Published online 05-05-2017
Daddi Fadel DOptom
The advent of gas permeable material in scleral lenses (ScCL) has reduced hypoxia related to pMMA [1-5]. However, new complications occurred and others still persist. The SCOPE (Scleral lenses in Current Ophthalmic Practice: an Evaluation) study reported the most common complications to be caused by lens handling (insertion and removal) and patient poor compliance using different solutions than those recommended by the specialist such as contact lens (CL) cleaner instead of conditioning solution to store lenses or saliva to clean lenses. The less common complication was microbial keratitis (MK) .
Poor compliance may be due to incorrect behaviors that trigger the onset of discomfort, eye surface alterations, and even reduction of visual performance. The association of contact lens use and microbial keratitis (MK) has been documented for several years and is more recurrent in soft lens wearers comparing to RGP lens ones [7-10] resulting 3-4 times lower than that of soft lenses . The most important factors related to MK using RGP lenses are were storing lenses in tap water, wearing their lenses while sleeping, topping off contact lens solution in the case, and overnight wearing lenses such as in orthokeratology .
It may be possible that the incidence of infections is even inferior with ScCL wearers because of several factors. ScCL are majorly worn during the day and there are few cases of overnight wear, which is a potential factor for developing infections [12-13]. Then, the presence of the liquid reservoir created by the lens vault over the cornea allows continuous corneal hydration, avoiding areas desiccation, and prevents mechanical irritation from the lids during blinking . Finally, compliance rate concerning hygiene is higher in ScCL wearers because of their ocular disease necessitating particular ocular hygiene, therefore, they are maybe more diligent in compliance than wearers of CL with other modalities .
Nevertheless, ScCL are indicated in individuals presenting compromised cornea, which is a potential risk factor for developing an infection. Also, it is common for these patients to take oral and/or topical corticosteroids which are responsible for reducing the immune defense [14,16-20]. Not storing and cleaning the lenses properly are potential extra risk factors [16,18].
To reduce the risk of contact lens-related infection the American Optometric Association submitted some recommendations for CL wearers regarding CL handling, wearing, solutions and cases
Concerning scleral lens use, further recommendations are necessary:
Scleral lens handling
1. Rinse the ScCL with preservative-free saline prior to insertion to remove debris, generally of organic origin, after disinfection process.
2. Overfill the ScCL to the top until the non-preserved solution appears convex above the lens.
3. Clean daily the ScCL rubbing in the palms with surfactant and isopropyl alcohol before disinfection process.
4. Clean the ScCL case rubbing than rinse with multipurpose solution or saline solution and then air dry it on a clean tissue.
5. Disinfect insertion and removal plungers after each use and then air dry them on a clean tissue.
6. Replace plungers every 6 months or before if they are damaged.
7. Follow the eye specialist instructions to ScCL insertion and removal.
Scleral lens wearing
1. Avoid sleeping in your contact lenses.
2. Inspect the lens after insertion in the eye for air bubbles.
3. Always follow the recommended contact lens replacement schedule prescribed by your eye specialist.
4. Observe your regularly scheduled follow-up ScCL and eye examination.
Scleral lens solutions and cases
1. Use only preservative-free saline solution to fill the ScCL.
2. Use hydrogen peroxide solutions for ScCL disinfection.
3. Use cases large enough to contain ScCL during storing and disinfection.
4. Use only insertion and removal plungers recommended by your eye specialist.
5. Avoid placing lens cases in the bathroom.
Patient education may be a factor to influence compliance. Observing the patient manipulating the lenses during the follow-up visit is crucial to ascertain the level of compliance. It is important that the fitter dedicates the necessary time to clarify to the patient the proper management of the lens case which is a crucial element to prevent infections . Using a questionnaire may be a supplementary tool to make sure of the level of compliance among ScCL wearers. Morgan, in a study, proposed series of questions to ask patients during the follow-up visits . Below there is an adaption of the Morgan’s questionnaire to the use of ScCL:
1. Do you sleep overnight in your lens?
2. Do you nap in your lens?
3. How often do you sleep in your lens?
4. Do you wash your hands before inserting and removing lens, and what with?
5. What do you use to clean/store your lens?
6. Where do you store your lens?
7. Do you replace your solution or top up?
8. Do you cover your lens completely?
9. Do you close your lens case tightly?
10. Do you clean your case?
11. How often do you change your case?
12. Do you close the cap of your bottle tightly?
13. Do you ever check the expiry date of your solution bottle?
14. How often do you replace your lens?
Comparing to this questionnaire further questions may be necessary using ScCL:
15. What solutions do you use to fill the lens?
16. What solutions do you use to disinfect and store lenses?
17. What device do you use to ScCL insertion and removal?
18. Do you disinfect your devices after each use? And what with?
19. How often do you replace your insertion and removal device?
20. Do you inspect the lens after insertion in the eye?
21. What case do you use to store lenses?
Also, patients must be educated to be aware to remove contact lenses and contact the eye-care professional if they’re experiencing irritation, worsening eye pain, light sensitivity, sudden blurry vision, or unusually watery eyes or discharge.
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Daddi Fadel Dip Optom (IT) is a lens designer and specialist in contact lenses for irregular cornea, scleral lenses and orthokeratology. She speaks five languages, Arabic, French, English, Italian and Greek. She studied optometry at Istituto Superiore di Scienze Optometriche (ISSO) in Rome (1998-2001), a four-years course achieved with honor. She started to lecture since the first year of school of Optometry. She runs a optometric practice specialized in contact lenses in Italy where she designs and fits special customized contact lenses. She lectures and publishes internationally especially on contact lenses in irregular cornea, scleral lenses and ortho-k. She is the Founder and President of Accademia Italiana Lenti Sclerali (AILeS), board member of Accademia Italiana Lenti a Contatto (AILAC) and Fellow of Scleral Lens Society (SLS).
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