care and maintenance of contact lenses
TRANSCRIPT
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CARE AND MAINTENANCE OF CONTACT LENSES
MANOJ ARYAL B. Optometry
IOM,Maharajgunj Medical Campus
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PRESENTATION LAYOUT
• Introduction• Overview of care and maintenance Care and maintenance of soft contact lenses Care and maintenance of RGP contact lenses Lens deposits Patient education and compliance: use and care of
contact lenses Discussion
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Introduction
Most crucial aspect of contact lens wear Influence the success of contact lens wear and
patient’s satisfaction with their lenses
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Overview Of Care And Maintenance
Purpose:Clean lensGood comfortGood visionSafe lens wear
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Components: Cleaner
Daily cleaner
Weekly/protein cleaner
Rinsing solution Disinfecting solution Lubricating/Re-wetting solution Lens storage cases
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CleanersMost common components
Surfactants(surface active agents)
Non-ionic Ionic
AnionicCationicAmphoteri
c
Buffers Osmolality
adjusting agents
Preservatives Chelating
agents water
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Cationic surfactants are not normally used with SCLs bcz. They may be bind with lens particles
Preservatives are primarily used to protect the cleaning solutions from microbial contaminations after opening
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Surfactant cleaners:
Normally used in conjunction with finger rubbing Rubbing step is always followed by rinsing step Rubbing: dislodges the contaminants Rinsing: removes the displaced contaminants
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Daily Cleaner
Function To remove:
Loosely bound foreign matter
Cell debris Mucus,lipid, protein Cosmetics or other
surface contamination
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Dailey cleanersContains friction enhancing agents/polymeric beads
These are the small solid particles that behave as a mild abrasive but which do not affect lens surface
Eg. Allergan LC 65&B&L sensitive eye daily cleaners
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Extra strength daily cleaner Alcon Opti-clean,
Polycleans ii B&L Concentrated
cleaner CIBA Miraflow
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General procedure: Wash hands Place lens in palm of hand Place 2-3 drop of cleaner on each lens Rub with forefinger for about 15 seconds per side
using a to and fro and fro action. Rolling the forefinger in both directions cleans the lens periphery
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Weekly cleaners:Usually formulated for protein removalSometimes called enzymatic cleaners bcz.
most contains one or more proteolytic enzymes
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Rinsing Solutions
Function: Removal of loosened lens contaminants Removal of residual cleaners Rehydrate lens Resolve enzyme tabs
Most common and most economical rinsing solution is saline
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Saline: Isotonic saline can also be used: As a medium for enzyme treatment in some
regimens To elute unbound adsorbed or absorbed lens
contaminants To rehydrate lens
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DisinfectionFunctions:
Kill or deactivate potentially pathogenic organisms includes Bacteria Fungi Virus Amoebas
Maintain lens hydration
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Types Thermal Chemical
Conventional Polymeric Tablet
Hydrogen peroxide
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Thermal Disinfection
High temperature kill micro-organism by:
Denaturation of cell components
Disruption of plasma membranes
DNA damage
2 methods of applying heat to lenses in a lens storage case
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Wet: immersing the lens case in water at or near its
boiling point or Placing the lens case above boiling water
Dry: direct heating of lens case by a matching, snug
fitting, electrically heated device After heating cycle allow lens to cool before use
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Advantages
Short disinfection cycle times(10-30)
Very effective in destroying microorganisms
Low risk of toxic or allergic reactions
Disadvantages
Incompatible with some lenses(usually SCLs)
Suitable electrical power for heat units may not always be available
Can cause lens discoloration
Increased protein deposition
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Chemical Disinfection
Conventional Chemicals: Thimerosal Chlorhexidine Sorbic acid Benzalconium chloride Iso-propyl alcohol
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Thimerosal: Effective as anti-fungal agent
Reduced effect when combined with EDTA
Cytotoxic to corneal epithelium
Chlorhexidine gluconate: Antibacterial agent
Leaches from Group 1 to Group 4
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Benzalkonium chloride Antibacterial agent
Cytotoxic
Sorbic acid Anti bacterial with limited
antifungal activity
Not cytotoxic
Causes discolouration of lenses
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Alcohol: Cleaners: isopropyl alcohol and ethanol Disinfection : isopropyl alcohol
E.g.CIBA Miraflow used in disinfecting solutions Both disinfectants and cleaners contain large
conc. of alcohol Cleaner 20% Disinfectant 17%
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Chemical Disinfection: Disinfectant Sensitivity
Symptoms
Sudden decrease in ocular tolerance
Decreased wearing time(2-4 hour)
Burning, grittiness, dry sensation
Signs
Conjunctival redness
Epithelial damage
Corneal inflammation
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diffuse corneal staining resultingfrom a reaction to a disinfectant or a preservative.
A mild red eye (conjunctival hyperaemia) due tosensitivity to a solution component, usually thedisinfectant.
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Disinfectant sensitivity depends upon: Preservative type Preservative concentration Lens material Soaking time
Lens age Patient susceptibility
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Polymeric Disinfection
Relatively recent class of disinfection Most common examples are
PHMB Polyquaternium-1
Used in multipurpose solution
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E.g B&l Mps ReNu,Alcon Opti-Free,
Allergan Complete ,CIBA Solo care soft
Disadvantages
Reduced disinfecting power
Rub/rinse still required
Compliance is more important
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Tablet Based System
Chlorine tablet system Halane(sodium dichloroisocyanurate) Halazone(poly(dichlorosulphanoyl)be
nzoic acid) E.g Alcon Softab, Sauflon Aerotab
Chlorhexidine E.g Optim eyes
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Hydrogen Peroxide Disinfection
Along with thermal disinfection is one of the earliest SCLs disinfection method
Hydrogen peroxide: Produces free oxygen radicals which are very reactive and quickly bind to many cell
components
Decomposes to water and oxygen
Requires neutralization
Can be formulated preservative free
Can be supplied in one-step form
Must be stabilized
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Hydrogen peroxide: neutralizationNon selective anti-microbial agentMinimum 3 hr in 3%h2o2 recommended
Bacteria 10-15 minFungi 60 min Acanthomoeba 3-6 hour
Neutralization:2-step peroxide disinfection1-step peroxide disinfection
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Neutralizers: Sodium pyruvate:
Na2C3H3O3+H2O2=NaC2H3O2+H2O+CO2
Sodium sulphite:
Na2SO3+H2O2=Na2SO4+H2O
Sodium thiosulphate:
2Na2S2O3+H2O2=Na2S4O6+2NaOH
Sodium tetrathionate
Highly deleterious to cornea
2-step peroxide neutralization: stoichiometric(reactive) Neutralization
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2-Step H2O2 Systems: Catalytic Neutralization
Have longer neutralization time
In either tablet or solution form, neutralization and equilibrium time of 10-15 minutes are generally adequate for low water content lenses
Higher water SCLs require longer times of up to 1 hour
Neutralizers:
Catalytic disc in second lens case
Catalase solution or tablet
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2- Step Peroxide Disinfection
Advantages
Can vary time of disinfection
Concurrent protein removal possible
Suited to occasional wear
Disadvantages
Less convenient
Some have preserved neutralization solution
Potential for irritation
expensive
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1-step neutralization system
Formulated so that the peroxide disinfection and neutralization are performed during the recommended time
With tablet using system a delay is applied to the neutralization phase
With disc-based systems, no delay is applied to the neutralization phase
When neutralization is performed as separate step, the system is called atwo-step neutralization
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Disadvantages: Inflexible neutralization time
H2o2 concentration decreases rapidly(3%-1%in less than 10 min)
Not effective against fungi and acanthamoeba species
Catalytic disc needs regular replacement
Potential for irritation
Possible recontamination
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In systems using catalytic disc, whenever H2O2 is in contact with the disc, the concentration is decreasing
User of disc based 1- step systems should be instructed to place their lenses in lens baskets before pouring peroxide solution into the case
If not, much of the peroxide is neutralized by exposure to the disc before lenses are immersed
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H2O2: Effect On Lens Parameters
May cause reversible parameters changes in high water lenses
HWC requires longer soaking time to reverse Caution:
Discomfort and irritation follow lens insertion if residual peroxide present
No permanent damage to normal ocular tissues
Corneal staining might be observed
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Protein Removers
Most protein removers are based on enzymes Enzymes cleaners work by leaving substrate specific
enzymes break down their target molecules, thereby facilitating their removal
Protease target proteins
Lipase target lipids
While amylase targets polysaccharides
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Enzymes can also remove other types of deposits if they are incorporated in the protein deposits
Enzymes may also break bonds between the lens materials and proteins
Enzymatic cleaning does not replace the disinfection system
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Procedure: Used regularly, after the daily cleaner and rinsing
step
Lenses should be soaked in enzyme dissolved in solution/saline for 15 min to overnight, depending upon manufacturer
Lenses should be thoroughly rubbed and rinsed again afterwards
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Enzymatic protein removers
Contain one of the following Papain Pancreatin Subtilisin A &B
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Papain: protease i.e. enzyme that act as protein specifically
Derived from papaya plant
Usually have a slightly unpleasant odour due to the inclusion of cysteine
Binds to contact lens material and can cause sensitivity reaction
Short 15 min soaking time possible
E.g. Allergans Soflens enzymatic cleaner or Profree
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Subtilisin A&B: Proteases
Subtilisin A formulated specifically for use in hydrogen peroxide lens care systems
Subtilisin B is formulated for use in conventional chemical and thermal systems
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Re-wetting/ Lubricating Drops
Used for: Promote comfort
Reduce deposit induced friction b/w eyelids and corneal surface
Rehydrates the lens
Lubricating and re-wetting eye drops are formulated with viscosity-enhancing agents(commonly polyvinyl alcohol, methylcellulose etc)
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Lens Storage And Cases
To avoid contamination, lens cases should be rinsed after every use and the lenses stored in fresh solution
Acanthamoeba and other free living protozoans are especially prevalent among those using tap water for rinsinf their lens cases, using home made saline as a rinsing solution for contact lenses, or swimming with contact lenses.
Biofilm or glycocalyx formation on the surface of contact lens storage cases can horbour pseudomonas aeruginosa and serratia marcesens
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Care of lens cases: Discard used solutions
Scrub with a toothbrush and detergent weekly.oil free soaps or detergents are recommended
Rinse with hot water and rub thoroughly with a clean, dry tissue
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Lens replacement schedule and care regimen
Daily disposable: Does not require use of surfactant cleaner, disinfecting solution or weekly enzyme
If needed the patient can use in eye re wetting drops or sterile saline for rinsing prior to insertion
Regular disposables
Suitable care includes multi-purpose solutions
No weekly protein removal is needed
Other options: Surfactant cleaners
1-step hydrogen peroxide disinfection
Lubricating/re-wetting solutions
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Care regimen guidelines for frequently replaced lenses,conventional lens wearers
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In-office diagnostic(trial set) lenses SCL use heat if possible otherwise peroxide
RGP use peroxide or store lens dry
Re-disinfect non disposable inventory trial lenses at least once a month
In-office procedures Oxidising agents
Standing waves
Ultrasound
Ultraviolet
Microwave
Common oxidizing agents used are LiprofinTM, 6 or 9% peroxide
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Care and maintenance
Important steps for patients
Wash hand prior to handling lenses
Rub each side of each lens for 10-15 seconds using a surfactant cleaner
Rinse each lens thoroughly in normal saline
Disinfect contact lenses in fresh disinfecting solution in a clean storage case Remember
Do not mix solution type and brands Assess patients compliance Repeat instructions and assess demonstration to patient Remind patient to clean lens case weekly
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The Message
C lean
R inse
A nd
D isinfect
L enses
E very time
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RGP Care And Maintenance
Purpose: Minimize deposit accumulation
Increase lens wettability
Facilitate comfort and vision during lens wear
Deposits:
RGP material containing
Siloxane are more prone to protein deposits
Fluorine are more susceptible to lipid coating
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Practitioner choose low Dk over high Dk RGP material despite the benefits of higher oxygen permeability
The high Dk RGP lenses are more susceptible to lens surface deposits than their low to moderate Dk counterparts
Cleaner :
daily surfactants
Protein removers
Disinfecting or soaking solution
Wetting solution
lubricants
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Daily surfactant: Similar to their SCL counterpart
An alcohol based cleaner is well suited to fluorosiloxane lenses which tend to acquire lipid deposits
Patient should be cautioned against soaking RGP lenses in alcohol based cleaner
Further, they should be adjusted to rinse their lenses thoroughly immediately after using such cleaners bcz. they have been shown to alter lens parameters if allowed to remain in contact with the lenses
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Enzyme: recommended for protein removal in deposit prone wearers
Polish: may be necessary for lenses over 12-18 months old Cleaning pad; may be effective in removing some
deposits from RGP lenses Avoid:
Vigorous rubbing
Excessive pressure on lens
Prolonged cleaning with mildly abrasive cleaners
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Recommended technique: Place the lens in the palm of hand Rub lens with finger for minimum of 10 seconds Rinse with saline or tap water approved for
drinking
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Disinfection Although microorganisms can not readily attach to
RGP lens surfaces , they can attach to deposits RGP lens should not be thermally disinfected
As this can cause warpage Soaking time (4hour to overnight or as
recommended)
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Preservatives used includes: Thimerosal Phenyl mercuric nitrate Benzalkonium chloride Chlorhexidine Poly(amino propyl bigunide) And polyquaternium-1
H2O2 IS NOT NORMALLY USED GOR RGP LENSES
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Wetting and soaking: It is better for RGP lens wearer to wet-store their lenses If RGP lens are stored dry, parameters such as BOZR
will invariably flatten and the lens surfaces may not wet properly
Wet storage also improves initial on eye comfort and greatly assists microbial control of lens storage conditions
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RGP wetting and soaking solution contains: Antimicrobial agents to disinfect the lenses and to
preserve the solution after initial opening
Wetting agent to improve lens wettability
Viscosity-enhancing agent to thicken the formulation
Buffer system to adjust and maintain solution pH
Salts to adjust solution osmolality
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Wetting agents: Better wetting result in better vision and greater comfort Improve the wetting characteristics of the lens surface: Convert hydrophobic surface to hydrophilic Assist tear film to spread more easily and evenly on lens
surface Increase comfort on insertion
E.g. Poly vinyl alcohol, Polyvinyl pyrolidone, Polysorbate
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RGP lens non-wetting areas due to: Deposits
Manufacturing process
Polishing compounds
Surface combinations
Rinsing solutions RGP lens can be inserted directly into the eye after soaking in
appropriate wetting/soaking solutions
Burning on insertion: change to a less viscous solutions
Stinging on insertion: change solution
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RGP-MPS
One bottle system(OBS)
Combination of cleaning, disinfecting, and soaking functions
E.g. Allergan Total, Boston Simplicity, CIBA SOLO-care-hard
Lubricating drops:
Used during lens wear to:
Improve comfort
Clean lens surface
Maintain lens wettability
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Trial Set Disinfection/Storage
RGP trial lens disinfection: the method recommended is:
Clean with alcohol-based cleaner immediately after use
Place in a clean container
Wet storage in a soaking solution when lens is not being used
Clean the storage solution periodically(monthly)
Clean lens again immediately before next use
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Summery
Because of their non-absorbent nature, surface properties, rigidity and durability RGP lenses are easier to care for
Clean ,rinse and disinfect lens every time(CRADLE) RGP lens kept in use longer than SCLs
Therefore efficacious lens care area more important Consider a programmed replacement scheme
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Contact Lens Deposits
Definition:
Any lens surface coating or lens matrix formation which is not flushed or rinsed from the lens by the tears during blinking. In effect, anything that remains on the surface despite blinking is a deposit
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Deposit formation:
Tear protein(lysozyme) are attached to the lens
Tear evaporates and leave residue on the lens
After protein are deposited, other components of the tear film (such as mucin) may adhere to protein
Over time. Layers build up and structural changes take place(e.g. Denaturation)
Factors influencing lens deposition:
Individual difference in tears
Lens materials Care system Wearing schedule
EW might induce more deposits than DW
Environment Patient hygiene
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Types Of Deposits
Teal related Protein Lipid Jelly bumps Inorganic
deposits
Non-tear related Fungi
Lens discoloration
Mercurial deposits
Cigarette residues
Surface combination
Rust spots
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Protein deposits:
Are a semi-opaque or translucent film usually thin whitish and superficial
Have a frosted glass appearance
may cover lens surface partially or full
Cause the lens surface to become hydrophobic
Can crack and peel if thick
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Factors favouring a build up of protein on a contact lens:
short BUT
Ionic binding capacity
Inadequate cleaning especially of the lens periphery
Altered blinking
Heat disinfection
Tear deficiency or altered tear composition
Chronic allergies and GPC
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Lipid Deposits
Appears as greasy, smooth, and shiny adherent films on both RGP and soft contact lenses
Best observed between blinks Appears as a thick ,oily coating Lipids involved includes: phospholipids, neutral
fats, triglyceride, cholesterol, cholesterol esters, and fatty acids
Origin: mainly from meibomian gland
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Predisposing factors: Tear film quality Slow blink pattern Poor lens compliance Careless use of inappropriate cosmetics/lotions
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Jelly Bumps
Appear as a clumps of raised transluscent mulberry like deposits
Typically form in inferior, exposed portion of lens
Occur more frequently in high water, ionic, EW lenses
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Predisposing factors
Quality of tear film Poor blinking Lens surface
contamination HWC>LWC Aphakia cleaning
consequences
Large and numerous jelly bumps lead to wearer discomfort
Large deposits can cause the lens to attach to the upper lid so that each blink causes excessive lens movement
When located within pupil zone-visual acuity can fluctuating
Maya also cause mechanical irritation of tarsal conjunctiva
In extreme case, may cause CLPC
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Inorganic Deposits
Calcium carbonate deposits Calcium phosphate deposits Appearance: White crystalline specks Can be small or large Rough surface Penetrate lens surface if severs
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Fungal Deposits
Appearance:
Filamentary growth on and into lens
Usually white, brown or black
Fungal formation
Spores on lens surface from eye or environment
Proliferates to large visible growth
Penetrate lens matrix
Contact lens good medium for fungal gruwth
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Lens Discoloration
Can result from: Natural lens ageing Surface contamination Mercurial deposits
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Mercurial deposits:
Appear as a greyish to black discoloration
Reuse of thimerosal containing solution is one cause
To prevent avoid mercury based preservatives
Ageing
Polymer breakdown Chemical absorption Handling Stress and strain deposition
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Surface contamination Make up Moisturizing lotions Hairspray Chemical fumes
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Management Advice patient on good hygiene Proper care and maintenance Do not reuse solutions Smokers should be warned
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Lens Deposition :Rust spots Appearance: Small superficial
raised spots Colored orange to
black Can be few to
numerous
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DISCUSSION
Importance of rub and rinse in use of multipurpose contact lens solution.
Optom Vis Sci. 2011 Aug
PURPOSE : The introduction of contact lens multipurpose disinfection solution (MPDS) that can be used in conjunction with a "no-rub" regimen has simplified lens care requirements. Once adhered to a surface, microorganisms can become less susceptible to disinfection. The aim of the study was to evaluate the effect of various regimen steps on the efficacy of MPDS when used with silicone hydrogel and conventional lenses.
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RESULTS: Overall, the greatest efficacy of MPDSs was observed when "rub and rinse" was performed before disinfection with each of the microorganisms tested, regardless of lens type. "No rub and no rinse" steps resulted in a greater load of microorganisms remaining on lenses compared with the other regimens (p < 0.05). When "rinse-only" was performed before disinfection, the MPDS containing polyquad performed generally better (p < 0.05) than MPDSs containing polyhexamethylene biguanide against bacteria. Significantly, less microorganisms were recovered from galyfilcon A than from other lenses (p < 0.05) when MPDSs were used with "rinse-only" step.
CONCLUSIONS:
This study has demonstrated that "rub and rinse" is the most effective regimen and should be recommended in conjunction with all multipurpose lens care solutions and all contact lens types, particularly with silicone hydrogel lenses.
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Comparative antimicrobial efficacy of multi-purpose lens care solutions using the FDA's guidelines
PURPOSE: evaluated six single-bottle, multi-purpose lens care solutions and a two component lens care system for disinfection efficacy according to the stand-alone primary criteria within the recently published U.S FDA Guidelines.
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RESULTS:
ReNu and ReNu MultiPlus met the FDA's acceptance criteria for stand-alone disinfectants against all challenge organisms: Staphylococcus aureus, Serratia marcescens, Pseudomonas aeruginosa, Candida albicans, and Fusarium solani. Opti-Free Express failed to meet the FDA's stand-alone disinfectant acceptance criteria for S. aureus, S. marcescens and C. albicans and Opti-Free Express with Opti-Free Supraclens failed to meet the acceptance criteria for either S. aureus and C. albicans. Opti-One failed to meet the FDA's stand-alone disinfectant acceptance criteria for C. albicans and F. solani. Both Complete and Solo-Care failed to meet the FDA's acceptance criteria for C. albicans.
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CLAO J. 2001 Jan;27(1):16-22.
Disinfection efficacy of contact lens care solutions against ocular pathogens
PURPOSE:
Three commercially available products labeled as multi-purpose contact lens solutions, one multi-purpose disinfecting solution, and a hydrogen peroxide system were evaluated for antimicrobial activity according to the current International Organization for Standardization (ISO) and the U.S. Food and Drug Administration (FDA) stand-alone procedure for disinfecting products. One multi-purpose solution was selected to assess its antimicrobial activity against two human corneal isolates of Pseudomonas aeruginosa.
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RESULTS:
ReNu MultiPlus (Bausch & Lomb, Rochester, NY), AOSEPT (CIBA Vision Corporation, Duluth, GA), and Opti-Free Express with Aldox (Alcon Laboratories, Ft. Worth, TX) were the only lens care products that met the stand-alone criteria for all required microorganisms within their minimum recommended disinfection time. Of these, ReNu MultiPlus provided the greatest overall antimicrobial activity. ReNu MultiPlus demonstrated a significantly higher mean log reduction of Staphylococcus aureus and Serratia marcescens than Opti-Free Express. ReNu MultiPlus also gave a higher mean log reduction of S. aureus and S. marcescens than AOSEPT, and a higher mean log reduction of Candida albicans and Fusarium solani than AOSEPT, Complete Comfort Plus (Allergan, Irivine, CA), and Solo-Care (CIBA Vision Corp.) (at 4 hours). Both Complete Comfort Plus and Solo-Care (at 4 hours) met the primary acceptance criteria for bacteria; however, neither product possessed enough antimicrobial activity to meet the minimum criteria for yeast or mold. ReNu Multiplus was effective against corneal isolates of P. aeruginosa.
CONCLUSION:
ReNu MultiPlus, AOSEPT, and Opti-Free Express met the requirements of the stand-alone primary criteria for disinfecting solutions. ReNu MultiPlus demonstrated the greatest overall disinfection efficacy, as well as excellent activity against clinical strains of P. aeruginosa
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Contact lens care products effect on corneal sensitivity and patient comfort
PURPOSE: To evaluate the possible effect of two leading soft
contact lens care products on corneal sensitivity, relative comfort, and superficial corneal staining in adapted disposable soft contact lens wearers.
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RESULTS:
Patients habitually using OPTI-FREE Express reported higher comfort ratings than did patients using ReNu MultiPlus. On crossover, patients who initially used ReNu MultiPlus experienced similar comfort when using OPTI-FREE Express, but OPTI-FREE Express users experienced a substantial decrease in comfort when switched to ReNu MultiPlus. Esthesiometry showed significant differences in average sensitivity in favor of OPTI-FREE Express (P=0.0041). Statistical trends supported observed increases in corneal sensitivity when switching to OPTI-FREE Express and decreased corneal sensitivity when switching to ReNu MultiPlus. ReNu MultiPlus was also associated with slightly more corneal staining.
CONCLUSIONS:
ReNu MultiPlus, a biguanide-based contact lens care product, was associated with decreased comfort during midday and end-of-day periods. ReNu MultiPlus was also associated with significant reduction in relative corneal sensitivity compared to Polyquad-based OPTI-FREE Express. Disturbance to normal corneal sensitivity may play a role in contact lens-related dry eye and discomfort. Further investigation is warranted
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Care and maintenance of SCLs
SCLs are susceptible to deposits due to: Lenses are covered by pre-lens film all the
times
The tear film undergoes hydration and dehydration cycle as a result of blinking and evaporation b\w blinks
Lens is a subject to atmospheric changes and pollutants
Decreased surface wettability is likely to accelerate deposition
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Deposits: Complications
Irritation and reduced comfort
Reduced visual acuity
Shortened lens life
Increased potential for infection
Increased incidence of GPC