This article is more than 5 years old. Information may no longer be current.
Practice in-office prophylaxis through disinfection, sterilization, hand washing
Click Here to Manage Email Alerts
DuBOIS, Pa. — Appropriate disinfection or sterilization of equipment and hand-held devices can go a long way in reducing the spread of infectious disease in an office setting. Hand washing, gloves and the use of disposables can also dramatically reduce contamination.
David J. Kairys, OD, who is in solo private practice here, believes that about half of optometrists do an adequate job of in-office prophylaxis, while the other half “probably have spotty adherence to good pathogenicity control,” he said. Particular attention should be given to trial contact lenses.
“Trial contact lenses are often simply soaked in a multipurpose solution for months at a time, then rubbed and rinsed vigorously prior to insertion in the next patient’s eye,” Dr. Kairys said. Highly valuable reusable toric lenses, in particular, “should be subjected to hydrogen peroxide disinfection weekly,” Dr. Kairys said. A log should also be maintained.
Tonometers
For semi-critical devices such as Goldmann tonometer heads, “a 10-minute soak in 3% hydrogen peroxide is recommended between patients, followed by rinsing vigorously with tap water and drying with a paper towel,” Dr. Kairys explained. “The old-fashioned practice of a 70% ethanol wipe will eventually result in transmission of the adenovirus known as epidemic keratoconjunctivitis (EKC).”
David P. Sendrowski, OD, FAAO, an associate professor at the Southern California College of Optometry in Fullerton, Calif., where he also serves as chief of ophthalmology consultation and special testing services, said that according to the Centers for Disease Control and Prevention, the peroxide should be changed twice a day. This ensures that even in heavy-use situations, it maintains its effectiveness as a disinfectant.
Some clinicians have tried to bypass the entire contact tonometer issue by using air-puff tonometers. “The newer air-puff tonometers are low air pulse,” Dr. Kairys said. “But the older air-puff tonometers have been shown to create a spray of tears within the testing room. Given the half-lives of adenoviruses, which is on the order of 15 minutes to 25 minutes in normal humidity and temperature, air-puff tonometers are likely to spread EKC even more so than an inadequately disinfected Goldmann tonometer. This comes as quite a surprise.”
In essence, newer air-puff tonometers “are much less likely to create a microaerosol and thereby are much less likely to spread adenoviruses and rhinoviruses,” said Dr. Kairys, an independent research associate and part-time instructor in microbiology at Penn State University.
Single use advocated
Dr. Kairys does not use an autoclave in-office, but has one available to him at Penn State. “Instead, I use disposable lens sets and disposable hypodermic syringes. Single-use items are preferable,” he said. An autoclave is “cumbersome, expensive and unreliable. In fact, right now, the autoclave in our lab is down. We can’t seem to make the heat sensor work.”
One of the greatest infection control problems among OD practices stems from not using latex gloves. “If you’re in too big of a hurry, at least take a tissue and wrap it around your thumb when you lift the eyelid,” Dr. Kairys said.
For EKC patients, Dr. Kairys uses 5% Betadine solution (povidone-iodine, Escalon Ophthalmics), diluted 50% with saline, on an eye he has previously anesthetized. “Doing this pushes the patient toward recovery a week early,” he said. “It also causes the patient to experience no small amount of ocular discomfort on a transient basis. I rinse out the Betadine solution after 30 seconds with 4 fluid ounces of saline.” However, Betadine soap is not to be used because “it will opacify a cornea,” Dr. Kairys said.
Written protocols
“I think the optometric office is a low-risk area of contamination,” Dr. Sendrowski said. In addition, “the majority of optometrists do a good job in preventing spread of infection and prevention of contamination to staff workers.”
Nonetheless, written protocols are necessary, Dr. Sendrowski stressed. “Not only does this get the OD thinking about what to do, but it also creates a thought process in the OD that the office may require some additional equipment or some additional protective gear, such as gloves and masks,” he said.
Every office should have a protocol for hand-held instrument cleaning, as well as preventing staff from acquiring infection. Instruments that break the epithelial surface of the cornea, such as a corneal spud or Alger brush, “require a moderate level of disinfection,” Dr. Sendrowski said.
According to Dr. Sendrowski, the gold standard for sterilization of any hand-held instrumentation is an autoclave. “But because autoclaves are fairly expensive pieces of equipment, costing up to $7,000, an optometrist can do an excellent job with a moderate level of disinfection using cold sterilization,” he noted. “The only difference between disinfection and sterilization is the amount of time a particular hand-held instrument spends in that solution.”
Effective disinfection takes only 20 to 30 minutes, in contrast to cold sterilization, which requires anywhere from 20 to 24 hours, depending on the solution. “Glutaraldehyde is both an excellent disinfectant and sterilizer,” Dr. Sendrowski said.
In addition, for high-volume offices, multiple Goldmann tonometer probes are recommended because of solution soak time. Despite varied hygiene standards among offices, though, “you don’t see a lot of contamination and spread of infection with tonometer probes across the nation,” Dr. Sendrowski said.
Red-eye alert
Still, practitioners should be on the alert for patients with red eye, either from an inflammation of the conjunctiva or cornea. “If the doctor feels tonometry is warranted, rather than applying an alcohol wipe, a higher level of disinfection to the tonometer probe is advised,” Dr. Sendrowski said. On the other hand, “there are no examples in the literature of the spreading of AIDS or hepatitis through a probe,” he said.
Clinicians should also be proactive in cases where they feel contamination may occur.
“If a doctor has an open wound on his or her hand, he or she should wear gloves,” Dr. Sendrowski said. An example of this includes an eczemoid weeping dermatitis.
Clinicians and staff should also glove up when a patient has suspected infectious ocular disease. “A good latex glove is recommended, as long as it provides a good barrier of protection between the hand and the eye,” Dr. Sendrowski said.
“But the absolute number one thing optometrists can do in their offices is wash their hands between patients,” Dr. Sendrowski pointed out. Practitioners and their staff adhering to hand washing “can dramatically reduce the spread of infection, both for the common cold and eye infection,” he said. “There’s an old adage that they teach in medical school: You wash your hands before you see the patient to protect the patient, and you wash your hands after the patient to protect yourself.”
Facial lesions
Ancillary staff can also be trained to notify the optometrist of any dermatologic lesions on patients at the dispensing table. “You particularly should be aware of any kind of facial lesions, such as a herpes facial blister. A dermatologic lesion on the face of a child can also be contagious,” Dr. Kairys said.
Furthermore, if a dispensing paraprofessional sneezes, “he or she needs to stop and wash his or her hands. This is standard practice in our office,” Dr. Kairys added.
Likewise, at the beginning of each eye exam, the OD should wash his or her hands in front of the patient, then make a verbal remark about his or her hygiene practice. “This action instills confidence in the patient that the office is hygienically proactive,” Dr. Kairys said.
Added Dr. Sendrowski, “with legislation expanding scope of practice in optometry, optometrists in the future are going to be required to look a little bit more seriously at their protocols and their means of disinfection.”
For Your Information:
- David J. Kairys, OD, can be reached at 269 Treasure Lake, DuBois, PA 15801; (814) 371-2211; fax: (814) 371-7784; e-mail: kairysod@penn.com. Dr. Kairys has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- David P. Sendrowski, OD, FAAO, can be reached at Southern California College of Optometry, 2575 Yorba Linda Blvd., Fullerton, CA 92831; (714) 449-7414; fax: (714) 992-7848; e-mail: dsendrowski@scco.edu. Dr. Sendrowski has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.