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Hygiene and Care
Scleral Lenses
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Proper hygiene and care prior to scleral lenses application and removal is crucial to avoid complications and eye infections. It is important to highlight that when we talk about the scleral lens hygiene and care we include the correct hygiene of the lens case and of the accessories for lens application and removal; this is equally fundamental because the microorganisms present on the lens case and on the plungers can transfer on the scleral lenses causing contamination.
I- Scleral Lens Application:
1- Rinsing
Take the scleral lens from the case where it was placed for overnight storage and rinse it thoroughly with the preservative-free saline solution. Rinsing the scleral lens before fitting is critical to remove the chemicals present in the preservative solution in which the lenses were placed overnight and thus to prevent irritation and chemical toxicity of the cornea [1,2].
2- Filling the lens
Overfill the lens with sterile preservative-free saline until the solution appears convex on the lens (Figure 1). The solution should be preservative-free as it will be in contact with the eye tissues throughout the lens wearing time. Prolonged contact with a solution containing preservatives will compromise the corneal tissues [1,2]. In cases where air bubbles or the presence of debris in the post-lens fluid reservoir persist, it is necessary to use a more viscous solution. In any case, the solutions for filling scleral lenses must be exclusively free of preservatives.
II- After Lens Application
Lens case:
Proper hygiene and care of the lens case, which is used to store the lenses overnight, is essential to minimize or prevent its contamination. The case should be cleaned by rubbing, rinsed and tissue wiped after each use. Several studies have shown the effectiveness of rubbing and cleaning the lens case with a clean tissue to reduce the formation of biofilm, which is responsible for the onset of eye infections and microbial keratitis [3-6].
1- Cleaning and rinsing
Lens case should be cleaned by rubbing it to detach microorganisms from surfaces. It is advisable to use a cleaning solution containing isopropyl alcohol combined with a surfactant, the same solution used for rigid contact lenses. Rinsing the cases with saline solution allows the total elimination of residues (microorganisms and chemical agents).
2- Tissue wiping
Tissue wipe the lens case after rinsing is essential. All the solutions used for contact lens care are isotonic * containing a small number of dissolved salts. Allowing the case to air dry without tissue wiping it, will lead to the evaporation of the liquid parts of the solution while the salts will remain attached to the surfaces (Figure 2). In the evening, the new isotonic solution that is used for lens storage will be mixed with the salts remaining on the surfaces, increasing the total amount of salts in the solution, transforming the new solution from isotonic to hypertonic. A hypertonic solution may promote the survival of Staphylococcus aureus [7]. Furthermore, tissue wiping the lens case removes the biofilm. After drying the lens case, close it again and keep it in a dry and clean place.
Accessories (plungers):
Accessories for fitting and removing scleral lenses should also be cleaned by rubbing, rinsed and tissue wiped after each use. Cleaning the accessories is essential as microorganisms can transfer to contact lenses causing contamination and eye infections.
1- Cleaning and rinsing
The disinfection solution or extra-strength cleaner, with isopropyl alcohol combined with a surfactant, may be used for cleaning the accessories. Alternatively, accessories may be cleaned with alcohol or alcohol wipes.
2- Tissue wiping
After cleaning it is crucial to tissue wipe the accessories with a clean tissue. Remember that humid environments favor the growth and proliferation of microorganisms. After cleaning and drying, put the accessories back in their container and place them in a dry and clean place
III- Scleral Lens Removal
1- Lens Cleaning
Scleral lenses should be cleaned prior to overnight storage to remove microbes, debris (including lipids and tear film proteins), cosmetics, and creams that can adhere to lens surfaces during wearing. This procedure makes the disinfection of the lenses more effective. It is necessary to clean the lenses by rubbing them in the palm of the hand or between the thumb and forefinger for a minimum of 15 seconds with a cleaning solution indicated by the specialist.
2- Rinsing
After rubbing the lenses, which allows the detachment of the various deposits and microorganisms from lens surfaces, it is essential to rinse the lenses with a saline solution to remove these residues, the debris that accumulate during the day and the chemical agents present in the cleaning solution.
These two procedures are essential to prevent the transfer of microorganisms from the lenses to the cases and from the cases to the lenses, and therefore to avoid eye infections and to improve the disinfection process.
3- Disinfection and storing processes
Scleral lenses should be stored in a solution that allows their disinfection. It has been reported that 3% hydrogen peroxide solution neutralized with a metal catalyst is the most effective system to minimize contamination [8]. This disinfection system is active with all pathogenic microorganisms including gram-positive and gram-negative bacteria, micro-bacteria, fungi, lipophilic viruses, hydrophilic viruses and spores [9]. The lenses should not be stored in hydrogen peroxide for more than one night as the neutralization process with the platinum catalytic disc breaks down the hydrogen peroxide into a saline solution, which does not provide a continuous disinfection process. However, the maximum storage period in the same solution depends on the type of hydrogen peroxide used and the manufacturer's recommendations. The storage time in some hydrogen peroxide solutions could be up to a week and others up to 14 days [9]. However, this limit is very marginal with scleral lenses as scleral lens patients need their lenses every day, after storing them for up to one night in the disinfectant solution. Another limitation of this solution is the small basket provided in the package. Other cases are available, and they are discussed in the section “Various Containers Available for Storing Scleral Lenses”. Furthermore, compliance with hydrogen peroxide is high because the use of this solution is simple and easy to do or understand. This was confirmed by a study which showed that only 37% of contact lens wearers using multipurpose solutions followed the instructions given by the specialist, while 100% of patients using hydrogen peroxide with platinum catalytic disc complied with the recommendations. of the professional [10].
Sometimes, scleral lens wearers need to remove the lenses during the day and reapply them after a short time. The use of hydrogen peroxide is not indicated in these cases as it requires a minimum of time for the neutralization of the solution itself. For these occasions it is advisable to use a multipurpose solution or a storing solution suitable for rigid contact lenses. You should consult your specialist to find the most suitable solution in these circumstances.
4- Additional solutions to be used weekly or monthly
The use of a weekly cleaner, which has a stronger action than a daily cleaner, is recommended to remove proteins and other deposits from lens surfaces. The back surface of the scleral lens has a concave shape which makes it more difficult to clean and rub properly. Over time, deposits accumulate on the back surface causing irritation and reduced wearing time. The weekly use of an enzymatic cleaner helps to eliminate deposits that are not easily removed with daily detergents.
Some solutions such as Progent® (www.menicon.com) allow effective removal of proteins by merely soaking the scleral lens for 30 minutes in a mixture of two solutions: (A) sodium hypochlorite and (B) potassium bromide. Furthermore, due to its antiviral efficacy and antibacterial, antifungal [11] and anti-acanthamoeba activity [12], this mixture of solutions can be indicated for a strong and rapid disinfection in 5 minutes, eliminating the microorganisms responsible for lens contamination [13 ]. Storage for more than 30 minutes in this combination of solutions can discolor contact lenses. Scleral lenses should be rinsed after treatment with sterile preservative-free saline. It is advisable to use this solution combination once every 15 days or every month, depending on the eye condition of the wearer. The Progent® container is designed for corneal contact lenses. Rotating one or both lens holders in the case provided will allow them to be used for most scleral lenses up to 18.00 mm in diameter (Figure 4).
Weekly cleaners should be used with caution as they may damage or remove surface treatments of scleral lenses.
Figure 1: A scleral lens overfilled with preservative-freesaline until the solution appears convex above the lens.
Figura 2: Salts residues remained in the case.
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Figure 3: Clean and tissue wiping an application plunger.
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B
C
A
Figure 4: Progent® case is designed for corneal contact lenses (A). Rotating one side (B) or both sides (C) will hold large scleral lenses.
IV- Replacement Frequency fo Lens Case and Accessories
Changing the lens case every two weeks significantly reduces the incidence of microbial contamination [14]. Nowadays, most solutions include a new container in the package that allows wearers to change the case every 4-6 weeks. Therefore, it is suggested to replace the case often or at the very least every time a new solution is used.
As for accessories for scleral lens application and removal, it is recommended toreplace them every 6 months or whenever the accessory is broken or its edges become irregular. In these cases the accessory may not provide good adhesion to the lens or leave residues on the lens surface [1,2].
Essential Note: NEVER USE TAP WATER. Various studies have shown a strong correlation between the use of tap water and the development of Acanthamoeba keratitis.
* An ophthalmic solution is isotonic if it contains the same concentration of solute as of tears.
References
1- Fadel, D. Scleral Lens Issues and Complications. Their Recognition, Etiology, and management. Dougmar Publishing Group, Ontario Canada 2020. Chapter 8, pp 261-276.
2- Fadel D, Toabe M. Scleral lens hygiene and care. J Cont Lens Sci. 2018;2;30–37.
3- Bates AK, Morris RJ, Stapleton F, Minassian DC, Dart JK. ‘Sterile’ corneal infiltrates in contact lens wearers. Eye (Lond). 1989;3:803–10.
4- Wiley L, Bridge DR, Wiley LA, Odom JV, Elliott T, Olson JC. Bacterial biofilm diversity in
contact lens-related disease: emerging role of Achromobacter, Stenotrophomonas, and Delftia. Invest Ophthalmol Vis Sci. 2012;53:3896–905.
5- Wu Y, Willcox M, Stapleton F. The Effect of Contact Lens Hygiene Behavior on Lens Case Contamination. Optom Vis Sci. 2015;92:167–174.
6- Willcox MD. Solutions for care of silicone hydrogel lenses. Eye Contact Lens.
2013;39:24–8.
7- Cho P, Boost M. Rivers and mountains may change, human nature does not! (traditional Chinese saying). Cont Lens Anterior Eye. 2009;31:155–6.
8- Lupelli L. Il contenitore: il brutto anatraccolo della contattologica. LAC. 2010;12:3–6.
9- Lupelli L. Il perossido d’idrogeno nella manutenzione delle lenti a contatto. Lac. 2015;
17:17–21.
10- Dumbleton KA, Woods J, Woods CA, Fonn D. Compliance with current contact lens regimens. Optom Vis Sci. 2007;84:E-abstract 070087.
11- Menicon Pharma ref: ISO/CD 14729 stand-alone test.
12- Bacteriology Institute, Strasbourg Medical University; Menicon Co., Ltd./Microbiology and Immunology Department, University of Leicester UK.
13- Medical University Nancy MDT, reference: CEN/TC216/N 98, AFNOR NFT 72-180.
14- Willcox MD, Carnt N, Diec J, Naduvilath T, Evans V, Stapleton F, Iskandar S, Harmis N, de la Jara PL, Holden BA. Contact lens case contamination during daily wear of silicone hydrogels. Optom Vis Sci. 2010;87: 456–64.