Can I Shower or Swim in Scleral Lenses?

By Jeffrey Sonsino, O.D., FAAO, Dipl AAO

Whether people can shower or swim in scleral lenses is one of the most common questions we receive at Optique. And, as you can image, the answer is not as simple as a yes or no. Let’s dive into it by starting with the purpose of scleral lenses.

What are Scleral Lenses Used For?

Scleral lenses are used primarily for two purposes: vision correction and/or to serve as a moisture barrier to the outside environment. In conditions such as keratoconus, post-RK, or post-LASIK surgery, corneal scars, or elevations or depressions in the cornea (such as Salzmann nodular degeneration or peripheral ulcerative keratitis), the ocular surface has an irregular shape. If that is the case, then standard glasses or contact lenses are not sufficient to improve the optics of the eyes.

A hard contact lens that doesn’t touch the cornea at all can improve the optics of the irregular cornea because the lens holds its “regular” shape. With a scleral lens, the hard contact lens does not touch the cornea at all, but instead lands on the white part of the eye, the sclera. The lens is therefore suspended above the cornea and is supported by a fluid layer of saline that is introduced to the system when the lens is put on.

Specialized sterile saline that has a specific salt content favorable to the ocular surface is inserted into the bowl of the lens prior to application. The lens is raised onto the sclera, all of the saline is trapped behind the lens, and any air is pushed out. By looking through a smooth lens surface, a saline fluid layer, and then the irregular cornea, the optical system is normalized to the regular shape of the contact lens instead of the irregular shape of the cornea. The theory of how this corrects vision has popularly been attributed all the way back to Leonardo Da Vinci plunging his head into a clear bowl filled with water (although this has been disputed).¹

The second reason why scleral lenses are used is for severe dry eyes. The same saline layer that improves the optics of the irregular cornea can be used to provide a constant source of moisture on the ocular surface. In much the same way as water sticks to a microscope slide by being sandwiched between two pieces of glass, the sterile saline sticks to both the cornea and the scleral lens. This is called capillary action and is a powerful force to keep the cornea constantly bathed in a saline bath.

The Importance of Sterile Saline for Dry Eyes

But, you will notice that I mentioned that the saline used with a scleral lens needs to be sterile. The reason for this is that whenever there is any compromise to the integrity of the cornea, there is a significant risk for bacteria, virus, fungus, or other pathogen to infect the eyes. People with dry eyes often have an unhealthy front surface to the cornea, resulting in a higher risk for infection. And, those with corneal diseases sometimes have worse natural protections against pathogens.

At Optique, we recommend that patients only use individual vials of saline, specifically purposed for use with scleral lenses, and approved by the Federal Drug Administration (FDA) for this use. Unfortunately, there are social media groups that promote saving money by using solutions that are not healthy for use with scleral lenses. For example, there is a commercially available, non-preserved solution that is “sterile saline,” but available in a 4- oz bottle. The problem with this is that as soon as the tip of this bottle touches anything, including your finger, the scleral lens, the bathroom countertop, etc, the entire bottle becomes infested with bacteria. Then, each time this solution is used, you are pouring bacteria directly into the lens, which stays under the lens and on the eye for the entire day without the body’s natural defenses, which include the flushing action of blinking and the natural antibiotic action of the tears.

Can I swim or Shower with Scleral Lenses?

Back to the question of if someone can swim or shower in their scleral lenses… what we are worried about is infection. It turns out that different water sources have different pathogens living in them. Sea water is full of organic compounds that are teeming with pathogens. In fact, if you weighed all of the living organisms in the oceans, 90% of the weight would be from bacteria and other microbes.

Likewise, it is probably apparent to most people that lake water can be pretty dirty. In fact, the Tennessee Department of Health publishes a list of the bacteria and viruses found in Tennessee lakes, and it is quite nasty. Saltwater or chlorine-treated backyard pools unfortunately do not fare much better when it comes to bacterial contamination. On top of the contamination, the salt or chlorine can be toxic to the eyes and make infection more likely.

You would think that the water coming into the tap in your home would be cleaner. The Center for Disease Control (CDC) provides a laundry list of pathogens that can infect the drinking water supply. Those are hypotheticals and as with anything in life, we are dealing with risk. Some people have a higher risk tolerance than others. But, when it comes to your eyes and the possibility of permanent vision loss, we prefer that people do not take risks.

Admittedly, the risk for a blinding eye infection is low. But, the consequence when this happens is very serious. A good analogy for this is speeding in your car on the highway. It is pretty easy to drive at 90 miles per hour on the highway in your car, and in most instances, you are going to be just fine. But, in the rare case that you do get in an accident, it is not going to be a fender bender at that speed. The consequence will likely be totaling the car and worse, a very serious injury.

A Case Study Example on the Importance of Protecting Your Eyes

This exact scenario happened in Chicago in the early 2000s. Contact lens wearers starting developing very serious eye infections with an amoeba called acanthamoeba in numbers that were very atypical. Acanthamoeba infections were traditionally very rare, but have serious consequences to people’s vision, including blindness. All of a sudden, optometry practices and medical centers started noticing contact lens wearers developing seven times more acanthamoeba infections than normal.²

No one could figure out why, until a young clinician/researcher at the University of Illinois at Chicago and fellow diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry, Charlotte Joslin started looking into it using very good research techniques. Dr. Joslin started looking at all variables, like how people were taking care of their contact lenses and found that one specific solution was associated with the infections.³ The company promptly removed that solution from the market. But, in 40% of the cases, that specific solution had not been used. So, there had to be another cause. She and other researcher ultimately found that a bloom in the acanthamoeba population in the Chicago drinking water supply was responsible for the increase in infections.⁴ People who allowed tap water to touch their lenses were becoming infected.

Because of this groundbreaking research, we now recommend that no tap water ever touches a scleral lens. This means that the only solutions that should touch the lens are the cleaning solution and/or storage solution and the sterile saline solution used to fill the bowl of the lens. The only exception to this is when you clean your case. The approved method to clean your case is to wash with soap and hot tap water, turn upside down and allow to air dry. Another tip is to make sure that you never “top off” your solution in the case. You must always fully dispose of any storage solution after each night and refill with new solution when ready to store the lenses.

Is it Enough to Close My Eyes When Wearing Contacts in the Shower or While Swimming?

When you swim or shower, does water actually touch the eyes and in our case, the scleral lenses? The answer to this is that if you just close your eyes, there is a great chance that tap water is getting in between your eyelids and touching your lenses. The eyelids are not water tight and if you’ve ever gotten soap or shampoo in your eyes in the shower, you know this to be true.

The best advice to be the safest you can possibly be is to not shower or swim with scleral lenses. Having said that, some of my patients have higher appetite for risk and tell me that they are going to swim and shower with their lenses no matter what I tell them. In that case, we use strategies to decrease the risk. First, if there is a water-tight seal in front of the eyes, then the risk should decrease. Using a good pair of goggles while swimming or a custom-fitted diving mask when diving reduces risk. Second, if water does touch the lenses, take the lenses off right after the activity finishes and soak the lenses in a hydrogen peroxide-based cleaning solution. Third, in some cases, we find a daily disposable, soft lens that provides adequate vision for swimming. Scleral lenses will always provide better vision than the soft lenses, but daily disposable lenses provides better vision than no lenses at all. The key there is to use a brand-new daily disposable lens when starting the activity and to remove the soft lenses and discard immediately after finishing the activity. The American Optometric Association (AOA) has many recommendations for proper use of contact lenses and most apply directly to scleral lenses.

Sometimes, despite our best efforts, the worst does happen and people get an infection in the eyes. We develop tight relationships with our patients so that they feel comfortable calling us to be seen immediately. Time is of the essence with infections and early treatment is always better than a delay. We teach our patients that if their eyes become red, painful, have sensitivity to light, vision changes, or a discharge, to call their doctor right away.

References

Posted in Contact Lenses, Eye Care, Eye Glasses, Eye Wear