Scleral Lens Tutorial 8 - Midday fogging & debris, RRR, rewetting drops and other practical daily tips

 

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What is "mid-day fogging"?

First, let me say, it doesn't happen to everyone! If you're not having issues, you can probably skip this topic altogether, but it might be best to read the first section so that you'll recognize it if it happens to you.

The term "mid-day fogging" is kicked around constantly in the scleral lens online community. But it means different things to different people, it is described many different ways, and it has many potential causes.

So there is also no single solution. Addressing midday fogging is all about returning to your doctor, troubleshooting, trying things, and, in some cases, accepting tradeoffs such as removing, rinsing and refilling once or more during the day.

Examples of experiences with "mid-day fogging":

  • Your vision starts going a bit cloudy. Signs are harder to read and you're blinking a lot more.
  • You think the inside, or the outside, of the lens is literally looking foggy.
  • There is particulate matter collecting in the fluid in the lens.
  • You are getting a buildup of deposits on the inside or outside of the lens (note that this one can cause not just poorer vision but discomfort too).

Whatever the case, you hit a point in the day when your lenses aren't doing their job.

Naturally, you want to know why this is happening and what to do about it.

Why is this happening to ME?

There are a great many things that can contribute to lens fogging. They include everything from the lens itself, to your lens care routines, the solutions you use for cleaning, disinfection, filling and rewetting, what you use in your eyes overnight, your eye disease(s), and more. 

Some of the causes are not well studied or well understood. So, as a practical matter, after the lens-related factors have been optimized, it may come down to trial-and-error with solutions and routines.

Following is a long list of potential contributors and potential solutions to explore. If you are having persistent issues, make sure your doctor is aware and involved in decisions about any steps you take.

Troubleshooting

Probably the most common solution reportedly anecdotally in our Facebook group is modifying the solutions used - especially filling solutions, but also overnight disinfection. But it's important to understand that there are many more things that can cause lens fogging! Hopefully you will find this table helpful in conversations with your doctor.

 Cause Potential solution(s)
Lens fit?

Return to doctor for assessment and fit tweaking if necessary (TIP: Get an appointment late in the day so they can see the problem while it's happening.)

In some cases it becomes necessary to explore another lens or lens fitting technology or seek a second opinion. If you get a second opinion, make sure it's from someone who has extensive experience with scleral lenses for your specific disease.
Poor surface wetting?

Plasma treatment.

Hydra PEG coating.

It's important to note that Hydra PEG coating will restrict your choice of lens cleaning solutions, and comes off sooner for some users than others. Ask your doctor if your lens can be re-coated if it wears off prematurely, or if you will have to purchase a new lens.
Hand soap containing moisturizers?

Switch to a non-moisturizing hand soap.

This is a frequently overlooked contributor! Scroll down for soap suggestions.
Filling solution pH?

Try a different preservative free saline.

There is anecdotal evidence that changing the type of preservative-free saline may directly affect fogging. Usually (but not always) those who report improvement have switched from unbuffered saline to buffered saline. Buffered options include ScleralFil, Nutrifill and Purilens Plus. Another way to modify the filling solution is to add preservative free artificial tears (see also "filling solution viscosity", below).

Nutrifill is a brand new ph-balanced and electrolyte-enriched preservative free saline and while there are no studies yet, there are anecdotal reports of it significantly improving fogging for some users. 
Filling solution viscosity?

Add or substitute preservative free artificial tears.

The conventional favorite for this over the years has been Refresh Celluvisc. More recently, we are hearing from people using many other types including Oasis Tears Plus, Refresh Relieva and Refresh Optive Advanced. 
Cleaning solution?

Try a different "rub" cleaning solution

There is some anecdotal evidence that for some users, certain cleaning solutions may cause more eye irritation and/or more midday fogging. Changing it up may be worth a try, but always check with your doctor to ensure you are using compatible solutions.
Disinfection solution?

For overnight disinfection, switch from multi-purpose solution to hydrogen peroxide disinfection (e.g. Clear Care).

Switch from Clear Care Plus to regular Clear Care.

There is extensive anecdotal evidence that for some users, switching from a multi-purpose solution to hydrogen peroxide improves their lens fogging. Some users report poor results with Clear Care Plus (Hydraglyde) versus regular Clear Care. 
Protein remover? Many solutions claim to remove protein deposits - but not all so-called protein removers are equally effective. Ask your doctor for a recommendation. The gold standard protein remover is Menicon Progent.
Are you a "heavy depositor"?

Viscous artificial tears in the lens to help keep out debris.

"Squeegie" the top of the lens (if deposits are on the outside) with a Q-tip (cotton only!) dipped in saline.

RRR (see below).

In some severe cases, your doctor may prescribe mucolytic eye drops.

Note:  Some eyes are described as "heavy depositors" because they produce so much excess mucous which attaches to the lens.
Adverse environments, high pollen counts, heavy screen use, etc.?

Dry eye glasses (e.g. Ziena)

Lubricating drops "over the top" (e.g. Refresh Relieva, Blink, etc)

Diligent compliance with dry eye treatments

Use of lid hygiene products, e.g. tea tree wipes

Seeking additional medical care for ocular surface disease(s).

This is a confusing area for many new users. Scleral lenses treat extreme surface disease/dryness by keeping the cornea covered with fluid. However, you can still be subject to ocular surface dryness at the interface between the top of the lens and your lids. This may require extra attention and care for best lens performance.
Residue from overnight ointment?

Rinse eyes thoroughly and cleanse lid margins, lids and lashes with lid wipes (e.g. Ocusoft).

Switch from petrolatum-based lubricating ointments to a polymer gel (e.g. Genteal Gel). If you do not find gel strong enough for nighttime protection, consider additional non-ointment options such as moisture goggles.

RRR (see below).

 

That is a VERY LONG LIST, and it's probably not exhaustive. But this also means that there are many possible solutions to explore. Please review these with your eye doctor to see which potential solutions are likeliest to help you.

The Triple-R Routine (RRR)

When to do it

When you need to, or when your doctor says you should.

For some users, there are additional medical reasons for the RRR routine, for example, patients who are especially vulnerable to the effects of hypoxia may need to have some "breathing" time for their eyes during the day.

Steps

  • Remove
  • Rinse
  • Use rub cleaner if needed
  • Re-fill
  • Re-apply

Don't make these common RRR mistakes!

  • WRONG: Washing your hands with whatever soap they have at the office. (Chances are, it contains moisturizers!) RIGHT: Bring your own soap!
  • WRONG: Failing to let your doctor know what's going on. There may be medical implications or lens fit implications that should be ruled out. RIGHT: Tell your doctor if you find yourself RRR'ing more than once a day.
  • WRONG: Taking your lenses out for a break and putting them in a case with preservative-free saline till you're ready to put them back in. RIGHT: Put your lenses in a multi-purpose solution such as Unique pH or Simplus.

Re-wetting drops and scleral lenses

Many people need to apply some kind of drop over their lens if their eyes feel dry or the top surface of the lens is getting a little uncomfortable during the day. 

So, what drops do you use on top of your lenses? Here are some options. Check with your doctor and get their advice.

Contact lens wetting drops, i.e. drops that are specifically labeled for this purpose. However, there are two issues with these drops: (1) many of them aren't that good - in particular, they may be too thick to be practical on scleral lenses, and (2) they ALL contain preservatives, and some of us prefer to avoid all preservatives where possible.

Preservative-free lubricant drops: These drops are never labeled for use with contacts (see below for the reason why). But the practical reality is that they are commonly used this way, and commonly recommended by optometrists for this use. Check with your doctor for a specific recommendation. Usually the limiting factors are how thick the drop is, and whether it contains any kind of oil, either of which can interfere with vision or lens comfort. You can also review eye drop ingredients on our ingredient reference list (oils are highlighted in blue).

Preservative-free saline: Many people ask if they can just use their saline to get the lenses wet. It's not labeled for the purpose, but it's obviously being used in the eye all day long and it's not harmful. The practical limitation of saline is that it has no lubricating qualities, so other than briefly wetting the drops, it can't give you very much mileage. 

Why do my artificial tears say that I can't use them with contacts? Lubricating drops and lens wetting drops are regulated by different parts of the FDA - the former is considered a drug, and the latter is considered a device. So even if they both have the exact same ingredients, they are labeled very differently. Traditionally, manufacturers have never 'overlapped' on these - although they may market the same product under two different labels. This is beginning to change as a few manufacturers are going through the testing process to be able to add language to drops indicating that they are contact lens compatible. As always, talk with your doctor about what is best for use with your scleral lenses.

Miscellaneous daily usage tips

Wear time

Your wear time may be determined by your doctor's instructions or, if they have not specified any limits to your wear time, simply comfort and vision. There is no 'normal' for wear time, as you'll see from our survey results. If you have concerns, definitely check in with your doctor. 

Bubbles

Discomfort and/or vision issues can crop up during the day if you got a bubble under a lens during lens application. It is absolutely worth putting in the effort to check carefully for bubbles immediately after application. You can't always "feel" a bubble, and they aren't always obvious on a casual glance in the mirror. There is nothing quite like discovering that you might have a bubble at an inconvenient time - like driving in traffic, or the middle of a meeting.

Prescription eye drops

The same rule of thumb applies to scleral lens users as all other contact lens users: If you need to apply an eye medication, remove your lenses, apply the drops, and wait 10-15 minutes before re-applying the lenses (or as advised by your doctor).

Opinion: The scleral lens balancing act

No one should ever expect scleral lenses to be as simple as conventional contacts. They're just not. And since they're being used to treat complex diseases, it is absolutely to be expected that there may be tradeoffs and limitations. For some people, RRR for midday fogging is one of those tradeoffs.

Sometimes you and your doctor have done everything right that there is to be done. But you're still struggling with some limitations or lens performance issues that really bother you. At that point it comes down to a balancing act: figuring out if the lenses are giving you enough benefit to compensate for the drawbacks and practical challenges.

Those who have the most to gain - either in terms of vision, ocular surface disease, pain, or a combination - are usually by far the most philosophical about accepting tradeoffs and limitations. Six to eight hours of good, comfortable vision is a much-hoped-for miracle for many people with advanced corneal diseases. But to others, who have more nuanced issues and come to the table with higher expectations and needs, even twelve or fourteen of continuous wear may seem intolerably limiting under some circumstances.

What do YOU need from sclerals, and what are you willing to give up? If midday fogging is seriously cramping your style, it's time for a heart-to-heart with your eye doctor about your needs and whether they can be achieved.

    IMPORTANT NOTE

    FOR INFORMATIONAL PURPOSES ONLY. THIS GUIDE IS COMPRISED OF PEER-TO-PEER SUGGESTIONS, NOT MEDICAL ADVICE. CONSULT YOUR EYE DOCTOR WITH ALL YOUR EYE CARE AND LENS QUESTIONS.