On Friday morning there were three different sessions I wanted so much to be at! I opted for Dr Johns' pain session, Chaidie (my 16yo) took the following great notes on the care and compliance session, and unfortunately we had to miss out on the hydrogen peroxide session.

I have left most of the notes intact and just annotated a bit with my comments in parentheses and highlighting a few things in yellow, so this post is in Chaidie's name. - Rebecca

How hygiene, care and compliance play a role in complications associated with scleral lenses

Drs Daddi Fadel & Mindy Toabe

First thing in Chaidie's notes that caught my eye (naturally, I'm a little sensitized right now):

Are scleral lenses a risk factor for Acanthamoeba ?

1. Large diameter, minimal tear exchange
2. Yes they are

(In other words, you're holding fluid over the eye all day - that fluid better not contain a nasty germ.)

Issues: Storing in saline, showering with lenses, storing lens in contaminated water, did not rub lenses

Cleaning: rub lenses for 15 seconds during cleaning to remove microbial debris

1. Multipurpose solution
2. Lots of PF saline solution

What can we do to help patients with education?

1. Scleral lens handling may lead to dropout
2. Scleral lens handling difficulties are rare (less that 1%) and may be managed with proper patient education
3. 62% of patients felt they did not receive enough edu from their Dr.s (WOW!)
1. Education lowers risk of infection and other complications

Patient inspection

1. Age, tremors, arthritic joints, health

(I love that they highlighted this. These things really make a difference in insertion technique and tools and the training process.)

Methods of insertion/removal:

Manual method: Two/three fingers; Open from the eyelashes

Device method:

1. Plunger stand/upside down coffee cup
2. Orthodontic dental band
3. Plungers/ring applicators
4. Plungers attached to LED lights

Tips/tricks: Vented plunger, using smaller plunger

Removal technique:

1. Different removal plungers
1. DMV ultra/45/classic (for post PK - less suction)
2. Place where lens is lifting off (side)

Station set-up

Quality of life and handling experience with the PROSE device

1. 93% inserted easily
2. 76% for removal - plunger positioning
3. Biggest concern: dropping lens

Scleral lens care:

1. Cleaning (enzyme (Boston) and progent), rinsing, disinfection, storage, application
2. Case - Menicon Progent case recommended
3. Cleaning
1. Tangible Hydra-PEG
1. Permanent bond surface coating
2. Multi-purpose or hydrogen peroxide
4. Rinsing
1. Enhances disinfection
2. Rinse before application and before disinfection
3. Removes microbes and debris
4. Reduces risk of chemical toxicity on cornea
5. Association of acanthamoeba keratitis with tap water use
5. Application solution
1. LacriPure, ScleralFil, NaCl Inhalation Saline Solution
6. Disinfection
1. Boston Simplus, Unique pH
2. Bottle contamination
1. Daily contamination
2. Opened bottle can get contaminated after 5 days, should be replaced after 3 months 
3. Hydrogen Peroxide
1. Best choice, good for sensitivity and dry eye
4. Basket case contamination, potential for chipping
1. Re-Disinfect every night
7. Hydrogen peroxide cases
1. ClearCare and PROSE cases
1. Using multiple ClearCare cases
2. Issue with PROSE - more solution, need to move catalyst
3. Recommended using regular multipurpose case and place one catalyst in each compartment (I found this surprising - how can you do that without risk of damaging a lens?)
8. Case care
1. Rubbing and rinsing
2. Tissue wiping - Not widely recommended
3. Air drying
1. Avoid bathroom/bedroom for location of air drying (leaves salt residue)
2. Only 50% wearers in US use this technique
3. Recommended: Case open-sides-down supported by lids so it is face down but there is air circulation
9. Written recommendation
1. Write and give recommendations for products and procedures to use
2. FAQ

(YES! YES! YES! Would you all pretty please do that?)

Issues

Air bubbles

1. Symptoms: discomfort, reduced VA
2. Large bubbles may cause dessication of the cornea (In Chaidie's original notes somehow this auto-corrected to desecration, which cracked me up)
3. Causes: bad-fitting lens, improper application, not filled with saline,
4. Management:
1. Overfill, educate patient, use device for SC application, use more viscous solution

Corneal staining

1. Toxic reaction or hypersensitivity to cleaning solutions
2. Handling issues
3. Air bubbles
4. Management: Rinse correctly, PF saline, inspect for debris, reeducate patient

Epithelial Bogging

1. No symptoms
2. Clinical signs
1. Ocular surface water-logged

Midday fogging

1. Debris in fluid reservoir, diffused cornea punctuate staining
2. Release of cells from cornea with preservative sensitivity
3. Management
1. Wash eye with eyebath, avoid rinsing and reinserting throughout day
2. Hold preservative free saline to the lens edge and squirt the solution into reservoir, viscous solution

Limbal hypertrophy

1. Toxic reaction, hypersensitivity

Limbal redness

1. Toxic reaction, hypersensitivity
2. Excessive pressure upon lens application

Deposits

1. Tear film, compliance, hygiene, care system, cosmetics and non-adequate soaps
2. Management
1. Proper storing, hydrogen peroxide
2. Weekly cleaner, rinse prior to application
3. Hydra-PEG

Poor wettability

1. Various factors: Poor hygiene, cosmetics, lab-related issues
2. Management: Appropriate soaps, apply cosmetics and creams after lens application
3. Use toothpaste without microgranules to polish the lens (yes, I was surprised too)

Microbial Keratitis

1. Overnight wear, poor compliance

Giant Papillary conjunctivitis

1. Mechanical irritation, toxic reaction, or allergic factor by deposits on lens surface

Conclusion:

1. Good fitting lens is not necessarily successful over time
2. Complications may occur due to poor compliance or misinterpretation or instructions