Supplementing the saline in your scleral lenses

Today's blog post was prompted by a question on last week's scleral lens survey. The question and answer are at the end of the post.

Why do some people add Refresh Celluvisc (or another lubricant drop) to the saline in their scleral lens?

For a very long time, some people have added one or more drops of Refresh Celluvisc to the bowl of their scleral lens before insertion.

A key motivation for the original "Celluvisc trick" was specifically to impede debris/mucous from migrating underneath the lens.

The classic situation was patients with serious ocular surface diseases (Stevens Johnson, GvHD, Sjogrens, OCP, etc) whose corneas needed the fluid reservoir that a scleral provides but whose conjunctiva were constantly producing more mucous, which would creep under the lens and lead to cloudy vision as the day progressed. The addition of Celluvisc, for some reason, seemed to help keep their lens reservoir clearer.

Fast-forward to today. In the past 20 years, scleral lenses have transformed from almost unknown to very popular for many corneal diseases, including, increasingly, dry eye. (They are now also being promoted to many people with healthy eyes, but that's another story.)

And lots of people getting sclerals translates into a wide variety of experiences and issues - particularly as regards lens fogging, deposits, and lens comfort. So there has been a lot of experimentation, to the point where we sometimes joke about all the "cocktails" people are mixing up in their lenses.

Is this something you should try? 

Possibly. Here's my suggestion of a little practical test.

Are each of the following true for you?

• I am consistently having issues with scleral lens comfort and/or fogging or deposits under my lenses.
• My optometrist knows about this and has ruled out all the obvious causes (e.g. treating dry eye, treating allergy, making sure the lens fit is optimized, etc.)
• My optometrist has reviewed my cleaning and disinfection routine and solutions and feels my lenses are getting as clean as needed.
• I have tried buffered preservative-free salines Scleralfil and Nutrifill, and still have the problem.
• I wash my hands with moisturizer-free soap.

In other words, IF you're having issues, and IF you've ruled out other obvious causes. Honestly, this is pretty cheap and easy to try, so I would think of it as a "can't hurt, might help" type of thing. If you're struggling with persistent midday fogging, don't forget to check out our tutorial.

Which lubricant drops are appropriate?

Please understand that there are NO lubricant eye drops (a/k/a "artificial tears") at all that are labeled for the purpose of filling scleral lenses. I'm not sure there ever will be, either, because this is such a "niche" need. 

So, putting lubricant drops in your lens is an "off label" use of the drops and should - like ALL your scleral lens solutions, be cleared with your eye doctor. In the scleral lens world, over the years, "off label" has been the norm for many of our solutions - from Unisol 4 to Addipak and others. There are certain usages that have gradually come to seem generally accepted as safe practices That doesn't mean your eye doctor will necessary consider them appropriate for you or helpful for you, so don't forget to have that conversation.

Anyway, on the basis of that "off-label" understanding, here are some "guard rails" for using drops in your lenses:

• Choose only preservative-free products. (The box will say Preservative-Free on the front if that's true.)
• Avoid drops containing oils (don't forget to check the inactive ingredients list) or described as an "emollient" as they may make your lenses magnets for crud.
• Choose FDA compliant OTC drops with a "Drug Facts" box. (This is, unfortunately, no longer an entirely failsafe rule; Regenereyes, for example, is currently masquerading as an OTC drop despite being a biologic which is clearly stated by the FDA to be ineligible for OTC status. If you want to keep your eyes safe, please use drops from trusted manufacturers that are not known to be dodging regulatory rules.)

Is there anything magical about Celluvisc?

Bit of a mystery. No one really knows for sure. We know Celluvisc is one of the thickest preservative-free drop on the market, and it may have been the only thick one on the market when this whole idea got started. Some feel that the viscosity helps keep any debris from migrating under the lens. It's also probably affecting the pH of the solution, which could conceivably have an effect on fogging or comfort, though who knows what the resulting pH of it is considering people historically add different amounts of drops to different types of saline. 

In recent years, many people have reported using other preservative free tears in their saline. The one I have personally heard about most is Oasis Tears (or Oasis Tears Plus), though honestly, people are experimenting with a wide variety of tears now in the quest for comfort and clarity.

At the end of the day, Celluvisc still appears to be by far the most popular drop for this purpose. We will run a survey about this soon to get a better handle on current trends!

Is there a low-cost alternative to Refresh Celluvisc for this purpose? 

This is the reader question that originally prompted this blog post!

Unfortunately, I don't have a short answer. But I do have some thoughts to share.

My first thought is always this: what is the reason for this need, and is the doctor in the loop (in case there's a medical piece that needs addressing)? Maybe the problem is allergy and it can be helped with allergy drops. Maybe it's blepharitis and an eyelid wipe used night and morning could help.In fact, I think another person commenting on the survey described a regimen that includes both of these. But these are just examples. There are so many possibilities.

My second thought is to make sure you've tried the buffered PF saline brands first (particularly Nutrifill and Scleralfil). I know those are more expensive than most unbuffered salines, but even a more expensive saline is cheaper than having to buy both artificial tears and saline for the lenses.

Next, about alternative lubricants. Since we don't necessarily know why lubricant drops help, it's very difficult to identify good alternatives. But if we assume that Celluvisc helps, at least in some cases, because of how thick it is, then I would suggest drops that are thick but NOT OILY - and make sure they are also not preserved. You might find our ingredient guide helpful.

The drop I most frequently hear about people using in sclerals, other than Celluvisc, is Oasis. But that's more expensive rather than cheaper! - Unless, of course, you get the multi-dose preservative-free bottle. This has a lot more drops than a box of 30 vials, and it has the advantage that you aren't tempted to stretch out a preservative free vial day after day leading to non-sterile drops. 

...Which leads me to my net-to-last point, which is that MDPF (multi-dose preservative free) bottles are definitely the way to go for cost savings of any lubricant drop that you add to your sclerals, assuming you are just adding a few drops at most per day. Don't forget, though, most brands of MDPF bottles need to be discarded 90 days after opening.

Finally, as regards decent PF drops at low cost, Refresh Plus is available in bulk at Costco. Depending on the specific need, this may or may not work well enough. But Refresh Plus is the same active ingredient as Celluvisc, just a lower concentration, so it may be worth a try.