Eyelid Elevation and Ocular Surface Rehabilitation Using Quadrant-Asymmetric Scleral Contact Lenses in Facial Nerve Palsy with Keratoconus: A 2-Case Series

Introduction: Facial nerve palsy (FNP) with associated ptosis and keratoconus (KC) presents a combined challenge of visual dysfunction, ocular surface disease, and cosmetic impairment. While surgical procedures are frequently performed, scleral contact lenses can offer both ocular surface protection and mechanical eyelid support. While scleral lenses have previously been described for exposure keratopathy and irregular corneal astigmatism, the present 2-case series provides objective MRD1 documentation of eyelid elevation achieved through quadrant-asymmetric scleral contact lens (QASCL) fitting in elderly patients with concurrent FNP and KC requiring simultaneous KC rehabilitation - an outcome combination not previously reported in this population. Case Presentation: Two elderly patients with KC and FNP were fitted with QASCL after poor tolerance of soft lenses. A 71-year-old man with severe lagophthalmos and brow ptosis showed margin reflex distance-1 (MRD1) improvement from 1.0 mm to 3.5 mm and best-corrected visual acuity (BCVA) from 1.3 logMAR to 0.1 logMAR. His Ocular Surface Disease Index (OSDI) score decreased from 79.16 to 33.33 after three months, and the Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8) score was 11. A 74-year-old man with mild synkinesis had MRD1 increase from 0.5 mm to 3.0 mm and BCVA from 1.0 logMAR to 0.02 logMAR. His OSDI decreased from 91.66 to 45.83 after three months, and CLDEQ-8 was 16. Both patients exhibited reduced ocular surface staining, improved meibomian gland function, and decreased conjunctival hyperemia over follow-up. Conclusion: QASCL fitting was associated with clinically meaningful improvements in eyelid elevation, visual acuity, and ocular surface integrity, together with reductions in symptom severity as measured by OSDI and CLDEQ-8. In these two elderly patients with FNP and KC, QASCLs appeared safe, effective, and reversible non-surgical option, providing sustained functional and anatomical benefit during long-term follow-up.