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Fogging with
Scleral Lenses
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Fogging may occur when wearing scleral lenses and may be due to poor lens wettability and midday fogging.
Wettability refers to how liquid spreads over a surface. Scleral lens wettability depends on the lens material, environment, quality of tear production, age, diet, medications, and ocular surface health. It is important to choose a material with a balanced relationship between oxygen permeability (Dk) and contact angle (This angle quantifies wettability) (1,2).
Patients predisposed to poor lens wettability are those with blepharitis, Demodex, and dry eyes from conditions such as graft-versus-host disease, Stevens-Johnson syndrome, severe meibomian gland dysfunction, blepharitis, rosacea, and atopic conditions (3). It is important to treat these conditions with eyelid cleaners, warm compresses, topical drops, and antibiotics before fitting scleral lenses.
Poor wettability at lens delivery may be due to lab-related over-polishing or the transfer of substances to the lens surfaces during the manufacturing process, shipment or in-office handling. Lens verification and inspection should be performed before patient visits. A poor wetting scleral lens should be cleaned with a lab-strength cleaner, then again with a cleaner and then stored in a disinfection care system (4).
If problems in lens wettability occur over time (1,2):
- Care regimen, plunger hygiene, hand soap, cosmetics, and use of lotions should be reviewed.
- Plungers should be disinfected after each use with alcohol or disinfecting solution and replaced every three to six months as suction tends to diminish and residue may accumulate over time. (see scleral lens and plungers care)
- Make sure the plunger is dry before use.
- Soaps containing lanolin, moisturizers or oil should be avoided by switching to soaps indicated for either acne treatment or contact lens use.
- Non-preservative artificial tears should be recommended.
- Apply the scleral lens before applying make-up and remove it before make-up removal.
- Avoid cosmetics inside the eyelid margins.
- Diet may help decrease ocular surface disease, including omega-3 and avoiding fats and fried food.
- Plasma treatment and Hydra-PEG may be indicated.
Video 1: A lens with poor wettability causing fogging of the anterior surface. Video credit Jason Jedlicka.
Video 2: A lens with Hydra-PEG applied in the same eye above, in video 1. Video credit Jason Jedlicka.
Figure 1: Poor wettability and deposits on lens the anterior lens surface in correspondence of the pupil area compromising vision.
Figure 2: Poor wettability in correspondence of the pupil area compromising vision.
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Figure 3: Poor wettability due to laboratory related issues.
Figure 4: Eye with ocular surface disease having issues with poor wettability indicated with the yellow arrow and mucoud in the liquid reservoir indicated with the white arrows.
Midday fogging refers to the presence of debris in the post-lens fluid reservoir. This phenomenon appears only with scleral lens wear and occurs in 33% of wearers, especially in those with a predisposition to dry eye (5). The etiology of this particular phenomenon is unknown and it seems to be multifactorial.
The factors that may contribute to midday fogging are (2,6):
- Adaptation of the ocular surface; in this case, the issue will resolve by itself as the ocular surface adapts to the wear of scleral lenses.
- Atopic or ocular surface diseases. It is important to manage atopy and ocular surface diseases before lens fitting.
- Giant papillary conjunctivitis that needs to be managed.
- A non-optimal fitting relationship such as excessive vault, excessive limbal clearance, a tight fit, mechanical stress of an excessively flat lens landing zone, toric or asymmetric sclera, irregular conjunctiva, thick edge, and edge lift-off. Lens fitting in these cases should be revised.
Further recommendations for midday fogging are the following (2):
- Verify lens design.
- Wash the eye with an eye bath in the morning before lens application.
- The scleral lens may be applied, removed, and reapplied to clear the eye of the morning gunk.
- Avoid making breaks during the day to remove, clean, and refill the lenses with a fresh non-preserved solution.
- Hold preservative-free saline to the lens edge and squirt the solution into the post fluid reservoir.
- Use a more viscous solution for lens filling.
- Use a balanced electrolyte solution for lens filling.
Figure 5: Debris formation in the post-lens liquid reservoir in an eye with oculr surface disease.
Figure 6: Debris in the post-lens fluid reservoir and poor wettability in a dry eye.
Figure 7: Milky midday fogging and poor wettability compromising vision in a patient with atopy.
Figure 8: Milky midday fogging and poor wettability compromising vision in a patient with atopy.
Figure 9: Debris in the post-lens fluid reservoir compromising vision. Image credit Greg De Naeyer.
References:
- Fadel D. Toabe M. Scleral lens issues and complications related to handling, care and compliance. Journal of Contact lens Research and Science, 2018, October; 2(1):e1-e13.
- Scleral Lenses Issues and Complications: Etiology, Recognition and Management. Dougmar Publishing Group Inc., Ontario Canada, 2020.
- Papas EB, Ciolino JB, Jacobs D, et al. The TFOS International Workshop on Contact Lens Discomfort: report of the management and therapy subcommittee. Invest Ophthalmol Vis Sci 2013 Oct 18;54(11):TFOS183-203.
- Bourassa S, Benjamin WJ. RGP wettability: the first day could be the worst day. International Contact Lens Clinic 1992;19:25-34.
- McKinney A, Miller W, Leach N, Polizzi C, van der Worp E, Bergmanson J. The Cause of Midday Visual Fogging in Scleral Gas Permeable Lens Wearers. Invest. Ophthalmol. Vis. Sci; 2013;54;15: 5483.
- Scleral lens issues and complications related to a non-optimal fitting relationship between the lens and ocular surface. Eye & Contact Lens: July 20, 2019;45(3):152-163.