A. Heat Disinfection (Thermal)
1. Consists of thermal unit, saline, daily cleaner, enzyme & rewetting/lubricating
drop
2. Advantages
a.Good disinfectant, kills all bacteria including pseudomonas
b. Quick (20 minutes)
c. Inexpensive
d. Few red eye reactions
e. Patients can be very compliant
f. Non-preserved solutions can be used with it
g. Kills both forms of Acanthamoeba (Cysts & trophozoites)
h. Effective against AIDS virus
3. Disadvantages
a. Shortens lens life
b. Electrical requirements
c. Bakes on deposits that are not cleaned off. Protein deposits baked on are just like egg
whites-the deposits turn white-yellow, discoloring the lens
d. Can not use with > 55% water content or tinted lenses
e. Heat disinfection isn’t interchangeable with all other disinfection systems
f. Inconvenience
4. First disinfection method for hydrogel lenses
5. Federal guidelines - must be above 80° C for at least 10 minutes
6. Popularity of system has declined
B. Chemical Disinfection (Cold)
1. Consists of a disinfecting solution containing 1 or more preservatives which
disinfect the lens. In addition, may have the following solutions: saline, daily cleaner,
enzyme and rewetting/lubricating drop.
2. Advantages
a. No appliances
b. Convenient
c. Use on all lenses
d. Less effect on lens life
e. Simple
f. Few steps
g. New systems closely approximate RGP care systems eliminating this advantage of RGP
lenses over hydrogel lenses
h. Patient compliance is generally good
3. Disadvantages
a. Red eye reactions (Sensitivity/allergies to preservatives)
b. Solution cost
c. Takes 4-6 hours at minimum
d. Can not disinfect properly if lenses not cleaned daily prior to disinfection as
preservatives bind to deposits rather than disinfecting
e. Little effect on Acanthamoeba used alone. When lenses are cleaned, rubbed and rinsed
these are more effective against Acanthamoeba.
f. Little to no effect against AIDS
4. Available solutions
a. ReNu Multipurpose Disinfecting Solution-B&L (DYMED-edetate disodium)
b. Opti-Free Express-Alcon (Aldox & Polyquad)
c. Opti-One-Alcon (Polyquad)
d. Complete Comfort Plus-Allergan (Tyloxapol & trischem)
e. Quick Care-Ciba
f. Solo-Care-Ciba (Edetate disodium dihydrate & Polyhexanide)
g. ReNu Multiplus-B&L (DYMED)
5. Preservatives
a. Criteria for selecting preservatives
1) Compatibility
2) Lack of toxicity
3) Active against potentially harmful viruses, fungi and bacteria
4) Appropriate level of activity
b. Thimerosal
2) Sensitized as a child when iodine used on injuries
3) Once sensitized, will react immediately when contact with thimerosal is used.
4) Symptoms of Thimerosal reaction: Immediate response (1 day - 2 months) Dry, itchy,
burning, gritty, tired, red eyes General feeling of discomfort Decreased wearing time
c. Chlorhexidine
1) Effective on Pseudomonas
2) Can not use with heat disinfection
3) 5-10% of the population sensitive
4) Toxic in increased concentrations and will bind to proteins, increasing the
concentration
5) Symptoms of Chlorhexidine reaction:
Symptoms appear after long-term use of chlorhexidine (months-years)
Symptoms similar to those with Thimerosal
d. Polyquad
e. DYMED
1) Found to be much less toxic than thimerosal or chlorhexidine
f. Trischem
g. Aldox
h. To remove preservatives, purge the lens
1) 3 cycles of 8 hours each in distilled water and 1 cycle of 8 hours in saline
2) Two 10 minute cycles in distilled water in a swirl clean & two 10 minutes cycles in
saline in swirl clean
C. Oxidative Disinfection (H2O2)
1. Consists of hydrogen peroxide disinfecting solution, neutralizing solution, tablet
or disc, saline, daily cleaner, enzyme & rewetting/lubricating drop
2. Hydrogen peroxide hydrogel solutions -vs- Drug store hydrogen peroxide
3. Advantages
a. Rapid
b. Effective
c. No preservatives
d. Cleans & bleaches (limited)
e. Increased lens life
f. No adverse reaction
g. No appliance
h. Effective against AIDS
i. Two step systems effective against Acanthamoeba if used over 4 hours
j. Enzyme step made simpler by combining it with disinfecting step
4. Disadvantages
a. Solution cost
b. Steps involved
c. Punctate keratitis
d. Can be confusing and complicated for the patient
5. Available systems:
a. AO Sept (Ciba) 1 step
b. Pure Eyes (Ciba) 1 step
c. UltraCare (Allergan) 1 step
6. Hydrogen peroxide is neutralized by a catalyst such as the platinum disc, tablet or
a neutralizing solution or is diluted by osmosis with a saline
7. Disinfection longer than 10 minutes is preferred
II. Salines
B. Preserved Salines (Thimerosal)
1. Sterile Preserved Saline Solution (B&L)
C. Preserved Salines (Non-Thimerosal)
1. Sensitive Eyes (B&L) Sorbic acid, Sensitive Eyes Plus (B&L) DYMED, not sorbic
acid
2. Saline Especially for Sensitive Eyes (Alcon)
3. SoftWear Saline (Ciba) antimicrobial buffer system-trace amounts of hydrogen peroxide
4. Your Choice Saline Soln. (Amcon) - sorbic
5. Blairex Sterile Preserved Saline (Blairex) - sorbic
D. Unpreserved Salines
1. Lens Plus (Allergan) aerosol
2. Sensitive Eyes Sterile Saline Spray (B&L) aerosol
3. Ciba Vision Saline aerosol
4. Sterile Saline Solution (Blairex) aerosol
5. Unisol (Alcon) vials, Unisol Plus (aerosol) & Unisol 4
6. Your Choice (Amcon)
7. Salt Tablets -NO!!!
a. Non-sterile
b. Easily contaminated
c. Use only before heat disinfection
d. Refrigerate solution and distilled water
e. Large container of distilled water easily contaminated
f. 60% of case of Acanthamoeba in hydrogel lens wearers were at significant risk posed by
homemade saline, swimming with lenses on or no disinfection system
III. Cleaning
A. Deposits
1. Source:
a. Moist, sticky lens surface
b. Surface quality of the lens
c. Poor blinking
d. Tear layer components, quality & quantity
e. Poor cleaning regimen
f. Hands
2. Cause:
a. Decreased preservative action
b. Decreased oxygen transmission
c. Alters lens physical parameters
d. Decreased surface wetting
e. Increased movement
f. Poor vision
g. Lens discoloration
h. Decreased wearing time
i. Red eyes, ulcers
B. Types of Deposits
1. Organic
a. Protein
1) Most common deposit
2) White opaque to clear and can give cracked appearance to lens surface.
3) Not removed by surfactants
b. Pigment Deposits
1) From melanin polymer in tears, increased with heat disinfection
c. Microorganismic Growth
1) Fungi-Yeast
2) Filamentary in appearance, various colors
3) Can’t remove, just prevent
d. Lipid Deposits
1) Smeared, greasy appearance
2) Removed with daily use of surfactants
2. Inorganic
a. Jelly bumps
1) Jelly bumps are made largely of calcium, lipids & cholesterol (controversial)
2) White-clear elevated bumps that appear on the anterior lens surface
3) Become part of the lens matrix; therefore, if they are cleaned off it will leave a pit
in the lens which will be prone to deposits
4) Commonly found in extended wear; however, some patients are more prone to these and
they will develop jelly bumps with daily wear also.
b. Mercurial deposits
1) Thermal disinfection of thimerosal-Smoky gray-black
c. Rust spots
1) Predominantly caused by the use of tap water with the lens
2) RED FLAG! Acanthamoeba also the result of tap water use with hydrogel lenses.
3) Red, orange or rusty colored dot or dots on lens surface.
4) Can also be a result of a metal foreign body just like a rust ring.
d. Mascara, Make-up, Hand Creams, Hairspray, Suntan Lotion
C. Surfactants
1. Daily cleaner which acts as a soap to enhance disinfection, decrease red eye
reactions and increases lens life. Rub back and forth in palm for 20-30 seconds.
2. Available surfactants/daily cleaners
a. Opticlean (Alcon) Thimerosal & Opticlean II (Alcon) Polyquad
b. Opti-Free Daily Cleaner (Alcon) Polyquad
c. Pliagel (Alcon) sorbic acid & edetate trisodium
d. Lens Plus daily cleaner (Allergan) Preservative free
f. MiraFlow (Ciba) Preservative free
g. Sensitive Eyes Daily Cleaner (B&L) sorbic acid & edetate disodium
h. Sof/Pro-Clean SA (Lobob) sorbic acid/edetate trisodium
3. Left lens syndrome
D. Enzymatic Cleaners
1. Used at minimum once a week to remove protein deposits. Breaks down peptide bonds
and allows protein to be mechanically rubbed off. Should be done prior to disinfection.
2. Available products
a. Allergan Enzymatic Cleaner (Papain), Ultrazyme (Subtilisin A), Complete (Subtilisin
A)
b. Alcon Optizyme (Pork pancreatin)
1) Can be used in peroxide neutralization step Alcon Opti-Free Enzymatic Cleaner (Pork pancreatin), Alcon Supraclens
c. B&L ReNu Effervescent Enzymatic Cleaner (Subtilisin A) & B&L Sens. Eyes
Enzymatic Cleaner & ReNu 1 step Enzymatic Cleaner
d. Ciba Unizyme (Subtilisin A)
IV. Lens Lubricants
A. Optional use by the patient for when the eyes feel dry, have a foreign body sensation, irritation, extended wear especially am & pm, etc. Do not use artificial tears, Visine type products, or RGP lubricants.
B. Available solutions
1. Alcon - Clerz 2 (Sorbic acid/edetate disodium), Opti-Tears, Opti-Free Rewetting
Drops,Opti-One Rewetting Drops (Polyquad)
2. Allergan - Lens Plus rewetting drops (Preservative free), Complete Rewetting Drops
(PHMB)
3. B&L -ReNu Multiaplus, ReNu Rewetting drops (DYMED), Sensitive Eyes Drop (sorbic
acid/edetate disodium)
4. Ciba - Focus Lens Drops, Ciba Vision Lens drops (sorbic acid/edetate disodium),
IV. Patient Education and Hygiene
A. Hygiene
1. Patient and practitioner’s hands should be washed before handling lenses to
decrease the bacteria found on the hands.
2. Be cautious about the soaps used to wash the hands. If they contain lanolin, cremes,
oils, etc. it can contaminate the lenses when handled.
3. Specially prepared optical soaps
a. Opti-Naps - pre-packaged towelettes to carry with patient
b. Opti-Soap
c. AO Soap
B. Make-Up, Hairspray & Cosmetics (This includes after shave lotion, men’s
cologne, etc.)
1. Water soluble makeup is best as it will wash off the lens
2. Make-up should be applied after lens insertion.
3. Make-up becomes contaminated and should be thrown out after 3 months of use.
4. Make-up should not be shared.
5. Hairspray should be used prior to lens insertion or while eyes are closed.
6. Creams & oils can be transferred to the lenses
7. Avoid glitter & irridescent makeup
C. Other Tips
1. Short naps are permissible with hydrogel lens wear; however, lenses will be dehydrated
upon awakening and should not be removed immediately unless a rewetting drop or saline is
used to rehydrate the lens, preventing an abrasion.
2. Swimming is best done without lens wear. Goggles may be worn over lenses, the eyes kept
out of the water or the eyes tightly shut. Acanthamoeba among other things can contaminate
the lenses.
3. Lens durability is generally 6 months-2 years.
4. Fingernails should be short to reduce the risk of fingernail tears.
5. Wearing time should be kept fairly steady. If a patient is out of lenses for a long
period of time (i.e., 2 weeks or more) then wearing time should increase slowly.
6. Patients should ask themselves 3 questions
a. Do my eyes feel good?
b. Do my eyes look good?
c. Can I see well?
If the answer is not yes to all three questions, the patient should contact his/her practitioner.
7. Lenses should stay hydrated, if lens is dehydrated, handle the lens carefully and
soak it in saline and disinfect it if it rehydrates
8. Don’t use ophthalmic medications while wearing lenses
9. Do not use RGP solutions with hydrogel lenses
10. Always cap solution containers
11. Don’t top off old solution with new, always use new solution
12. Avoid touching the tip of the solution bottles
13. Don’t use tap water on the lenses
14. Read labels on solution bottles
VI. Patient Compliance
A. Factors for non-Compliance
1. Complexity
2. Duration
3. Cost
4. Knowledge
5. Patient-Dr. Relationship
6. Taking shortcuts
7. Sloppy habits
8. Incorrect information from pharmacies
9. Mixing or substituting solutions
B. Practitioner factors for non-compliance
1. Poor instructions
2. No written instructions
3. Overload patient on dispensing
4. Poor example
C. To increase compliance
1. Train staff
2. Provide audio-visual and written material
3. Emphasize consequences of non-compliance: GPC, Acanthamoeba, loss of lens wear
4. Staff must be experts or refer the questions to you
D. Results of Non-Compliance
1. GPC
2. Infiltrates
3. Acanthamoeba
4. Ulcers
5. Shorten lens life
6. Uncomfortable lenses
VII. The "Big 10" List of Bad Habits
1. Storing lenses in saline and not disinfecting
2. Not using a disinfectant at every lens removal
3. Eliminating the use of a daily cleaner or the enzymatic cleaner
4. Not disinfecting after enzymatic cleaning
5. Re-using solutions instead of throwing them away and using fresh solutions
6. Topping off previous solution in the storage cases with fresh solution
7. Using lens cases that are dirty and old
8. Overwearing lenses (i.e., wearing daily wear lenses extended wear and wearing extended
wear lenses for periods greater than 7 days)
9. Mixing and matching solutions that are not compatible
10. Contaminating solutions by keeping old, expired solutions, leaving solutions uncapped
or repackaging solutions in non-sterile containers.
Packaging Colors for Hydrogel Contact Lens Solutions
Chemical Oxidation
ReNu Multiplus- Navy AOSept - White with purple
Solo-care - turquoise with color spectrum
ReNu - White with blue/green Pure Eyes - Greenish blue w/ navy or Opti-One - orange red
Opti-Free Express- Green/Red decoration Ultracare - Black & orange
Complete-Navy blue & yellow
Quick Care-White, blue, pink & green with clock
Salines
ReNu - White with blue/green
Lens Plus - White with green
Ciba Vision Saline - Navy Blue
Blairex - White with blue
SoftWear - Blue, turquoise, purple with pink Softwear on side
Unisol - Silver with blue & pink-purple
Cleaners Enzyme cleaners
Opticlean - Blue Allergan - White box with blue writing
Opticlean II - Blue Optizyme - Blue
Optifree Daily Cleaner - Green Optifree Enz. Cl. - Green
Pliagel - White ReNu Effer. & 1step - White with blue/green
Lens Plus Daily Cl. - White with yellow Unizyme - Blue
MiraFlow - Navy blue & red Ultrazyme - Black & green
Sensitve Eyes(B&L) - White & blue/green Complete-Navy blue & yellow
Supraclens-Green
VII. Cases
A. Case 1 - Patient who was a previous wearer received replacement pair of lenses. Visual acuity was OD 20/15 and OS 20/15 upon dispensing. Two days later, she calls to report hazy vision through her contact lenses which doesn’t clear up on the blink. Slit lamp examination reveals a filmy coating on the lenses. The patient admits to using hairspray after lens insertion.
B. Case 2 - Patient has lenses that are 9 months old. Patient wears lenses extended wear and has been prone to deposits. He calls your office as the OD lens feels like sand or something under it. Lens removal and cleaning do not improve the condition.
C. Case 3 - First time wearer returns to the clinic for 1 week visit complaining of discomfort OS. Slit lamp examination reveals two diagonal lines on the lens surface centrally.
D. Case 4 - Patient returns to the clinic for a 6 month follow-up visit. He has worn hydrogel lenses for 8 years. Present lenses are 6 months old. Inspection of the lens reveals a small round orange mark.
E. Case 5 - Patient has lenses that are 6 months old. Slit lamp examination reveals several areas of debris and hazy film.
F. Case 6 - Patient has lenses that are 9 months old. Slit lamp examination reveals limbal engorgement, slight injection and 0.5mm neovascularization superiorly and inferiorly.
G. Case 7 - Patient is unhappy with lenses. The lenses move excessively, vision is reduced and upon viewing with the biomicroscope the edges flare out.
H. Case 8 - Patient is asked about the solutions they are using. The disinfecting solution used is in a green bottle.
VAH 1999