Back to Basics: New Protocols for Improved Contact Lens Care

In order to optimise the performance and safety of contact lens wear it’s critical a patient follows the correct protocol. Leading eye care specialists around the world have unanimously agreed that it is time for contact lens care to go back to basics.

On returning from the British Contact Lens Association (BCLA) meeting in London this year, New Zealand optometrist and Contact Lens expert Alan Saks, told mivision in August that ‘rub and rinse’ was a “serious agenda issue” and “one of the highest number of presentations on these issues, ever.”

He said: “the whole ‘no-rub’ issue has always been a ‘no-brainer’ as far as I’m concerned. It was forced on practitioners, against our will, by the solution manufacturers as a response to the actions of lazy consumers! No-rub was never shown to actually clean lenses; it was only tested to see if it killed bugs.”

It’s time for us to get a little more serious about CL patient care and get back to basics

Whilst most practitioners would claim their CL patients adhere to a strict ‘Rub and Rinse’ protocol as part of their cleaning regime, there is a clear disconnection between practitioners’ advice and what the patient is doing or not doing. Many patients who have traditionally used a ‘no-rub’ solution, don’t, or can’t be bothered to, ‘rub and rinse’. Most of these patients have never experienced an adverse reaction to the ‘no-rub’ regime and often believe eye infections ‘won’t happen to me’.

It is important that practitioners and manufacturers be responsible and adopt a duty of care to effectively communicate to their patients the correct ‘Rub and Rinse’ protocols. We need to make every effort to ensure the patient understands and complies with these instructions both initially and during return visits. It’s imperative that practitioners and manufacturers work together in the interests of patients’ health.

Numerous outbreaks of eye infections caused by Fusarium and Acanthamoeba keratitis in recent years have drawn the attention of eye care professionals to the importance of proper contact lens care. One of the key factors contributing to this issue was the omission of important steps in the lens care process. This included not using fresh solution daily, not rubbing the lenses after removal and not adhering to the recommended replacement schedule, thus over-wearing the lenses.²

‘No Rub’ multi-purpose solutions originally intended to increase consumer convenience so they would be more compliant to the lens care regimen. However, since their availability in the market, most contact lens wearers have instead formed the misconception that soaking lenses for four to six hours is the only procedure they need to do to take care of their lenses. Many of them skip the pre-soak rinsing procedure which is essential in removing micro organisms and debris from the lenses.

It’s time for us to get a little more serious about CL patient care and get back to basics. Research conducted in recent years has found that the act of ‘rubbing’ is the most effective procedure in the lens cleaning process. Ninety-nine per cent of micro organisms can be dislodged from the lens surface by performing a simple ‘Rub and Rinse’ protocol.³ More than 80 per cent of lens surface deposits can be removed by rubbing and rinsing lenses, whereas only less than 20 per cent of surface deposits can be removed by rinsing alone.⁴

Multi-purpose solutions by themselves do not perform well against rare, but hard-to-eliminate, organisms such as Acanthamoeba. Apart from using the peroxide system, it is only by performing the ‘Rub and Rinse’ protocol that the cysts of these rare organisms can be fully eliminated.⁵ Although multi-purpose solutions are more convenient and theoretically safer, as they disinfect and lubricate at the same time, the rubbing of lenses during the lens cleaning process will greatly reduce the risk of eye infections and should be practiced. For example, tests on Advanced Medical Optic’s Complete Easy Rub multi-purpose solution, which promotes easy rubbing of lenses, showed a close to six log reduction of Serratia marcescens and Staphylococcus, as well as a four log removal of hard-to-eliminate organisms such as Fusarium and Acanthamoeba when used as directed.

A recent survey conducted in seven Asia-Pacific countries (Australia, Singapore, Malaysia, Hong Kong, China, Taiwan and South Korea), which interviewed 350 eye care practitioners, showed that majority of eye care practitioners in the region believe that 90 per cent of contact lens wearers were not compliant to the proper contact lens cleaning regimen, and that only 55 per cent of contact lens wearers practice the ‘Rub & Rinse’ protocol on a daily basis. Therefore, there is a need for eye care practitioners to advocate and educate their patients to practice the ‘Rub & Rinse’ protocol. This can help provide their patients with cleaner lenses, clearer vision, greater comfort and most importantly, a very much reduced risk of eye infections.

A proper ‘Rub and Rinse’ protocol should include the following steps:

Nightly contact lens cleaning regime

Step 1 (refer image 1a and 1b)

Before removing lenses, wash hands with a non-scented, non-oily/creamy soap or antibacterial pump soaps. Creamy soaps transfer from hands to lens surfaces and may leave a film on lenses, while some scents in soaps can irritate eyes. Then dry your hands. Set the lens case in front of you with the right compartment in front of your right hand. Remove right lens from eye.

Step 2 (refer image 2a and 2b)

Place three or more drops of multi-purpose solution, formulated for rubbing if possible, on one side of the lens surface. Rub the lens gently from the centre to the edges for at least 10 seconds. Never rub in a circular motion, as it can tear the lens and does not clean the outer edge of the lens. Do not rub the lens between your fingers as it can warp or tear. Repeat the rubbing technique for the other side of the lens.

Step 3 (insert image 3)

Rinse each side of the lens for five seconds with multi-purpose solution. Replace the right lens in the case and repeat the steps for your left lens.

Step 4 (refer image 4)

Make sure your lens case is filled with fresh multi-purpose solution and allow lenses to soak for a minimum of six hours before next use.

Morning contact lens cleaning regime

Step 1 (refer image 5)

In the morning or before the next use, wash and dry hands before handling lenses.

Step 2 (refer image 6)

Rinse each side of your lenses for five seconds to remove any debris before inserting lenses.

The full guidelines are available at the International Association of Contact Lens Educators (IACLE) (www.iacle.org) website.

Contact Lens Do’s and Dont’s

It is also important to remind contact lens wearers the following Do’s and Don’ts: Contact Lens Do’s: Do carefully follow cleaning and handling instructions from eye care specialists. Do throw out all multi-purpose solution from the lens case, rinse the case with multi-purpose solution, and refill it with fresh multi-purpose solution. Do rinse the lens case nightly and refill with fresh solution in order to maintain maximum strength for disinfecting the lenses. Do refill the case before placing your lenses in, as they may be damaged (scratched, torn) if placed in a dry case. Do wash your hands before handling lenses. Do rub both sides of the lenses during cleaning to help remove deposits more effectively (cleaning lenses without rubbing is like passing a dirty dish through soapy water without scrubbing it). Contact Lens Don’ts: Don’t ‘top-off’ or reuse old solution as it will not kill micro organisms effectively. Don’t allow the tip of the multi-purpose solution bottle to be immersed in the old solution while the bottle is squeezed, as the dirty solution will be suctioned up and the entire bottle of solution may become contaminated. Don’t expose lenses or cases to tap water or contaminated or expired multi-purpose solution. Don’t wear lenses longer than they’re intended for. Don’t ever use saliva to clean your contact lenses.

10 Ways to Increase Contact Lens Compliance

Dr. Milton Hom, an optometrist in the United States, has suggested 10 ways to increase contact lens compliance with patients6: Use materials that can prove useful in encouraging compliance include written instructions and appointment reminders such as calendars, recall cards and stickers. Know the types of non-compliance (overwearing, sleeping in lenses, inadequate disinfection or improper lens cleaning). Profile the patient. Younger patients, long-time wearers, refitted patients are those more likely to be non-compliant. Don’t make the assumption that wearers with a certain profile are great with compliance. Clear instructions should be given throughout the initial visit and subsequent visits. Require patients to bring in their lens care products to each visit. Request them to demonstrate the steps in their care regimen, while explaining which solution is used for each step. Recommend a monthly case replacement schedule. Recommend the right lens material and prevent overwearing. Compliance appears to improve when emphasis is placed on the interpersonal relationship between practitioner and patient. Practitioners should talk to patients about compliance. Reward your patients with praise.

Dr. Gunter Wong graduated from the optometry program at the Hong Kong Polytechnic University in 1995. He furthered his study at the University of New South Wales and obtained the Master of Optometry in 1997 with specific interests in contact lens studies, orthokeratology, visual neuroscience and behavioral optometry. During his stay in Australia, he worked together with Dr. Helen Swarbrick in the study of mechanism in orthokeratology. After returning to Hong Kong, he worked in a private child care centre specialized in the assessment and management of children with autism, dyslexia and learning problems. In 2001, he entered the doctoral program at the University of Hong Kong in the area of visual perception, working under Dr. Kim Poon McBrayer and Dr. John M.K. Lian. In 2005, he joined the Advanced Medical Optics as scientific promotion manager.

References:
1. ‘ECP Research Report’, Research Link, July 2007
2. Bennett ES. What have we learned from the Fusarium outbreak? Rev Optom 2007 April 15:34-39
3. Snyder C. Lens care complications – where’s the rub? Cont Lens Anterior Eye 2006;29:161-162.
4. Cho P, Cheng SY, Chan WY, et al. Cleaning soft contact lenses – rub versus no-rub. Programme and Abstract Book of the 4th Asia Cornea & Contact Lens Conference, Hong Kong, 26-27 April, 2007.
5. Kilvington S, Anger C. A comparison of cyst age and assay method of the efficacy of contact lens disinfectants against Acanthamoeba. Br J of Ophthal 2001;85:336-340.
6. Hom MM. Improving contact lens compliance. Rev Optom 2007 Sep (Special Edition):44-47.