Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery

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Her presenting uncorrected high contrast distance visual acuity (HCDVA) was 20/60 in the right eye (RE) and 20/40 in the left eye (LE). On examination, the cornea showed a ring-shaped area of ablation with faint scarring and a well-apposed lenticule-extraction site. Subjective refraction improved the HCDVA to 20/20p in RE and 20/25 in LE but the patient was not happy with the quality of vision. Ocular aberrometry revealed an increase in total HOAs as the underlying cause of unsatisfactory vision. Result A contact lens trial was recommended for BE to enhance visual quality. Rigid corneal lenses (RCLs) were tried, but the patient was intolerant to them. Large diameter SCLs of different FSEs (0, 0.6, and 0.8) were tried to reduce these aberrations. SCL with FSE 0 yielded the most favourable visual outcome, which was confirmed subjectively on ocular aberrometry. Conclusion With this case report, we hypothesize that the eccentricity of SCL can be selected according to the asphericity (at 6 mm) of the posterior corneal surface. This case also re-emphasizes the impact of SCL with varying FSEs on reducing HOAs and enhancing visual quality in eyes where conventional RCLs yield suboptimal results. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-1323/v1", "name": "Case Report: Front surface eccentricity of scleral lens: Its impact..." } } ] } Home Browse Case Report: Front surface eccentricity of scleral lens: Its impact... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Ghimire D, Bhagat M, Chappidi K and Chaudhary S. Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1323 ( https://doi.org/10.12688/f1000research.158170.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery [version 1; peer review: 1 approved with reservations] Deepak Ghimire 1 , Manish Bhagat 2 , Kiranmayi Chappidi 1 , Simmy Chaudhary https://orcid.org/0000-0003-0350-512X 1 Deepak Ghimire 1 , Manish Bhagat 2 , Kiranmayi Chappidi 1 , Simmy Chaudhary https://orcid.org/0000-0003-0350-512X 1 PUBLISHED 05 Nov 2024 Author details Author details 1 Cornea and Contact Lens, LV Prasad Eye Institute, Hyderabad, Telangana, 500034, India 2 Contact lens, LV Prasad Eye Institute Kode Venkatadri Chowdary Campus, Vijayawada, Andhra Pradesh, India Deepak Ghimire Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Manish Bhagat Roles: Investigation, Resources, Supervision, Writing – Review & Editing Kiranmayi Chappidi Roles: Investigation, Methodology, Supervision, Writing – Original Draft Preparation Simmy Chaudhary Roles: Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Eye Health gateway. Abstract Purpose To report the impact of front surface eccentricity (FSE) of scleral lenses (SCLs) on the visual performance of eyes exhibiting refractive surgery-induced higher-order aberrations (HOAs) Method A female teenager presented to the clinic with blurring of vision and dependency on spectacles even after undergoing Small Incision Lenticule Extraction (SMILE) in both eyes (BE). Her presenting uncorrected high contrast distance visual acuity (HCDVA) was 20/60 in the right eye (RE) and 20/40 in the left eye (LE). On examination, the cornea showed a ring-shaped area of ablation with faint scarring and a well-apposed lenticule-extraction site. Subjective refraction improved the HCDVA to 20/20p in RE and 20/25 in LE but the patient was not happy with the quality of vision. Ocular aberrometry revealed an increase in total HOAs as the underlying cause of unsatisfactory vision. Result A contact lens trial was recommended for BE to enhance visual quality. Rigid corneal lenses (RCLs) were tried, but the patient was intolerant to them. Large diameter SCLs of different FSEs (0, 0.6, and 0.8) were tried to reduce these aberrations. SCL with FSE 0 yielded the most favourable visual outcome, which was confirmed subjectively on ocular aberrometry. Conclusion With this case report, we hypothesize that the eccentricity of SCL can be selected according to the asphericity (at 6 mm) of the posterior corneal surface. This case also re-emphasizes the impact of SCL with varying FSEs on reducing HOAs and enhancing visual quality in eyes where conventional RCLs yield suboptimal results. READ ALL READ LESS Keywords Scleral lens, front surface eccentricity, higher order aberrations, refractive surgery, Small Incision Lenticule Extraction Corresponding Author(s) Simmy Chaudhary ( [email protected] ) Close Corresponding author: Simmy Chaudhary Competing interests: No competing interests were disclosed. Grant information: Hyderabad Eye Research Foundation, Hyderabad, India. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2024 Ghimire D et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Ghimire D, Bhagat M, Chappidi K and Chaudhary S. Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1323 ( https://doi.org/10.12688/f1000research.158170.1 ) First published: 05 Nov 2024, 13 :1323 ( https://doi.org/10.12688/f1000research.158170.1 ) Latest published: 31 Dec 2025, 13 :1323 ( https://doi.org/10.12688/f1000research.158170.2 )  There is a newer version of this article available. Suppress this message for one day. Introduction Small incision lenticule extraction (SMILE) is a keraratorefractive procedure that is popular as an effective surgical management of common refractive errors. 1 The central corneal curvature is modified, making it flatter to correct myopia and steeper to correct hyperopia. Thus, influencing the corneal optical quality and producing aberrations leading to distorted images. SMILE may increase the total higher-order aberrations (HOAs) which are thought to be responsible for poor quality of vision, even with visual acuity (VA) of 20/25 or better. 2 Many visual symptoms like starbursts, shadowing, reduction in contrast sensitivity and ghost images postoperatively may be secondary to an increase in the HOAs. 3 Total HOAs induced after Wavefront-guided (WFG) keratorefractive procedures are similar to SMILE. 2 Scleral contact lenses (SCLs) are large-diameter lenses that vault over the entire cornea, mask the corneal irregularity, and enhance vision in irregular corneas. 4 They are known to effectively neutralize HOAs induced by the anterior corneal surface. 5 The use of different eccentricities on the front surface of SCLs has been shown to improve the visual performance in eyes with irregular cornea by reducing the HOAs. 6 This case demonstrates the impact of different FSEs in the Boston Sight Scleral (BSS) lens (Boston, Massachusetts, USA) on ocular aberrations and visual acuity, and also hypothesizes how eccentricity of SCLs can be calculated according to the asphericity of the posterior corneal surface. Case report A female in her 20s presented with complaints of diminution of vision for both near and distance for the last 4 months associated with shadowing and ghosting of images after keratorefractive surgery. She had undergone SMILE surgery for myopic refractive error of -4.50 Dioptre Sphere (DS) in the right eye (RE), and -8.00 DS in the left eye (LE) 6 months back. Her uncorrected high contrast distance visual acuity (HCDVA) recorded under room illumination using the COMPlog chart (COMPlog Clinical Vision Measurement Systems Ltd, London, UK) was 20/60 and 20/40 in RE and LE respectively. The near VA using the English Chart under room illumination was noted to be N6 @ 25 cms in both eyes (BE). After subjective refraction, her HCDVA improved to 20/20p in RE and 20/25 in LE. With pinhole, VA in LE improved to 20/20. Even with the best-corrected vision, her complaints of shadowing of optotypes, and ghosting of images persisted. On slit-lamp biomicroscopy, the cornea in BE revealed a well-demarcated ring-shaped area of ablation with faint scarring at the anterior stroma. Intra-ocular pressure and posterior segment were within normal limits in BE. Corneal topography (Allegro Oculyzer, WaveLight, GmbH, Erlangen, Germany) ( Figure 1A and B ) showed average flat and steep keratometric readings. The front and back surface asphericity (@6 mm) for RE was 0.47 and 0, and for LE was 1.57 and -0.03. iTrace (Tracey Technologies Corp. TX, USA) performed under scotopic conditions keeping the fixed scan of diameter 3.2 mm showing HOAs of 0.230 μ in RE and 0.237 μ in LE. Anterior segment optical coherence tomography (AS-OCT) (Optovue, Inc., Fremont, CA) showed epithelial irregularity bilaterally. With complaints of ghosting of images, and unwillingness to use spectacles, the patient was advised for a contact lens trial. Figure 1. Corneal topography of the right (1A) and the left eye (1B) showing the central area of flattening post SMILE surgery. It shows the posterior surface asphericity (Q-value) for the right (0.00) and the left eye (-0.03). Figures 2 and 3. Digital photograph of the same patient with the final scleral lens fit in the right (Figure 2) and in the left eye (Figure 3) in primary gaze (2A, 3A), downgaze (2B,3B), upgaze (2C, 3C), and lateral gazes (2D, 3D and 2E, 3E) showing optimal scleral lens haptic and edge alignment. Both conventional RCL (Purecon, New Delhi, India) and Rose K2 lenses (Menicon Co. Ltd, Nagoya, Japan) were tried with no significant improvement in visual quality. Consequently, the patient was advised BSS lens trial. The initial trial lens was selected based on the company’s guidelines to achieve optimal fitting characteristics which included a central vault ranging from 200-400 microns, and a limbal vault ranging from 50-100 microns with well-aligned lens haptics resting on the sclera and overlying conjunctiva. The specifications of the selected BSS lenses were 18.5 mm diameter, 2.80 mm sagittal height, 8.00 mm base curve, with standard haptics. All trial devices shared similar parameters except their eccentricity, which varied from 0, 0.6 and 0.8. Initially, a lens with 0.6 eccentricity (FSE 1) was tried followed by 0 (FSE 0) and lastly, 0.8 (FSE 2), while keeping all other parameters constant. The patient was given an adaptation time of 15 minutes after the application of each lens, after which visual acuity was noted followed by over-refraction. Figures 2 and 3 illustrate the final SCL fit prescribed for the patient. Ocular aberrometry was performed using iTrace with SCLs of different eccentricities. Between two consecutive lenses, a gap of 10 minutes was given. All these measurements were recorded with a lens in situ under scotopic conditions with a scan size diameter of 3.2 mm. The best corrected HCDVA of 20/20 and a subjective reduction in image ghosting were observed with an FSE 0 lens. Table 1 summarizes the impact of various FSEs on HOAs and HCDVA. Since both the quality of vision and HOAs improved with the FSE 0 lens, these lenses were ordered. Table 1. HCDVA and HOAs without and with scleral lenses of different FSEs. Without contact lens 0 FSE 0.6 FSE 0.8 FSE Eye RE LE RE LE RE LE RE LE HCDVA 20/60 20/40 20/20 20/20 20/25p 20/25p 20/30 20/30 Total HOAs 0.230 μ 0.237 μ 0.145 μ 0.117 μ 0.113 μ 0.115 μ 0.171 μ 0.124 μ Coma 0.058 μ × 88° 0.172 μ × 102° 0.072 μ × 14° 0.087 μ × 172° 0.056 μ × 90° 0.070 μ × 319° 0.078 μ × 287° 0.093 μ × 335° Spherical +0.059 μ +0.130 μ +0.042 μ +0.043 μ -0.050 μ -0.00 μ -0.051 μ -0.029 μ Secondary astigmatism 0.043 μ × 66° 0.039 μ × 85° 0.033 μ × 174° 0.035 μ × 5° 0.013 μ × 58° 0.026 μ × 156° 0.012 μ × 55° 0.024 μ × 146° Trefoil 0.162 μ × 97° 0.068 μ × 77° 0.104 μ × 115 0.032 μ × 26° 0.080 μ × 101° 0.078 μ × 75° 0.104 μ × 5° 0.071 μ × 102° Discussion While keratorefractive surgeries are designed to reduce pre-existing aberrations, they can also induce newer aberrations affecting visual quality and contribute to patient dissatisfaction. 7 Although WFG enhancement surgeries may mitigate these aberrations, many patients are either reluctant to undergo a repeat surgery or deemed unfit for it due to the associated risk of post-surgical ectasia. RCLs have been widely used for visual rehabilitation in patients with irregular corneas. The tear film between the lens and the cornea effectively masks corneal irregularity. They not only correct refractive errors but also eliminate third to fifth-order and total HOAs. 8 Fitting corneal lenses can be particularly challenging in oblate corneas. Reverse geometry lenses can give a better fit, however, the continuous gliding movement of these lenses on the cornea with blinking can lead to instability and discomfort. In our case, the RCLs were neither tolerated nor improved visual quality. SCLs provide better comfort and tolerability than RCLs. Kumar et al have shown that SCLs can effectively reduce HOAs by 70-80% in eyes with penetrating keratoplasty, radial keratotomy, and in eyes with post-LASIK ectasia. 9 Hastings et al have shown that WFG SCLs provide superior visual and optical rehabilitation than conventional SCLs. 10 Use of these customised SCLs will need technical expertise, and a sub-micro precision customised lathe-cutting machine, which can be challenging to manufacture, and may not be accessible to all clinicians. Jagadeesh et al reported that an FSE of 0.60 maximized visual performance and reduced HOAs in moderate keratoconus. 11 Hussion et al also observed enhanced high and low-contrast visual acuity with different eccentricities. 12 Similarly, Badrinarayanan et al noted improvements in HOAs, corrected distance VA and contrast sensitivity in keratoconus patients with varying eccentricities. 13 Despite these findings, an optimal FSE value has not been established. HOAs due to the anterior surface will get neutralized with SCL but those due to the posterior surface remain. 14 In that case, FSEs may compensate for aberrations due to the posterior corneal surface. FSE also helps in aligning the optical axes of the eye and the optic portion of the SCL which may contribute to visual improvement. 12 The thickness of the fluid reservoir, 15 the lens material, 16 and the polymer coating 17 have minimal impact on HOAs. Considering the irregularities of the corneal anterior surface, and the anterior and posterior asphericity of the cornea, we hypothesize that a lens with FSE closely matching the eccentricity (Ɛ) of the posterior surface of the cornea should be selected as the first lens for trial. In our case, the posterior asphericity (Q) was noted to be 0 and -0.03 in RE and LE, respectively. The formula Q = –Ɛ 2 can be used to convert asphericity into eccentricity, 18 resulting the values of 0.00 for RE and 0.17 for LE. Consequently, the selected SCL for the trial was chosen based on the closest FSE, which was 0 for both eyes. In this case, HOAs were altered by all the lenses. However, it is crucial to consider the patient’s ability to distinguish the target. Our patient perceived improved vision with FSE 0, even though HOAs were further reduced with FSE 0.6. This observation can be demonstrated by the simulation of the ‘E’ optotype depicting the point spread function. Further studies on corneas with varying posterior surface eccentricities and larger sample sizes are necessary to validate our hypothesis. Until any strong correlation is established, it is advisable to try lenses with different eccentricities before finalizing a lens. The inability to achieve pin-hole VA and complaints of ocular distortion despite optimal refraction can be indicators of the need to incorporate different eccentricities in the SCL. Furthermore, quantifying ocular aberration is crucial. This enhances our understanding of the patient’s experience of blurred vision and also facilitates comparison of the effects of different FSEs. Conclusion This case illustrates the influence of different FSEs of BSS devices on visual outcomes following SMILE surgery. SCL with varying FSEs helps to further mitigate these aberrations, thereby enhancing optical quality. The insights gained from this case may facilitate the selection of the first trial lens, considerably reduce the chair time and guide in prescribing lenses with appropriate FSE in post-keratorefractive surgery. Consent Written informed consent for publication of their clinical details was obtained from the patient. Data availability No data are associated with this article. References 1. Reinstein DZ, Archer TJ, Gobbe M: Small incision lenticule extraction (SMILE) history, fundamentals of a new refractive surgery technique and clinical outcomes. Eye Vis (Lond). 2014 Oct 16; 1 : 3. PubMed Abstract | Publisher Full Text | Free Full Text 2. Tian H, Gao W, Xu C, et al. : Clinical outcomes and higher order aberrations of wavefront-guided LASIK versus SMILE for correction of myopia: A systemic review and meta-analysis. Acta Ophthalmol. 2023 Sep; 101 (6): 606–618. PubMed Abstract | Publisher Full Text 3. Chalita MR, Chavala S, Xu M, et al. : Wavefront analysis in post-LASIK eyes and its correlation with visual symptoms, refraction, and topography. Ophthalmology. 2004 Mar; 111 (3): 447–453. PubMed Abstract | Publisher Full Text 4. Schornack MM, Patel SV: Scleral lenses in the management of keratoconus. Eye Contact Lens. 2010 Jan; 36 (1): 39–44. Publisher Full Text 5. Yoon G, Johns L, Tomashevskaya O, et al. : Visual Benefit of Correcting Higher Order Aberrations in Keratoconus With Customized Scleral Lens. Invest. Ophthalmol. Vis. Sci. 2010 Apr; 51 (13): 3432. 6. Gumus K, Gire A, Pflugfelder SC: The impact of the Boston ocular surface prosthesis on wavefront higher-order aberrations. Am. J. Ophthalmol. 2011 Apr; 151 (4): 682–690.e2. PubMed Abstract | Publisher Full Text 7. Jabbur NS, Sakatani K, O’Brien TP: Survey of complications and recommendations for management in dissatisfied patients seeking a consultation after refractive surgery. J. Cataract Refract. Surg. 2004 Sep; 30 (9): 1867–1874. PubMed Abstract | Publisher Full Text 8. Tan G, Yang J, Chen X, et al. : Changes in wave-front aberrations after rigid gas permeable contact lens fitting in post-laser in situ keratomileusis patients with visual complaints. Can. J. Ophthalmol. 2010 Jun; 45 (3): 264–268. PubMed Abstract | Publisher Full Text 9. Kumar M, Shetty R, Lalgudi VG, et al. : The effect of scleral lenses on vision, refraction and aberrations in post-LASIK ectasia, keratoconus and pellucid marginal degeneration. Ophthalmic Physiol. Opt. 2021 Jul; 41 (4): 664–672. PubMed Abstract | Publisher Full Text 10. Jagadeesh D, Mahadevan R: Visual performance with changes in eccentricity in PROSE device: a case report. Aust. J. Optom. 2014 Apr-Jun; 7 (2): 108–110. PubMed Abstract | Publisher Full Text | Free Full Text 11. Hastings GD, Applegate RA, Nguyen LC, et al. : Comparison of Wavefront-guided and Best Conventional Scleral Lenses after Habituation in Eyes with Corneal Ectasia. Optom. Vis. Sci. 2019 Apr; 96 (4): 238–247. PubMed Abstract | Publisher Full Text | Free Full Text 12. Hussoin T, Le HG, Carrasquillo KG, et al. : The effect of optic asphericity on visual rehabilitation of corneal ectasia with a prosthetic device. Eye Contact Lens. 2012 Sep; 38 (5): 300–305. PubMed Abstract | Publisher Full Text 13. Badrinarayanan A, Balakrishnan AC, Dutta R, et al. : Impact of Scleral Lens Front Surface Eccentricity on Visual Acuity, Contrast Sensitivity, and Higher-Order Aberrations in Eyes With Keratoconus. Eye Contact Lens. 2023 Sep; 49 (9): 374–378. PubMed Abstract | Publisher Full Text 14. Anand S, Pesudovs K, Coster D: Wavefront Aberrations Arising at the Posterior Corneal Surface in Normal and Keratoconus Eyes as Reported by the Oculus Pentacam. Invest. Ophthalmol. Vis. Sci. 2008 May 14; 49 (13): 1031. 15. Balakrishnan AC, Badrinarayanan A, Sivaraman V, et al. : Fluid reservoir thickness and aberration relationship in keratoconic eyes with scleral lenses. Ophthalmic Physiol. Opt. 2022 Jan; 42 (1): 178–184. PubMed Abstract | Publisher Full Text 16. Domínguez-Vicent A, Esteve-Taboada JJ, Ferrer-Blasco T, et al. : Optical quality comparison among different Boston contact lens materials. Clin. Exp. Optom. 2016 Jan; 99 (1): 39–46. PubMed Abstract | Publisher Full Text 17. Hastings GD, Zanayed JZ, Nguyen LC, et al. : Do Polymer Coatings Change the Aberrations of Conventional and Wavefront-guided Scleral Lenses? Optom. Vis. Sci. 2020 Jan; 97 (1): 28–35. PubMed Abstract | Publisher Full Text | Free Full Text 18. Benes P, Synek S, Petrová S: Corneal shape and eccentricity in population. Coll. Antropol. 2013 Apr; 37 Suppl 1 : 117–120. Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 05 Nov 2024 ADD YOUR COMMENT Comment Author details Author details 1 Cornea and Contact Lens, LV Prasad Eye Institute, Hyderabad, Telangana, 500034, India 2 Contact lens, LV Prasad Eye Institute Kode Venkatadri Chowdary Campus, Vijayawada, Andhra Pradesh, India Deepak Ghimire Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Manish Bhagat Roles: Investigation, Resources, Supervision, Writing – Review & Editing Kiranmayi Chappidi Roles: Investigation, Methodology, Supervision, Writing – Original Draft Preparation Simmy Chaudhary Roles: Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Hyderabad Eye Research Foundation, Hyderabad, India. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 31 Dec 2025, 13:1323 https://doi.org/10.12688/f1000research.158170.2 version 1 Published: 05 Nov 2024, 13:1323 https://doi.org/10.12688/f1000research.158170.1 Copyright © 2024 Ghimire D et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Ghimire D, Bhagat M, Chappidi K and Chaudhary S. Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1323 ( https://doi.org/10.12688/f1000research.158170.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 05 Nov 2024 Views 0 Cite How to cite this report: Chaurasiya SK. Reviewer Report For: Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1323 ( https://doi.org/10.5256/f1000research.173725.r384466 ) The direct URL for this report is: https://f1000research.com/articles/13-1323/v1#referee-response-384466 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 May 2025 Suraj Kumar Chaurasiya , Department of Optometry and Vision Science, CL Gupta Eye Institute, Moradabad, Uttar Pradesh, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.173725.r384466 This case report explores the impact of incorporating front surface eccentricity (FSE) into the design of scleral lenses to improve visual quality in a patient with significantly higher-order aberrations (HOAs) following Small Incision Lenticule Extraction (SMILE) refractive surgery. Despite good ... Continue reading READ ALL This case report explores the impact of incorporating front surface eccentricity (FSE) into the design of scleral lenses to improve visual quality in a patient with significantly higher-order aberrations (HOAs) following Small Incision Lenticule Extraction (SMILE) refractive surgery. Despite good corrected distance visual acuity with conventional lenses, the patient experienced poor visual quality under low lighting. After trials with various designs, the use of an FSE-modified scleral lens resulted in significant subjective visual improvement. The report suggests that front surface eccentricity can serve as an alternative to wavefront-guided designs, particularly in complex post-refractive eyes with irregular optical profiles. Is the background of the case’s history and progression described in sufficient detail? The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up period with the final lens, including any assessments of stability in visual quality, ocular health, or patient satisfaction Information on the lens care regimen prescribed, including recommended cleaning, disinfection, and storage systems, as well as any patient instructions regarding handling and hygiene Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? To enhance the clinical relevance and scientific clarity of the manuscript, I recommend expanding the Discussion section to address the following: Elaborate on the potential optical mechanisms by which FSE may reduce specific higher-order aberrations (HOAs), such as spherical aberration and coma, particularly in eyes with irregular corneas. Discuss when FSE should be considered for example, in post-refractive surgery patients with large mesopic pupils, asymmetric ablation profiles, or in settings where wavefront-guided lenses are not accessible. If possible, comment on the need for the development of FSE-guided fitting algorithms and clinical trials to evaluate the role of various FSE profiles in optimizing visual quality across different patient groups. Is the case presented with sufficient detail to be useful for other practitioners? The manuscript would benefit from the inclusion of a table summarising the specifications of all scleral lenses used during the trial (e.g., diameter, base curve, sagittal height, haptic design, and FSE values) to provide clarity and reproducibility. Please ensure consistent use of terminology: use "higher-order aberrations (HOAs)" throughout the manuscript, and refer to "front surface eccentricity (FSE)" rather than "aspheric front optics," unless explicitly stating that the terms are equivalent in the given context. In Table [1], all higher-order aberration (HOA) values appear to be lower with the 0.6 front surface eccentricity (FSE) scleral lens compared to both 0.0 and 0.8 FSE lenses. Could the authors please clarify why the 0.6 FSE lens was not selected as the final lens choice despite demonstrating the most favourable HOA profile? Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Contact Lens, Anterior Segment, Optometry optics, Keratoconus, Myopia I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Chaurasiya SK. Reviewer Report For: Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1323 ( https://doi.org/10.5256/f1000research.173725.r384466 ) The direct URL for this report is: https://f1000research.com/articles/13-1323/v1#referee-response-384466 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 13 Jan 2026 Simmy Chaudhary , Cornea and Contact Lens, LV Prasad Eye Institute, Hyderabad, 500034, India 13 Jan 2026 Author Response 1. The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up ... Continue reading 1. The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up period with the final lens, including any assessments of stability in visual quality, ocular health, or patient satisfaction Information on the lens care regimen prescribed, including recommended cleaning, disinfection, and storage systems, as well as any patient instructions regarding handling and hygiene Response: We thank the reviewer for the comment. We have added the follow-up period, visual quality and patient satisfaction at the last visit. We have also added the recommended cleaning, disinfection and storage systems as well as handling and hygiene instructions. 2. To enhance the clinical relevance and scientific clarity of the manuscript, I recommend expanding the Discussion section to address the following: Elaborate on the potential optical mechanisms by which FSE may reduce specific higher-order aberrations (HOAs), such as spherical aberration and coma, particularly in eyes with irregular corneas. Discuss when FSE should be considered for example, in post-refractive surgery patients with large mesopic pupils, asymmetric ablation profiles, or in settings where wavefront-guided lenses are not accessible. If possible, comment on the need for the development of FSE-guided fitting algorithms and clinical trials to evaluate the role of various FSE profiles in optimising visual quality across different patient groups. Response: We thank the reviewer for the recommendations. We have made necessary changes in the discussion to elaborate on the mechanism of HOA correction with scleral lenses and the clinical conditions that may require these lenses. Also, we have recommended the need for algorithms as guidelines for the use of SCL with different FSEs. 3. The manuscript would benefit from the inclusion of a table summarising the specifications of all scleral lenses used during the trial (e.g., diameter, base curve, sagittal height, haptic design, and FSE values) to provide clarity and reproducibility. Please ensure consistent use of terminology: use "higher-order aberrations (HOAs)" throughout the manuscript, and refer to "front surface eccentricity (FSE)" rather than "aspheric front optics," unless explicitly stating that the terms are equivalent in the given context. Response: We thank the reviewer for the comment. We have added a table (Table 1) with all the parameter details. The use of terminology throughout the manuscript has been rechecked. 4. In Table [1], all higher-order aberration (HOA) values appear to be lower with the 0.6 front surface eccentricity (FSE) scleral lens compared to both 0.0 and 0.8 FSE lenses. Could the authors please clarify why the 0.6 FSE lens was not selected as the final lens choice despite demonstrating the most favourable HOA profile? Response: We thank the reviewer for the comment. The FSE 0.6 lens was not selected as the patient reported a better, improved vision with FSE 0.0, subjectively. We have rephrased the explanation in the discussion for better clarity. 1. The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up period with the final lens, including any assessments of stability in visual quality, ocular health, or patient satisfaction Information on the lens care regimen prescribed, including recommended cleaning, disinfection, and storage systems, as well as any patient instructions regarding handling and hygiene Response: We thank the reviewer for the comment. We have added the follow-up period, visual quality and patient satisfaction at the last visit. We have also added the recommended cleaning, disinfection and storage systems as well as handling and hygiene instructions. 2. To enhance the clinical relevance and scientific clarity of the manuscript, I recommend expanding the Discussion section to address the following: Elaborate on the potential optical mechanisms by which FSE may reduce specific higher-order aberrations (HOAs), such as spherical aberration and coma, particularly in eyes with irregular corneas. Discuss when FSE should be considered for example, in post-refractive surgery patients with large mesopic pupils, asymmetric ablation profiles, or in settings where wavefront-guided lenses are not accessible. If possible, comment on the need for the development of FSE-guided fitting algorithms and clinical trials to evaluate the role of various FSE profiles in optimising visual quality across different patient groups. Response: We thank the reviewer for the recommendations. We have made necessary changes in the discussion to elaborate on the mechanism of HOA correction with scleral lenses and the clinical conditions that may require these lenses. Also, we have recommended the need for algorithms as guidelines for the use of SCL with different FSEs. 3. The manuscript would benefit from the inclusion of a table summarising the specifications of all scleral lenses used during the trial (e.g., diameter, base curve, sagittal height, haptic design, and FSE values) to provide clarity and reproducibility. Please ensure consistent use of terminology: use "higher-order aberrations (HOAs)" throughout the manuscript, and refer to "front surface eccentricity (FSE)" rather than "aspheric front optics," unless explicitly stating that the terms are equivalent in the given context. Response: We thank the reviewer for the comment. We have added a table (Table 1) with all the parameter details. The use of terminology throughout the manuscript has been rechecked. 4. In Table [1], all higher-order aberration (HOA) values appear to be lower with the 0.6 front surface eccentricity (FSE) scleral lens compared to both 0.0 and 0.8 FSE lenses. Could the authors please clarify why the 0.6 FSE lens was not selected as the final lens choice despite demonstrating the most favourable HOA profile? Response: We thank the reviewer for the comment. The FSE 0.6 lens was not selected as the patient reported a better, improved vision with FSE 0.0, subjectively. We have rephrased the explanation in the discussion for better clarity. Competing Interests: No competing interest Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 13 Jan 2026 Simmy Chaudhary , Cornea and Contact Lens, LV Prasad Eye Institute, Hyderabad, 500034, India 13 Jan 2026 Author Response 1. The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up ... Continue reading 1. The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up period with the final lens, including any assessments of stability in visual quality, ocular health, or patient satisfaction Information on the lens care regimen prescribed, including recommended cleaning, disinfection, and storage systems, as well as any patient instructions regarding handling and hygiene Response: We thank the reviewer for the comment. We have added the follow-up period, visual quality and patient satisfaction at the last visit. We have also added the recommended cleaning, disinfection and storage systems as well as handling and hygiene instructions. 2. To enhance the clinical relevance and scientific clarity of the manuscript, I recommend expanding the Discussion section to address the following: Elaborate on the potential optical mechanisms by which FSE may reduce specific higher-order aberrations (HOAs), such as spherical aberration and coma, particularly in eyes with irregular corneas. Discuss when FSE should be considered for example, in post-refractive surgery patients with large mesopic pupils, asymmetric ablation profiles, or in settings where wavefront-guided lenses are not accessible. If possible, comment on the need for the development of FSE-guided fitting algorithms and clinical trials to evaluate the role of various FSE profiles in optimising visual quality across different patient groups. Response: We thank the reviewer for the recommendations. We have made necessary changes in the discussion to elaborate on the mechanism of HOA correction with scleral lenses and the clinical conditions that may require these lenses. Also, we have recommended the need for algorithms as guidelines for the use of SCL with different FSEs. 3. The manuscript would benefit from the inclusion of a table summarising the specifications of all scleral lenses used during the trial (e.g., diameter, base curve, sagittal height, haptic design, and FSE values) to provide clarity and reproducibility. Please ensure consistent use of terminology: use "higher-order aberrations (HOAs)" throughout the manuscript, and refer to "front surface eccentricity (FSE)" rather than "aspheric front optics," unless explicitly stating that the terms are equivalent in the given context. Response: We thank the reviewer for the comment. We have added a table (Table 1) with all the parameter details. The use of terminology throughout the manuscript has been rechecked. 4. In Table [1], all higher-order aberration (HOA) values appear to be lower with the 0.6 front surface eccentricity (FSE) scleral lens compared to both 0.0 and 0.8 FSE lenses. Could the authors please clarify why the 0.6 FSE lens was not selected as the final lens choice despite demonstrating the most favourable HOA profile? Response: We thank the reviewer for the comment. The FSE 0.6 lens was not selected as the patient reported a better, improved vision with FSE 0.0, subjectively. We have rephrased the explanation in the discussion for better clarity. 1. The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up period with the final lens, including any assessments of stability in visual quality, ocular health, or patient satisfaction Information on the lens care regimen prescribed, including recommended cleaning, disinfection, and storage systems, as well as any patient instructions regarding handling and hygiene Response: We thank the reviewer for the comment. We have added the follow-up period, visual quality and patient satisfaction at the last visit. We have also added the recommended cleaning, disinfection and storage systems as well as handling and hygiene instructions. 2. To enhance the clinical relevance and scientific clarity of the manuscript, I recommend expanding the Discussion section to address the following: Elaborate on the potential optical mechanisms by which FSE may reduce specific higher-order aberrations (HOAs), such as spherical aberration and coma, particularly in eyes with irregular corneas. Discuss when FSE should be considered for example, in post-refractive surgery patients with large mesopic pupils, asymmetric ablation profiles, or in settings where wavefront-guided lenses are not accessible. If possible, comment on the need for the development of FSE-guided fitting algorithms and clinical trials to evaluate the role of various FSE profiles in optimising visual quality across different patient groups. Response: We thank the reviewer for the recommendations. We have made necessary changes in the discussion to elaborate on the mechanism of HOA correction with scleral lenses and the clinical conditions that may require these lenses. Also, we have recommended the need for algorithms as guidelines for the use of SCL with different FSEs. 3. The manuscript would benefit from the inclusion of a table summarising the specifications of all scleral lenses used during the trial (e.g., diameter, base curve, sagittal height, haptic design, and FSE values) to provide clarity and reproducibility. Please ensure consistent use of terminology: use "higher-order aberrations (HOAs)" throughout the manuscript, and refer to "front surface eccentricity (FSE)" rather than "aspheric front optics," unless explicitly stating that the terms are equivalent in the given context. Response: We thank the reviewer for the comment. We have added a table (Table 1) with all the parameter details. The use of terminology throughout the manuscript has been rechecked. 4. In Table [1], all higher-order aberration (HOA) values appear to be lower with the 0.6 front surface eccentricity (FSE) scleral lens compared to both 0.0 and 0.8 FSE lenses. Could the authors please clarify why the 0.6 FSE lens was not selected as the final lens choice despite demonstrating the most favourable HOA profile? Response: We thank the reviewer for the comment. The FSE 0.6 lens was not selected as the patient reported a better, improved vision with FSE 0.0, subjectively. We have rephrased the explanation in the discussion for better clarity. Competing Interests: No competing interest Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 05 Nov 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 2 (revision) 31 Dec 25 read Version 1 05 Nov 24 read Suraj Kumar Chaurasiya , CL Gupta Eye Institute, Moradabad, India Priyam Chaudhary , CL Gupta Eye Institute, Moradabad, India Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Chaurasiya S et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Jan 2026 | for Version 2 Suraj Kumar Chaurasiya , Department of Optometry and Vision Science, CL Gupta Eye Institute, Moradabad, Uttar Pradesh, India Priyam Chaudhary , Department of Optometry and Vision Science, CL Gupta Eye Institute, Moradabad, Uttar Pradesh, India 0 Views copyright © 2026 Chaurasiya S et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for adding suggestion and revising the manuscript. No further comments to make. Competing Interests No competing interests were disclosed. Reviewer Expertise Contact Lens, Anterior Segment, Optometry optics, Keratoconus, Myopia We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Chaurasiya SK and Chaudhary P. Peer Review Report For: Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1323 ( https://doi.org/10.5256/f1000research.194415.r446368) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1323/v2#referee-response-446368 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Chaurasiya S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 May 2025 | for Version 1 Suraj Kumar Chaurasiya , Department of Optometry and Vision Science, CL Gupta Eye Institute, Moradabad, Uttar Pradesh, India 0 Views copyright © 2025 Chaurasiya S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This case report explores the impact of incorporating front surface eccentricity (FSE) into the design of scleral lenses to improve visual quality in a patient with significantly higher-order aberrations (HOAs) following Small Incision Lenticule Extraction (SMILE) refractive surgery. Despite good corrected distance visual acuity with conventional lenses, the patient experienced poor visual quality under low lighting. After trials with various designs, the use of an FSE-modified scleral lens resulted in significant subjective visual improvement. The report suggests that front surface eccentricity can serve as an alternative to wavefront-guided designs, particularly in complex post-refractive eyes with irregular optical profiles. Is the background of the case’s history and progression described in sufficient detail? The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up period with the final lens, including any assessments of stability in visual quality, ocular health, or patient satisfaction Information on the lens care regimen prescribed, including recommended cleaning, disinfection, and storage systems, as well as any patient instructions regarding handling and hygiene Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? To enhance the clinical relevance and scientific clarity of the manuscript, I recommend expanding the Discussion section to address the following: Elaborate on the potential optical mechanisms by which FSE may reduce specific higher-order aberrations (HOAs), such as spherical aberration and coma, particularly in eyes with irregular corneas. Discuss when FSE should be considered for example, in post-refractive surgery patients with large mesopic pupils, asymmetric ablation profiles, or in settings where wavefront-guided lenses are not accessible. If possible, comment on the need for the development of FSE-guided fitting algorithms and clinical trials to evaluate the role of various FSE profiles in optimizing visual quality across different patient groups. Is the case presented with sufficient detail to be useful for other practitioners? The manuscript would benefit from the inclusion of a table summarising the specifications of all scleral lenses used during the trial (e.g., diameter, base curve, sagittal height, haptic design, and FSE values) to provide clarity and reproducibility. Please ensure consistent use of terminology: use "higher-order aberrations (HOAs)" throughout the manuscript, and refer to "front surface eccentricity (FSE)" rather than "aspheric front optics," unless explicitly stating that the terms are equivalent in the given context. In Table [1], all higher-order aberration (HOA) values appear to be lower with the 0.6 front surface eccentricity (FSE) scleral lens compared to both 0.0 and 0.8 FSE lenses. Could the authors please clarify why the 0.6 FSE lens was not selected as the final lens choice despite demonstrating the most favourable HOA profile? Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Contact Lens, Anterior Segment, Optometry optics, Keratoconus, Myopia I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 13 Jan 2026 Simmy Chaudhary, Cornea and Contact Lens, LV Prasad Eye Institute, Hyderabad, 500034, India 1. The manuscript would benefit from the inclusion of a clear clinical timeline and follow-up details to enhance clarity and reproducibility. Specifically, please consider adding: The total follow-up period with the final lens, including any assessments of stability in visual quality, ocular health, or patient satisfaction Information on the lens care regimen prescribed, including recommended cleaning, disinfection, and storage systems, as well as any patient instructions regarding handling and hygiene Response: We thank the reviewer for the comment. We have added the follow-up period, visual quality and patient satisfaction at the last visit. We have also added the recommended cleaning, disinfection and storage systems as well as handling and hygiene instructions. 2. To enhance the clinical relevance and scientific clarity of the manuscript, I recommend expanding the Discussion section to address the following: Elaborate on the potential optical mechanisms by which FSE may reduce specific higher-order aberrations (HOAs), such as spherical aberration and coma, particularly in eyes with irregular corneas. Discuss when FSE should be considered for example, in post-refractive surgery patients with large mesopic pupils, asymmetric ablation profiles, or in settings where wavefront-guided lenses are not accessible. If possible, comment on the need for the development of FSE-guided fitting algorithms and clinical trials to evaluate the role of various FSE profiles in optimising visual quality across different patient groups. Response: We thank the reviewer for the recommendations. We have made necessary changes in the discussion to elaborate on the mechanism of HOA correction with scleral lenses and the clinical conditions that may require these lenses. Also, we have recommended the need for algorithms as guidelines for the use of SCL with different FSEs. 3. The manuscript would benefit from the inclusion of a table summarising the specifications of all scleral lenses used during the trial (e.g., diameter, base curve, sagittal height, haptic design, and FSE values) to provide clarity and reproducibility. Please ensure consistent use of terminology: use "higher-order aberrations (HOAs)" throughout the manuscript, and refer to "front surface eccentricity (FSE)" rather than "aspheric front optics," unless explicitly stating that the terms are equivalent in the given context. Response: We thank the reviewer for the comment. We have added a table (Table 1) with all the parameter details. The use of terminology throughout the manuscript has been rechecked. 4. In Table [1], all higher-order aberration (HOA) values appear to be lower with the 0.6 front surface eccentricity (FSE) scleral lens compared to both 0.0 and 0.8 FSE lenses. Could the authors please clarify why the 0.6 FSE lens was not selected as the final lens choice despite demonstrating the most favourable HOA profile? Response: We thank the reviewer for the comment. The FSE 0.6 lens was not selected as the patient reported a better, improved vision with FSE 0.0, subjectively. We have rephrased the explanation in the discussion for better clarity. View more View less Competing Interests No competing interest reply Respond Report a concern Chaurasiya SK. Peer Review Report For: Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery [version 1; peer review: 1 approved with reservations] . F1000Research 2024, 13 :1323 ( https://doi.org/10.5256/f1000research.173725.r384466) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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