Yeah, well a scleral lens is any lens that vaults the cornea and rests
on the sclera.  The definition does not include the diameter, it
doesn't specify the material, and it doesn't specify the thickness,
nor any of the many shape parameters that are possible.  I've seen
scleral lenses that look like shot glasses, and I've seen some that
look like large soft lenses.  The devil is in the design and the
details.  So, I bet bitoric scleral lenses could be a GREAT options
for you.

50% of my scleral fits are for non-surgical patients.  I have fit them
on teenagers and adults for whom other options had not worked very
well.  I've even done a multifocal scleral lens.

It's just a matter of time before their use becomes more widespread
and they outgrow the stigma of being thought of as lenses for people
with disfigured eyes.

I would like to make a few comments regarding contact lenses for high
astigmatism.  I must state that I have a vested interest in what I am
about to say, but I hope most will find the information useful,
especially since I never see this discussed in this forum.

I have had a 25 year love-hate relationship with toric soft lenses,
and those patients represent the single largest pool of potential
LASIK candidates.  The majority of them do not achieve the vision and
comfort that the rest of us do with soft contact lenses.  Surely there
have been improvements, but the parameters are still limited, and
20/20 comfortable vision is still an elusive target for many.  I have
worked with large GP lenses over the years.  During the past year I
have been doing intensive research in fitting methods and design,
primarily for therapeutic applications, i.e. situations that one would
consider medically necessary.  One important outcome of this is that
the lenses have become easier to fit, and very complicated designs are
now possible, including torics and multifocals.  The result is that I
am fitting more non-therapeutic patients, and the scleral-type lenses
are proving to be reliable problem solvers for high astigmatism and
other situations.

There are a few drawbacks, including cost and limited availability,
but once I point out the positives, the patients are more receptive to
trying them.  The positives are: better vision, comfort, and lower
annual replacement costs than disposable lenses.  I have had some
patients go as long as 3 or 4 years between replacements, and 2 years
is probably the norm.  Most of the upfront costs go to the initial
design and fitting, and replacement costs are quite reasonable, i.e.
about the same as a set of custom toric soft lenses.  The vision is
nothing short of stunning, with many patients stating that they have
never seen so clearly, and most report no lens awareness at all.
Because the oxygen permeable polymer contains no water, it doesn't dry
out, and a few blinks are enough to wet the surface without having to
rehydrate the entire lens mass.  One of my patients is a family friend
with 5 diopters of against-the-rule astigmatism.  Contact lenses had
never worked for him for optical reasons and dry eye.  He developed a
corneal condition (corneal surface irregularities following cataract
surgery) that warranted a therapeutic lens, and so I put him into
small bitoric scleral lenses.  His quote:  "I have never seen this
clearly, and I often forget that I have them in when I go to bed."  He
is more than 70 years/old.

While there is a significant learning curve to fitting these lenses, I
know that there has been a dramatic interest in them from practioners
around the world.  I also believe that this type of lens will prove to
be a great platform for advanced optical design, such as wavefront
optics.