C L I N I C A L A N D E X P E R I M E N T A L
`
`OPTOMETRY
`
`Infection control guidelines for optometrists 2007
`
`DOI:10.1111/j.1444-0938.2007.00192.x
`
`Information from peer-reviewed articles, guidelines from professional societies and man-
`ufacturers’ instructions were considered to determine the risk factors in optometric
`practice and to make recommendations for disinfection, sterilisation and reprocessing
`of instrumentation and other equipment used in practice and measures for personal
`protection.
`Wherever possible, all practitioners should adopt measures to decrease the risk of
`transmission of infection, such as single use instruments/equipment, appropriate meth-
`ods of reprocessing where items are reused, routine employment of standard infection
`control precautions and application of more rigorous procedures for infected or
`immuno-suppressed individuals.
`
`Clin Exp Optom 2007; 90: 6: 434–444
`
`Carol Lakkis*† BScOptom PhD
`PGCertOcTher
`Ka-Yee Lian*§ BOptom PGCertOcTher
`Genevieve Napper§ MScOptom MPH PhD
`PGCertOcTher
`Patricia M Kiely# BScOptom PhD
`* Clinical Vision Research Australia,
`Carlton, Victoria, Australia
`† Department of Optometry and Vision
`Sciences, The University of Melbourne,
`Victoria, Australia
`§ Melbourne Optometry Clinic, Victorian
`College of Optometry, Carlton, Victoria,
`Australia
`# Optometrists Association Australia,
`Carlton, Victoria, Australia
`E-mail: clakkis@unimelb.edu.au
`
`Submitted: 7 February 2007
`Revised: 27 May 2007
`Accepted for publication: 29 May 2007
`
`Key words: disinfection, infection, infection control, sterilisation, vaccination
`
`Optometrists have an obligation to take
`reasonable precautions to ensure that
`their patients and staff are not exposed to
`infection while attending or working at
`their practice. This paper presents infec-
`tion control guidelines that aim to provide
`information to optometrists to assist them
`in minimising the risk of transmission of
`infection in their practices.
`
`Infection control guidelines for optom-
`etric practice in Australia were developed
`in 19861 and revised in 1995.2 Since then,
`the scope of optometric practice has ex-
`panded in a number of states in Australia,
`so that optometrists may now be involved
`in the therapeutic management of pa-
`tients, some of whom may have infectious
`conditions such as conjunctivitis. Some of
`
`the procedures that are used for these
`patients require more rigorous attention
`to infection control than was previously
`necessary.
`In 1996, the National Health and
`Medical Research Council (NHMRC) and
`the Australian National Council on AIDS
`(ANCA) adopted the terms ‘standard
`precautions’ and ‘additional precautions’
`
`Clinical and Experimental Optometry 90.6 November 2007
`434
`
`Journal compilation © 2007 Optometrists Association Australia
`
`© 2007 The Authors
`
`PARAGON - EXHIBIT 2035
`
`

`
`(based on modes of transmission of infec-
`tious agents) to define appropriate work
`practices with infection control for the
`care and treatment of all patients, regard-
`less of their infectious status.3 The precau-
`tions include work practices that aim to
`achieve a basic level of infection control,
`particularly in the handling of blood,
`other body fluids, secretions and excre-
`tions, non-intact skin and mucous mem-
`branes. Although there
`is no direct
`reference to optometric practice, the
`standard precautions have application in
`optometric practice because of the possi-
`bility of contact with mucus membranes,
`tears and blood. All optometrists need
`to be aware of the infection control
`procedures designed to minimise cross
`infection.
`Additional precautions are recom-
`mended in health-care settings for pa-
`tients known or suspected of being
`infected or colonised with disease agents
`that cause infections and which may not
`be contained with standard precautions
`alone. They should be applied when there
`is risk of airborne or droplet transmission
`of respiratory secretions or when there is
`inherent resistance to standard sterilisa-
`tion procedures, for example, suspected
`variant Creutzfeldt-Jakob disease (vCJD).
`There are no universal guidelines that
`apply to the decontamination of oph-
`thalmic instruments used by optometrists
`and thus it is necessary to refer to the
`manufacturers’ guidelines or other profes-
`sions for information.
`
`Risk factors in optometric practice
`In optometric practice, infection may be
`transmitted from patient to staff, staff to
`patients, patient to patient and staff to
`staff by direct contact, aerosol formation
`or contamination of equipment or instru-
`ments in the practice.
`There are several instances in which
`optometrists may be exposed to blood,
`tears and mucous membranes or to
`infection:
`1. removal of foreign bodies
`2. assessment of patients with ocular
`trauma
`3. assessment
`conjunctivitis
`
`with
`
`of
`
`patients
`
`Infection control guidelines for optometrists 2007 Lakkis, Lian, Napper and Kiely
`
`4. assessment of patients with microbial
`keratitis
`5. lacrimal lavage, removal of eyelashes
`6. expressions of glands and cysts
`7. contact lens fitting
`8. assessment of patients who are inconti-
`nent (this includes young children) or
`patients who vomit.
`that
`Some communicable diseases
`could be encountered
`in optometric
`practice are human immunodeficiency
`virus (HIV)/acquired immune deficiency
`syndrome (AIDS), hepatitis A, B and C,
`tuberculosis, measles, mumps, rubella,
`chicken pox, shingles, mononucleosis
`(glandular fever), herpes, influenza, im-
`petigo, infectious conjunctivitis and kera-
`toconjunctivitis, adenovirus 8 and CJD.
`
`HIV/AIDS
`HIV has been isolated from the tears, con-
`tact lenses and ocular tissues4–7 but there
`is no evidence of transmission through
`these. Infection requires direct contact
`between blood/body fluids and mucous
`membranes or damaged skin for example,
`through sexual contact or sharing needles
`and/or syringes with an infected person,
`through transfusions of infected blood or
`blood clotting factors. Injuries from nee-
`dles containing HIV-infected blood or
`infected blood entering an open cut or
`a mucous membrane have also been
`reported as causing HIV infection.8
`
`HEPATITIS A, B AND C
`Hepatitis B surface antigen may be
`present in the conjunctival fluid and there
`is a risk that it may be transferred to a
`tonometer or contact lenses.9,10
`
`CJD
`The number of cases of CJD in Australia
`is extremely low11 and there is no evidence
`that it is a significant risk in optometric
`practice. Similarly, there is no evidence of
`CJD transmission by contact with intact
`skin. As there is lymphoid tissue in the
`cornea,12 there is a theoretical possibility
`of transmission of vCJD and other forms
`of CJD between patients through oph-
`thalmic devices that contact the eye, for
`example, trial contact lenses and tonome-
`ters. Such transmission is described as
`
`‘highly improbable’.12 The NHMRC lists
`the cornea and anterior chamber as ‘low
`infectivity sites’ (sites that are demon-
`strated or predicted to be infectious but
`not consistently) and the conjunctiva as a
`semi-critical site.
`
`ADENOVIRUSES
`Adenoviruses are highly contagious and
`can survive outside the host for long peri-
`ods, even on dry surfaces.13
`
`Disinfection, sterilisation
`and reprocessing
`Several terms are used to describe infec-
`tion control procedures. Optometrists
`should be familiar with these.
`‘Cleaning’ is the removal of foreign
`material using water and detergents or
`enzymatic products14 and is the first stage
`recommended in reprocessing. Cleaning
`of instruments is an essential prerequisite,
`as organic material such as dried mucus,
`tears, skin or make-up may harbour infec-
`tive organisms in dangerous concentra-
`tions and prevent adequate disinfection or
`sterilisation. Cleaning may require scrub-
`bing of all surfaces of an instrument to
`remove debris. Insoluble deposits may
`require utilisation of isopropyl alcohol,2
`however, alcohol can damage some mate-
`rials, so its use will depend on the type of
`material to be cleaned.
`‘Disinfection’ is the term used for the
`inactivation of virtually all pathogenic
`micro-organisms but not necessarily all
`microbial forms, for example, bacterial
`endospores, fungi, protozoa. Disinfection
`is usually achieved using thermal (heat
`and water) or chemical means.
`‘Sterilisation’ is the term used when all
`viable micro-organisms are eliminated,
`including bacterial spores. Sterilisation is
`usually achieved through autoclaving,
`which involves exposure of the item to
`high temperature and pressure.14
`‘Reprocessing’ is the process of clean-
`ing and disinfection and/or sterilisation
`of a device that is to be reused.
`A ‘hygienic’ state is a state of cleanliness
`that offers little or no threat to health.2
`‘Sanitary conditions’ are those that are
`physically clean and healthy.2
`
`© 2007 The Authors
`
`Journal compilation © 2007 Optometrists Association Australia
`
`Clinical and Experimental Optometry 90.6 November 2007
`435
`
`

`
`Infection control guidelines for optometrists 2007 Lakkis, Lian, Napper and Kiely
`
`1. Remove jewellery.
`2. Wet hands with water (to decrease the risk of dermatitis avoid using hot water).
`3. Apply recommended amount of product to hands (use liquid hand-wash dispensers with disposable cartridges and disposable dispensing nozzles).
`4. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.
`5. Rinse hands with water.
`6. Dry thoroughly with disposable towel, patting hands dry to minimise chapping (do not use multiple-use cloth towels or hand-dryers).
`7. Use disposable towel to turn off tap, if elbow or foot controls not available.
`Additional recommendations
`• Cover cuts and abrasions with water-resistant occlusive dressings or use surgical gloves.
`• Keep fingernails clean and short; do not wear artificial nails.
`• Use non-perfumed, hypoallergenic hand creams to avoid cracking of skin/dermatitis, e.g. sorbolene.
`
`A poster demonstrating an appropriate hand-washing technique with soap and water is available on the World Health Organization’s website.20
`
`Table 1. Recommended procedures for hand-washing18,19
`
`Information from peer-reviewed arti-
`cles, guidelines from professional societies
`and manufacturers’
`instructions were
`considered in determining risk factors
`in optometric practice and recommen-
`dations on disinfection, sterilisation and
`reprocessing procedures for instrumenta-
`tion and other equipment used in optom-
`etric practice.
`
`RECOMMENDATIONS FOR
`OPTOMETRIC PRACTICE
`
`Identification and management
`of staff and patients with
`infectious diseases
`Optometrists may consider asking pa-
`tients to provide information about their
`general health in a registration form,
`when they present at the practice. If
`their eye examination is not urgent,
`patients with short-term infectious ill-
`nesses should be asked to reschedule
`their appointment.
`Optometrists and staff with infectious
`diseases need to be aware of the precau-
`tions to take to avoid the transmission of
`disease when dealing with patients and the
`conditions that should exclude them from
`attending work (examples include influ-
`enza and conjunctivitis).
`If it is practice policy that some pretest-
`ing of patients is undertaken by other
`practice staff prior to the patient being
`
`seen by the optometrist, staff should be
`advised to seek the advice of the optome-
`trists for any patients presenting with a
`‘red eye’ or ocular discharge before this
`testing is undertaken.
`
`Hand-washing
`Hand-washing is considered to be the
`most important measure in preventing
`the spread of infection in the healthcare
`setting.15 The prevalence of infection
`decreases as hand hygiene is improved.16,17
`The aim of hand-washing is to remove
`transient flora that colonise the superficial
`layers of the skin, which are most fre-
`quently associated with health-care associ-
`ated infections. Usually, resident flora are
`attached to deeper layers of the skin and
`are more resistant to removal but are less
`likely to cause infection.
`Hand-washing must be performed
`before and after significant contact with
`any patient and after activities likely to
`cause contamination, for example, han-
`dling food, emptying waste paper baskets,
`going to the toilet, blowing one’s nose.
`Hand-washing should also be performed
`after the removal of gloves. When seeing
`patients, optometrists must avoid touch-
`ing their own face, nose, mouth and eyes.
`Hand-basins should be fitted in all con-
`sulting rooms and locations where contact
`lenses may be inserted or removed and
`must be kept clean. Elbow or foot controls
`are recommended to regulate the flow of
`
`water. Recommended hand washing pro-
`cedures are presented in Table 1.
`
`PRODUCTS FOR HAND HYGIENE
`It is difficult to compare studies of suitabil-
`ity of products for hand hygiene due to
`differences in methodology and study
`design. Hand hygiene products in order
`from most to least effective are alcohol
`formulations, chlorhexidine, iodophors,
`triclosan, plain soap.18 Other factors influ-
`ence the suitability of products, for exam-
`ple, the drying effects of alcohol-based
`soaps limit frequent use.
`
`Plain soap
`Plain (non-antimicrobial) soap is not
`recommended for use by health-care
`workers, as it has minimal antimicrobial
`activity (although it can remove loosely
`adherent transient bacteria)21 and it can
`become contaminated with gram-negative
`bacteria.18,22
`
`Alcohol-based antiseptics
`Alcohol-based hand antiseptics contain
`isopropanol, ethanol, n-propanol or a
`combination of two agents; they denature
`proteins and are effective against gram-
`positive and gram-negative bacteria, myco-
`bacteria, fungi, enveloped viruses (HSV,
`HIV, influenza), hepatitis B (less suscepti-
`ble) and hepatitis C. They are not effective
`against bacterial spores, protozoan cysts
`(for example, Acanthamoeba), certain non-
`
`Clinical and Experimental Optometry 90.6 November 2007
`436
`
`Journal compilation © 2007 Optometrists Association Australia
`
`© 2007 The Authors
`
`

`
`Infection control guidelines for optometrists 2007 Lakkis, Lian, Napper and Kiely
`
`enveloped viruses and CJD. They are more
`effective for hand-washing than soap or
`antimicrobial soaps but are not effective
`when hands are visibly dirty or contami-
`nated with proteinaceous materials such
`as blood.18
`
`Chlorhexidine
`Preparations that use 4% chlorhexidine
`are most effective. Chlorhexidine has
`residual activity on the skin23 but allergic
`reactions are uncommon. Infection rates
`have been reported as being lower after
`antiseptic hand-washing using chlor-
`hexidine than after hand-washing with
`plain soap or alcohol-based hand rinse.19
`Chlorhexidine-based hand-wash is com-
`monly accepted as the most suitable hand
`hygiene product, with 4% w/v chlorhexi-
`dine widely used as a bacterial skin cleaner
`for hygienic and surgical handwashing.15
`
`Other products
`Iodine and iodophors have good bacteri-
`cidal activity but cause more irritant con-
`tact dermatitis. Quaternary ammonium
`compounds for example, benzalkonium
`chloride, are only bacteriostatic and fung-
`istatic and are affected by organic mate-
`rial. Triclosan (found in antibacterial
`hand-wash for home use) is often only bac-
`teriostatic and has poor activity against
`gram-negative bacteria.18
`
`Water versus waterless hand-cleaning
`Alcohol-based hand rubs/gels15,18 are
`more effective at encouraging health-care
`workers to clean their hands between
`patients despite being poorer antimicrobi-
`als.24 Care must be taken to remove visible
`soil before use. Dry skin and irritation are
`common. Hand rubs/gels should only be
`used when:
`1. there are emergency situations where
`there is insufficient time/facilities
`2. there are inadequate hand-washing
`facilities
`3. staff members have allergies.
`
`• Suitability of hand-rubs
`Although hand-rubs are used in some hos-
`pital and medical situations, where there
`is restricted access to hand-washing facili-
`ties, they are unsuitable for use in contact
`
`lens practice because the residual debris
`and bacterial toxins on the hands, and
`chemicals from the hand-rub, may be
`transferred to the lens prior to insertion
`in the patient’s eye. All optometrists fitt-
`ing contact lenses should ensure that
`they have access to proper hand-washing
`facilities.
`
`Personal protective equipment
`Powder-free surgical gloves should be
`available for use in all practices. Gloves
`should be worn when there is a possibility
`of contamination with blood or body
`fluid (for example, where either the
`patient or the optometrist has open
`wounds) or when optometrists or their
`staff are in contact with high-risk patients
`(for example, those with serious commu-
`nicable diseases, such as hepatitis B,
`active herpetic lesions).18 Optometrists
`should frequently check their hands for
`cuts or abrasions. Gloves do not replace
`hand-washing; hands should be washed
`before and after using gloves. Although
`broken skin may be detected through
`stinging when the hands are wiped with
`an alcohol swab, there is the possibility of
`contact dermatitis developing from alco-
`hol swab use.25
`Latex gloves are not suitable for all
`optometrists and patients, and latex-free
`nitrile gloves are available as an alterna-
`tive. Latex allergy has been reported to
`occur in 4.3 per cent of health-care work-
`ers and in 1.4 per cent of the population.26
`Optometrists
`intending to wear
`latex
`gloves during a patient examination must
`ask the patient if they are allergic to latex
`prior to conducting any procedures in-
`volving direct contact.
`Safety glasses, face shields and masks
`should be used during procedures where
`there is potential for splashing/splattering
`or spraying of blood or body fluids or the
`potential for airborne infection.15 Surgi-
`cal masks should be used, if either the
`optometrist or the patient has a cold or
`influenza. Enclosed footwear should be
`worn to protect from injury/contact with
`sharps, such as needles used for foreign
`body removal.
`Gloves are also recommended when
`contact with cleaning solutions such as
`
`glutaraldehyde or sodium hypochlorite
`cannot be avoided.
`
`Immunisation for optometrists
`Optometrists
`should consider being
`immunised against
`influenza (yearly),
`hepatitis A (when seeing institutionalised
`patients, including nursing homes) and
`hepatitis B. There is currently no vac-
`cination against hepatitis C available.
`In addition, optometrists should con-
`sider whether they have been immunised
`against measles/mumps/rubella.
`
`Instrumentation in
`optometric practice
`Single-use instruments and equipment
`should be used whenever possible in opto-
`metric practice but there are several items
`in optometric practice that are reused. All
`reusable instruments need to be cleaned
`immediately and then disinfected or ster-
`ilised, depending on intended use. Guide-
`lines for disinfection or sterilisation of
`devices, instruments and equipment are
`discussed below and summarised in the
`Appendix.
`
`REPROCESSING OF
`OPHTHALMIC DEVICES
`Device classifications help guide practitio-
`ners to select the appropriate method of
`reprocessing for devices. The Centers for
`Disease Control and Prevention (CDC),27
`US Food and Drug Administration
`(FDA)28 and the Australia Government
`Department of Health and Ageing29
`describe different levels of risks for reus-
`able devices: critical, semi-critical and
`non-critical. Examples of devices used in
`optometric practice are shown in Table 2.
`
`CONTACT LENSES
`Ideally trial contact lenses should be used
`only once. If it is necessary to use trial
`lenses on a number of patients, in-
`practice disinfection procedures must
`be effective against bacteria, viruses (ade-
`novirus, hepatitis, HIV), fungi and Acan-
`thamoeba. Although there is a theoretical
`risk of transmission of HIV via trial con-
`tact lenses, there have been no reported
`cases.
`All trial contact lenses used in patients
`who are carriers of infectious diseases
`
`© 2007 The Authors
`
`Journal compilation © 2007 Optometrists Association Australia
`
`Clinical and Experimental Optometry 90.6 November 2007
`437
`
`

`
`Infection control guidelines for optometrists 2007 Lakkis, Lian, Napper and Kiely
`
`Level of risk
`Critical
`
`Semi-critical
`
`Application
`Entry/penetration into sterile
`tissue, cavity or bloodstream
`Contact with intact mucosa or
`non-intact skin
`
`Non-critical
`
`Contact with intact skin
`
`Process
`All items must be sterile
`e.g. steam under pressure
`Items should be sterile or there must be a
`minimum of high-level disinfection—preferably
`steam sterilisation or thermal disinfection
`(or high level chemical if heat not tolerated)
`Items must be clean or undergo low/
`intermediate level disinfection
`
`Example
`Needles, scalpels14
`
`Tonometer probes, contact lenses,
`gonioscopy lenses, lacrimal cannulae14
`
`Blood pressure cuffs, stethoscopes,
`head and chin rests, phoropters,
`epilation forceps
`
`Table 2. Levels of reprocessing of medical devices
`
`(for example, CJD, HSV, hepatitis, HIV
`or adenovirus) must be disposed of
`immediately. All multiuse contact lenses
`should be cleaned and rinsed just prior
`to and
`immediately after use and
`patients should be warned of the risks of
`reused lenses prior to fitting. Note: soft
`contact
`lenses
`that cannot be heat-
`treated are not suitable for use as trial
`lenses unless they are discarded after
`use.
`
`Soft contact lenses cleaning procedures
`The following procedures are based on
`the International Organization for Stan-
`dardization (ISO) instructions for clean-
`ing soft contact lenses:30
`1. Clean contact lens with a hydrogel lens
`cleaner via digital cleaning (20 seconds
`per side).
`2. Rinse with sterile preserved/aerosol
`saline.
`3. Fill glass vial with sterile saline.
`4. Label with lens parameters and date of
`heating.
`5. Sterilise in autoclave at 134 degrees C
`for at least three minutes or 121
`degrees C for at least 10 minutes.
`6. Alternative: thermal disinfection unit
`78 to 90 degrees C for 20 to 60
`minutes.31–33
`7. Optometrists could consider asking a
`local dentist or general medical practi-
`tioner to autoclave contact lenses, if
`they do not want to purchase their own
`bench-top unit.
`
`Additional notes:
`• Despite its efficacy, 3% hydrogen per-
`oxide is not recommended, as contact
`lens parameter changes may occur with
`prolonged storage in peroxide.34 In
`addition, lenses cannot be stored for
`longer than 24 hours in the neutralised
`peroxide solution35 and transfer to a
`new storage solution carries the risk of
`recontamination.
`• Chemically preserved disinfectants are
`not suitable, as they have unknown effi-
`cacy against viruses and are question-
`able at limiting biofilm formation and
`fungal growth.
`• Practitioners should take care to avoid
`cutting
`themselves when removing
`metal seals on contact lens containers.
`
`Gas permeable contact lenses
`cleaning procedures30
`1. Clean contact lens with approved gas
`permeable (GP) cleaner via digital
`cleaning (20 seconds per side).
`2. Rinse with sterile preserved/aerosol
`saline.
`3. Soak in 3% hydrogen peroxide for a
`minimum of three hours.
`4. Rinse with sterile preserved/aerosol
`saline.
`5. Dry GP lens with a clean tissue and store
`in a dry container. There is significantly
`less risk of contamination during dry
`storage compared to long-term storage
`in conditioning solutions.36,37
`6. GP lenses must be thoroughly surface
`cleaned and rinsed prior to reuse.
`
`The use of a solution of sodium
`hypochlorite containing 20,000 ppm of
`available chlorine has been declared
`important for decontamination proce-
`dures for the reuse of rigid trial set contact
`lenses and ophthalmic devices in England
`because of vCJD.38
`
`Recording of contact lens use
`and processing30
`Optometrists should maintain a record of
`processing of contact lenses that logs:
`1. the patient reference
`2. the date of use
`3. the date and method of hygienic man-
`agement
`4. contact lens details
`5. a note to indicate when it is time to
`disinfect trial lenses again (this should
`occur monthly).
`
`TONOMETERS
`the most
`As
`tonometer probes are
`common item in the consulting room to
`regularly come into contact with mucous
`membranes and tears of patients, optom-
`etrists must ensure that they are cleaned
`and maintained appropriately. They
`should be cleaned before and after use.
`In the literature,33,39 there is some con-
`troversy about the most suitable method
`to disinfect tonometers. Common practice
`is to wash the tonometer prism, wipe with
`an alcohol swab and allow to air dry. The
`hepatitis C virus is removed only with a
`five-minute soak in 3% hydrogen peroxide
`or 70% alcohol, followed by wash in cold
`
`Clinical and Experimental Optometry 90.6 November 2007
`438
`
`Journal compilation © 2007 Optometrists Association Australia
`
`© 2007 The Authors
`
`

`
`Infection control guidelines for optometrists 2007 Lakkis, Lian, Napper and Kiely
`
`• Clean tonometer prism by rubbing with a mild (neutral pH) soap or a non-abrasive contact lens cleaner before debris has dried.
`• Rinse off the soap or contact lens cleaner with sterile water/saline before disinfecting.
`• Soak the tonometer prism on its side for five minutes fully immersed in 3% H2O2, 70% isopropyl alcohol or 1:10 dilution of bleach.33,39 Alternatively,
`a set-up that allows the 2 to 3 mm area adjacent to the tonometer tip to be immersed in solution without the tip resting on the bottom of the container
`may be suitable (Figure 1).
`• Rinse with sterile water/saline and air dry.
`• Have at least two prisms available for use so that one can be soaking while the other is being used.
`• If you have had to remove the tonometer prism by putting your fingers into the solution, the solution needs to be changed each time. If you are able
`to remove the tonometer tip without contaminating the solution, the solution should be changed twice a day. Any device used for soaking tonometer
`tips must be cleaned with soap and water each day.
`
`Table 3. Recommended procedure for disinfection of tonometers
`
`Although CJD and vCJD are not major
`risks in Australia, optometrists should be
`aware that infectious prions are highly re-
`sistant to inactivation by many current dis-
`infection techniques such as alcohol and
`chlorhexidine (for CJD and vCJD) and au-
`toclaving (for vCJD).48 If the optometrist
`believes that there is a possibility that a
`patient is at risk of having CJD, non-
`contact tonometry or disposable tonome-
`ter tips/shields/prisms/probes should be
`used and disposed of immediately.
`
`ADDITIONAL RECOMMENDATIONS
`tip/
`1. Use a disposable
`tonometer
`shield/prism/probe or non-contact
`tonometry in cases of infection or if the
`patient has HIV. Note: non-contact
`tonometry may result in splash-back
`and as the tonometer could contact the
`eye, it is necessary to wipe it with an
`alcohol swab between patients.
`2. If tonometry is not performed, record
`the reason and whether the patient has
`been referred to another eye-care prac-
`titioner to have it performed.
`3. It is useful to have two tonometer
`prisms available for use.
`4. The instructions from the manufac-
`turers of Haag-Streit tonometer (Gold-
`mann)49 recommend not exposing the
`prism to alcohol. They advise:
`• Remove prism and clean with mild
`soap and cold water. (Because of the
`potential for Acanthamoeba contami-
`nation of water supplies, we are cau-
`tious in recommending the use of
`
`tap water for rinsing and suggest the
`use of sterile water/saline.)
`• Soak in 3% H2O2 for 10 minutes.
`• Rinse thoroughly with cold water, dry
`with tissue.
`• Store in a clean, dry container.
`Alternative solutions are listed on the
`Haag-Streit website.49
`
`GONIOSCOPY LENSES
`Disinfection of gonioscopy lenses should
`follow tonometry guidelines but also con-
`sider the manufacturer’s instructions, for
`example, the manufacturers of the Volk
`Gonioscopy lens recommend:50
`1. Clean the entire lens using a mild
`cleaning solution (diluted dishwashing
`liquid) and a clean soft cotton cloth.
`2. Disinfect with either 2% aqueous glut-
`araldehyde or 1:10 dilution of sodium
`hypochlorite/household bleach, using
`fresh solution each time. Position the
`lens on its side, then immerse the
`entire lens in the selected solution for
`25 minutes. Remove the lens from
`the solution and rinse thoroughly with
`room temperature water, then dry with
`a soft, lint-free cloth.
`3. Clean both sides of the anterior glass
`element and the inside of the ring with
`Volk Precision Optical Lens Cleaner
`(POLC) or a Volk LensPen.
`Following disinfection, store the gonios-
`copy lens in a closed case or container.
`Any device used for soaking gonioscopy
`lenses must be cleaned with soap and
`water before and after use.50
`
`Figure 1. Device that can be used for
`soaking tonometer prisms.47 Holes are
`drilled in the top of a petri dish to allow
`the prism surface and surrounding 2 to
`3 mm to be soaked in the disinfectant.
`Similar devices are commercially available
`through US manufacturers.
`
`water,40 while the hepatitis B virus is not
`removed with alcohol wipes, so this must
`be followed by rinsing with soap and
`water.41 HIV is totally eliminated with a
`70% alcohol wipe or a five-minute soak in
`3% hydrogen peroxide, 70% alcohol or
`1:10 bleach42 and Adenovirus 8 (a com-
`mon cause of epidemic keratoconjunctivi-
`tis)43 is removed with alcohol, iodophor or
`hydrogen peroxide wipe or a five-minute
`soak in these disinfectants or bleach.44
`Alcohol swabbing and long-term (four
`days) continuous soaking with alcohol
`have been reported to cause damage to
`tonometer prisms, such as surface scratch-
`ing and dissolving of the glue holding the
`tonometer prism together.45,46 The recom-
`mended method to disinfect tonometer
`prisms is shown in Table 3.
`
`© 2007 The Authors
`
`Journal compilation © 2007 Optometrists Association Australia
`
`Clinical and Experimental Optometry 90.6 November 2007
`439
`
`

`
`Infection control guidelines for optometrists 2007 Lakkis, Lian, Napper and Kiely
`
`FUNDUS LENSES
`Fundus lenses should be cleaned with mild
`detergent and water, and air dried or dried
`with a lint-free cloth. If infection is sus-
`pected, the lenses should be disinfected,
`according to manufacturer’s instructions,
`for example, the manufacturers of Volk
`Fundus lenses recommend:50
`1. Clean with a mild cleaning solution
`(disinfectant soap) and a clean soft
`cotton cloth or swab.
`2. Disinfect with either 2% aqueous glut-
`araldehyde or 1:10 dilution of sodium
`hypochlorite/household bleach. Posi-
`tion the lens on its side, then immerse
`the entire lens in the selected solution
`for 25 minutes. Remove the lens from
`the solution and thoroughly rinse with
`room temperature water, then dry with
`a soft, lint-free cloth.
`3. Clean the anterior glass element and
`the inside of the ring with Volk POLC.
`4. Store in a closed case or container.
`
`EYE-DROP BOTTLES
`External rims of bottles (for example,
`anaesthetic, mydriatic, Fluress, in-practice
`contact lens solutions and saline bottles)
`may become contaminated. Optometrists
`should: 51,52
`the product has not
`that
`1. Check
`reached its expiry date.
`2. Store the product within the tempera-
`ture range recommended by the man-
`ufacturer.
`3. Mark the opening date on the bottle.
`4. While using the bottle ensure that the
`bottle cap is held in the hand.
`5. Ensure the bottle tip never touches
`the patient’s eyes or the optometrist’s
`hands.
`6. Replace the bottle cap immediately
`after use.
`7. Refrigerate if appropriate (note: not
`all eye-drops can be refrigerated after
`opening; it is recommended that food
`is not kept in refrigerators where drugs
`are kept).
`8. Store the product for the time after
`opening recommended by the manu-
`facturer. Discard at the end of this time
`(usually one month after opening) or
`by the product’s expiry date if this is
`earlier.
`
`9. Use minims whenever possible and if
`the eyes are infected use only minims.
`If it is not possible to use a minim on
`an infected eye, discard the bottle after
`use.51 Alternatively, use a sterile glass
`rod or disposable dropper to adminis-
`ter the drops. The glass rod may be
`disinfected by autoclaving.
`
`OTHER CONSIDERATIONS
`
`Control of infection includes effective and
`regular cleaning of the practice premises,
`insertion of plastic liners in waste baskets,
`disposal of waste and elimination of
`insects within the premises. There should
`be regular cleaning of all surfaces and
`fittings. Isopropyl alcohol tissues, 30%
`alcohol solution or sodium hypochlorite
`solution (1% solution can be obtained by
`a 1:5 dilution of 5% household bleach)
`may be used for large surface swabbing,
`although some surfaces may be damaged
`by alcohol. The practice should have a
`well-equipped first aid kit and cardiopul-
`monary resuscitation (CPR) masks.
`
`Waste disposal
`Infectious material must be disposed of
`as biohazardous waste.53 Material is to be
`placed in yellow containers or plastic bags,
`which are marked with black biological
`hazard symbols. To avoid needlestick
`injury, needles should not be resheathed
`or removed from disposable syringes.
`‘Sharps’ must be discarded in clearly
`labelled, puncture-proof containers.53 Col-
`lection of ‘sharps’ and potentially infec-
`tious waste can be organised through a
`collection service or arrangements made