Is This the New Norm?

Is Scleral Fogging the New Norm?

Is This the New Norm?

Is Scleral Fogging the New Norm?


Daily, we fit new patients into scleral lenses and see how their lives are transformed. However, with new technology, new innovations, and new research ideas come new challenges and question marks. The question that we are all encountering is: Is scleral fogging a new normal?

Before we begin our dialog, here is our answer: We hope not, but we think so.

Most of us agree that around one-third of our patients experience some level of fogging. For some patients, this fogging is a constant and creates a breaking point; they simply cannot handle it and end up resorting to other options. Others experience a minor fogging later in the day that is nothing more than an annoyance.

Many theories have come up to address the cause of fogging. Work at Pacific University has revealed that foggers have an abundance of lipid built up behind their lenses, but the cause of this lipid accumulation is still speculative. Additional work at Pacific has revealed a lack of tear exchange, which potentially traps the tears under the lens and may alter the normal tear film into a stagnated state.

Possible Strategies

Regardless of the cause, we are curious about what we can do now. Currently, no solution has revealed itself as the golden egg. Rather, several clinicians have hypothesized strategies that may help some patients. Thanks to our team at Pacific (especially Dr. Sheila Morrison) and others, we are looking for further research to help us solve this conundrum and keep fogging from occurring. Although these have not all been published, we will attempt to give some credit to those who have explained their recommendations.

Tear Flush Sindt (2015) has suggested a method to flush the fluid under the lens while the patient is still wearing the lens (click here to see a video of this technique courtesy of Dr. Sindt). Some believe that the constant removal of the lens causes a mucus fishing-like reaction that leads to additional mucus creation by the cornea.

Solutions in the Bowl Morrison (2015) has worked with various solutions in the lens bowl and has found that some solutions may reduce or hinder the creation of fog for some patients.

Lens Alterations It is generally understood that lenses with significant sagittal depths may encourage more fogging. Most agree that lenses with 100 to 200 microns of clearance may be the most ideal.

Piggyback Sclerals Hypothesized by Kading (2015) and under current investigation, the use of a soft lens under a scleral, with little or no clearance between the soft and scleral lens, might help some patients. The thought is that without a chamber to have fogging, and by using a high-Dk lens to keep oxygen flowing, this environment may help some patients who have extreme problems.

The Verdict

Although all of these strategies need further vetting, and we need to learn more about what causes fogging, we think that we are in this for the long haul. Fogging doesn’t seem to be going away anytime soon. As such, we need to embrace it as a new normal for our scleral lens patients and continue to share and look for options to reduce it. CLS

For references, please visit and click on document #241.

Dr. Brujic is a partner of Premier Vision Group, a three-location optometric practice in northwest Ohio. He has received honoraria in the past two years for speaking, writing, participating in an advisory capacity, or research from Alcon Laboratories, Allergan, B+L, Optovue, Nicox, Paragon, SpecialEyes, TelScreen, Transitions, Valeant Pharmaceuticals, Valley Contax, VMax Vision, VSP, and ZeaVision. Dr. Kading owns the Specialty Dry Eye and Contact Lens Center in Seattle. He is the co-owner of Optometric Insights with Dr. Brujic. He has received honoraria for consulting, performing research, speaking, and/or writing from Alcon, Allergan, Bausch + Lomb, CooperVision, Oculus, Ocularis Pharma, RPS, Shire, TearScience, Valeant Pharmaceuticals, Valley Contax, Zeiss, and ZeaVision. Follow him on Twitter @davekading.