuse scleral lenses with conventional rigid gas-permeable (RGP) lenses, which can cause discomfort. They are frequently unaware that scleral lenses entirely vault the sensitive cornea and land on the less sensitive sclera.^1,20 Another common misconception among patients with advanced corneal disease, such as severe keratoconus, is the belief that corneal transplantation is the only available management option. They are surprised to learn that scleral lenses may offer excellent visual rehabilitation and, in many cases, help delay or avoid surgery.^21,22 Interestingly, one misconception we frequently encounter is the belief that scleral lenses may melt when exposed to heat during everyday activities, such as cooking or baking. We usually resolve these concerns by providing a simple explanation: scleral lenses are designed for routine daily use and are not expected to melt under normal environmental temperatures encountered during everyday activities. From our clinical experience, these misconceptions can result in patient hesitation, delayed management acceptance, and reduced compliance with follow-up protocols. Adequate patient education about scleral lenses, the fitting process, expected adaptation, lens care, and realistic visual outcomes helps patients make informed decisions and improves their motivation and adherence to long-term care.²³ In our resource-limited setting, effective patient counseling is not simply supportive; it is an important component of successful scleral lens management.

Challenges of Follow-Up and Continuity of Care

Long-term follow-up is an essential aspect of the safe and effective management of patients with scleral contact lenses.^20,23 Regular monitoring visits enable practitioners to emphasize proper lens maintenance and hygiene, evaluate lens fit, monitor the ocular surface, and detect potential adverse events before they become clinically significant.^20,23,24 Our clinical observations suggest that maintaining consistent follow-up appointments is a major challenge in our clinical setting. Many patients travel long distances from rural governorates to tertiary eye centers in Sana’a to seek specialized contact lens care. In our environment, repeated follow-up visits are often hindered by travel costs, transportation difficulties, work and family commitments, and the broader economic challenges associated with living in a conflict-affected area.⁷ As a result, some patients miss scheduled appointments or re-present only after experiencing significant discomfort or visual problems. The absence of regular follow-up may delay the detection and management of potential contact lens-related complications and restrict the ability to make timely modifications to lens parameters as ocular conditions or patient needs change over time.^20,24 In our clinical practice, all patients receive clear counseling on lens care, the importance of regular follow-up, and a direct telephone number for reporting any concerns that may arise. For patients at higher risk of complications, we place particular emphasis on adherence to follow-up visits and, in selected cases, may defer scleral lens fitting if reliable follow-up is considered unlikely. For lower-risk patients who are unable to return to our center, we recommend follow-up with the nearest available ophthalmologist to facilitate the early detection and management of potentially sight-threatening complications, including microbial keratitis.^24,25

Practical Recommendations and Future Directions

An end to conflict, greater political stability, and restoration of essential healthcare infrastructure are fundamental to the long-term development of scleral lens services in Yemen. A more stable environment would improve transportation, facilitate the restoration of supply chains, and expand access to specialized eye services. At the same time, meaningful improvements in scleral lens care can be pursued within existing constraints by adapting clinical practice to local circumstances. Based on our experience, scleral lens practice in resource-limited settings may not always be able to follow models developed for high-resource environments. Continuing clinical education, practical workshops, and opportunities for expert supervision may help practitioners strengthen their fitting skills and clinical confidence. Patient education should remain an integral part of care, particularly regarding the purpose of scleral lenses, lens handling and hygiene, expected adaptation, and realistic visual outcomes. Broader public awareness initiatives may help improve understanding of scleral lenses as a potential option for visual rehabilitation and facilitate appropriate referrals to specialized eye care services. Collaboration with regional manufacturers, distributors, and international professional organizations may help improve access to lenses and care products, reduce supply delays, and facilitate the replacement of lenses when needed. Practical referral pathways between primary and tertiary eye care providers may also improve access to specialized care and support continuity of follow-up. Future research should examine clinical outcomes, affordability, cost-effectiveness, patient satisfaction, adherence, and continuity of care in resource-limited and conflict-affected settings. Such evidence could help identify feasible models of specialty contact lens service delivery and inform the development of context-appropriate clinical frameworks. Ultimately, improving access to scleral lens care will require not only clinical expertise and technology but also practical solutions that address affordability, supply, patient education, and continuity of care. Taken collectively, these considerations are summarized in Table 1, which presents the principal barriers identified in our clinical setting, their effects on patient care, and the corresponding local adaptive strategies and longer-term solutions.

Table 1.

Principal Barriers to Scleral Lens Practice within Our Clinical Setting in Yemen, Local Adaptive Strategies, and Longer-Term Solutions

Principal Barriers	Effects on Patient Care	Local Adaptive Strategies	Longer-Term Solutions
Financial constraints	Influence management decisions and limit access to scleral lens rehabilitation	Patient counseling and individualized management planning	Develop more affordable and accessible scleral lens services
Supply-chain limitations	Delayed lens delivery and replacement	Coordination with regional suppliers and efficient use of available resources	Direct manufacturer partnerships and local distribution
Limited access to advanced technologies	More challenging assessment and optimization of lens fit	Greater reliance on practitioners’ clinical experience and available tools	Practical training and improved access to advanced technologies
Patient misconceptions	Hesitation, reduced motivation and adherence	Comprehensive patient counseling and education	Patient and public awareness initiatives
Follow-up difficulties	Inadequate monitoring and delayed identification of complications	Direct patient communication and referral to the nearest available eye-care provider	Strengthened referral pathways that support the continuity of scleral lens care

Notes: The strategies presented here are context-specific, practice-based approaches developed in response to challenges encountered in our clinical setting, with potential relevance to similar resource-limited settings.

Limitations

Although the real-world clinical observations presented herein provide valuable context-specific insights, some limitations should be considered when interpreting these practice-based perspectives. This commentary is largely based on clinical experience from a single tertiary eye care center in the capital, Sana’a. Thus, it may not fully capture scleral lens practices in other governorates across Yemen or in similarly resource-limited settings. Some observations were drawn from routine clinical practice and clinical records, rather than being collected under a predefined research protocol. As a result, aspects such as patient preferences and satisfaction, long-term adherence, and the reasons underlying management decisions were not assessed systematically. The practical strategies described here are intended as context-specific approaches rather than formal clinical guidelines, and their feasibility may differ according to available resources, infrastructure, and local clinical circumstances. These limitations underscore the importance of future efforts to systematically characterize scleral lens services in resource-limited settings.

Conclusion

Our experience suggests that, within our clinical context in Yemen, successful scleral lens practice goes beyond the technical considerations of contact lens fitting. In our clinical setting, practitioners must pragmatically navigate economic constraints, disrupted supply chains, limited patient awareness, and difficulties in securing long-term follow-up. Through flexible clinical decision-making, individualized patient-centered care, comprehensive counseling, and efficient use of available resources, many of these barriers may be addressed, potentially facilitating meaningful visual rehabilitation. This commentary highlights the major challenges identified through our clinical experience and presents context-informed approaches that may offer practical insights for other contact lens clinics working under similar conditions, rather than constituting established clinical guidelines. Further investigation of these approaches through systematic clinical studies is warranted. We hope that these clinical insights prompt expanded awareness of the practical complexities of scleral lens practice in underserved environments and stimulate professional collaboration, further research, and global health programs aimed at improving equitable access to specialty contact lens services worldwide.

Funding Statement

No funding or financial support was received for this commentary.

Ethics Statement

This commentary was approved by the Research and Ethical Committee of Noor Alyemen Eye and ENT Consulting Center, Sana’a, Yemen (Reference No. 06.10.27; approval date: June 4, 2026). The review of routine patient records involved minimal risk to participants, and the records were reviewed in an anonymized form. Informed consent was waived by the Research and Ethical Committee.

Disclosure

The author declares no conflicts of interest in relation to this work.