What solution do you use for sclerals?

By now you may have seen a couple of webinars, attended a wet lab or two, watched some YouTube videos and have chosen a couple of lens designs. Good start! Equally important, critical even, to a successful fit is using proper solutions.

The post-lens tear layer (PLTL) remains in contact with the cornea for long periods of time with a scleral lens so chemical toxicity may occur.  Management consists of three equally important components: 1.) solution tolerance 2.) adequate disinfection 3.) patient compliance.  All are critical to success.

Solution tolerance

The current standard-of-care is non-preserved, sterile saline usually dispensed from unit dose vials. LacriPure (Menicon -5 ml) and ScleralFil (Bausch and Lomb -10 ml) are the only two FDA approved solutions for filling the bowl of a scleral lens. LacriPure is unbuffered 0.9% NaCl saline while ScleralFil is also pure saline but employs borate buffers.

Differences of opinion exist as to the benefits of buffered versus non-buffered solutions.  Historically, experienced practitioners have used nebulizer inhalation saline (Addipaks) in the bowl as the FDA approvals are quite recent.

Purilens Plus (The Lifestyle Company) saline is a multi-dose (4 oz.) buffered, non-preserved saline that has become popular since the discontinuation of Unisol 4. Purilens recommends disposing of any unused solution after 15 days.

Some practitioners prefer the larger bottle as they feel that it encourages a thorough rinsing of the lens following cleaning and/or disinfection. Others feel that a larger quantity of non-preserved solution carries the increased risk of contamination. The Lifestyle Company states that the solution is manufactured in an FDA approved facility but as of yet does not have the approval to be used for insertion.

Many practitioners (including this one) frequently instill 3-4 drops of a non-preserved artificial tear first in the scleral bowl before topping up with saline. The thinking is that a more viscous solution helps stabilize the saline, provides additional cushioning, lubrication and slows the influx of tear debris that could contribute to midday fogging. Commonly used brands include Oasis Plus, Refresh Optive Advanced, Celluvisc, Systane Non-Preserved and Thera Tears.

Adequate disinfection

It is important to remember that disinfection is not the same as sterilization. Disinfection does not mean that that the lens is “sterile” but simply that the bacterial load has been reduced to a level where an infection is unlikely. Therefore it is important for the fitter to select solutions that will adequately disinfect but will not leave a residue on the lens which could irritate.

The recent SCOPE Study Group  (Harthan, Barr, Nau, Schornack, et al) reported that 62% of practitioners recommend hydrogen peroxide disinfection probably for this reason. Debate continues and more research is required in order to determine exactly the time and concentration required to kill bad actors like acanthamoeba and adenovirus.   

While hydrogen peroxide may disinfect the lens, it does not possess any conditioning properties for the plastic. All-in-one RGP solutions like Unique pH (Menicon) and Boston Simplus (Bausch & Lomb) provide disinfection when used properly while at the same time condition the lens surface. 

An adequately conditioned lens will be more hydrophilic, deposit resistant and may be more comfortable. Scleral lenses are, after all, just a very large RGP lens. An “all-in-one” solution also has the advantage, in many cases, of being well-tolerated by the cornea in the event that a thin residue remains on the lens after rinsing. 

It is important that we stress the necessity of a thorough rinsing to our patients. However, we all know that, in their haste, patients sometimes take shortcuts.

Patient compliance

Compliance with the recommended cleaning, disinfecting and storage solutions is an inalterable facet of successful scleral lens wear. This must be reinforced over and over at every progress visit. Patients may become lax or bewildered by all the products on the solutions aisle at the supermarket. Sometimes they take advice from well-meaning friends or family.  

For these reasons we have the patient explain to us what their current care regimen entails; both the sequence and the products used. We review, correct when necessary and sometimes offer tips. All the recommended products are available for sale in quantity at our office. Many patients enjoy this convenience. Handouts are also provided with website addresses where products can be ordered directly.

With proper care, scleral lenses can last up to two years before needing to be replaced. We find that this is the norm for many patients in our practice.

Scleral lenses can make such a positive impact in the lives of many of our patients. For some, it is the difference between living a productive and meaningful life or becoming a virtual prisoner of their compromised vision. It is incumbent on us to guide our patients in the proper care and handling of their lenses so they may receive the maximum benefit.

Editorial comment by Dr. Laura Periman, MD

Dr. Arnold eloquently summarizes the key issues of scleral lens bowl fluids in his article. I appreciate the opportunity to share my own experience with the sensitive nature of “What’s In Your Bowl”.

The EyeCare Provider’s role in clearly directing patients’ lens care techniques, wearing patterns and filing agents cannot be overemphasized. As an OSD specialist, I am very grateful for the skilled scleral lens fitters in my community. The “What’s In Your Bowl” aspect of this wonderful therapeutic device indeed matters. 
One severe OSD patient in particular returned for follow up after a beautiful scleral lens fit. His cornea had worsened confluent staining and I was indeed surprised. He had all day comfort but marked blurring after scleral lens removal (understandable given the extensive staining). Upon systematic review of his techniques, the culprit was discovered…..he had misunderstood the (verbal) directions on what to use to fill the bowl and had been using a generic all-in-one SCL solution! The all day contact with preservatives and other ingredients explained the marked epitheliopathy. That day, our wonderful front desk person helped him order the exact preservative free saline product. In follow up, four weeks later, a beautiful cornea with almost no symptoms and almost zero staining rewarded us all.   The new micro environment created with the scleral RGP and the appropriate PF fluid set the stage for corneal healing and ongoing protection. 
Patients with OSD have a lot of information to assimilate and execute. Late state OSD is expensive, time-consuming and burdensome for our patients. I believe that by removing as many patient barriers as possible and by providing exacting, directed, specific bowl filling recommendations, we can avert such set backs and guide our often overwhelmed patients to greater successes. 

Editorial Comment By Dr. Steven Sorkin, OD

Proper care of scleral contact lenses is very important in the success of your patients with typically challenging corneas and medical conditions. Most patients utilizing scleral lenses have corneal disease. Using incorrect solutions can adversely affect the patient. In my office, we provide handouts with photos of all of the lens care solutions and application and removal devices required by the patient. In addition, we give starter kits to reinforce the proper care of these specialized lenses. My technicians and I also review all solutions with the patient at every visit.

Lens care solutions are very specific in their indications. With new generation lens materials, it is very important to make sure that you are prescribing the appropriate care system in order to ensure healthy, safe lens wear. Many of our patients have concurrent, ocular surface disease, and incorrect solutions can affect the wettability, comfort, and performance of these lenses. Complications such as anterior surface filming can be exacerbated by incorrect lens care.

Recently, a new contact lens surface treatment, HydraPeg, from Tangible Sciences, has been introduced. This has made a significant improvement in wettability and deposit resistance. There are only a select few solutions approved for use with the HydraPeg coating. In addition, no harsh cleaners can be used with this coating. As technology in lens materials, lens coating, and solutions improve, it is vitally important for practitioners and patients alike to comply with proper lens care for successful, safe lens wear. 

Tangible HydraPeg is a 90% water polyethylene glycol polymer mixture that is permanently bonded to the surface of the contact lens, according to the company. Early clinical studies of HydraPeg show improvement in wettability, lubricity, deposit resistance, tear film quality, subjective comfort and overall patient preference (Sindt).

Early use of this technology in my practice has improved comfort and wearing time of my specialty contact lens wearers, especially those with ocular surface disease and heavy lens depositors. Of significant importance is that the coating should last a minimum of 1 year.