CONTACT LENS CARE SYSTEMS AND
SOLUTIONS USED BY THE
PRACTITIONER
Fiona Stapleton and Judith Stechler
25.1 INTRODUCfION
The purpose of a contact lens care system is
to maintain lenses clean, free of microbial
contamination and wettable in the eye.
Lens cleaning is necessary to remove
surface debris and to prevent the formation
of surface deposits. Deposition may reduce
acuity, alter lens performance by changing
the lens fitting and movement, cause aller­
gic responses such as giant papillary con­
junctivitis/ cause corneal oedema,
discomfort, lens related red eye and reduce
lens life (see Tripathi & Tripathi, 1984/ for a
review).
Maintaining a lens free of microbial con­
tamination is an important consideration in
the prevention of ocular infection. it has
been established that lens wearers are at a
significantly higher risk of microbial kerati­
tis compared with non-lens wearers (Dart ei
al., 1991)/ although the relationship between
lens wear and microbial conjunctivitis has
not been well established. Microbial keratitis
requires corneal epithelial damage and an
inoculum of organisms. Contact lenses may
increase the susceptibility of the cornea to
infection in several ways. Epithelial barrier
function may be reduced as a result of
Contact Lens Practice. Edited by Montague Ruben and Michel Guillon.
Published in 1994 by Chapman & Hall, London. ISBN 0 412 35120 X
25
impaired corneal metabolism or mechanical
stress causing microtrauma (Holden et al.,
1985)/ tear flow dynamics and normal tear
resurfacing mechanisms are altered during
lens wear; toxic or hypersensitivity responses
may arise from the cany over of lens care
solutions to the eye (Wilson et al., 1981a) and
raised temperature behind a lens may encour­
age bacterial proliferation (Martin & Fatt,
1986).
Pseudomonas aeruginosa, a ubiquitous
environmental Gram-negative rod, is fre­
quently associated with soft contact lens
related infections (Weissman et al., 1984;
Ormerod & Smith, 1986)/ although other
Cram-negative rods, such as Serratia species
(Lass et al., 1981)/ Proteus species (Alfonso et
al., 1984) and other Pseudomonas species
(Wilson et al., 1981b), have been reported. Of
the Gram-positive organisms, Staphylococcus
species are the most prevalent (Galentine et
al., 1984; Ormerod & Smith, 1986). Much less
commonly, other micro-organisms such as
filamentous fungi (Wilhelmus et al., 1988)
and protozoans such as Acanthumoebo spe­
cies (Stehr-Green et al., 1989) have been
associated with lens related keratis.
Contact lens wear alone is thought not to
modify the spectrum of organisms which can

530 Contact lens caresystems and solutions used by the practitioner
be recovered from the normal non-lens wear­
ing conjunctiva (Tregakis et al., 1973a; Raus­
chl & Rogers, 1978; Smolin et al., 1979;
Callender et al., 1986a; Larkin & Leeming,
1991). Common conjunctival organisms
rarely cause infection in normal eyes. Gram­
negative pathogens are rarely isolated from
the conjunctiva of asymptomatic wearers,
hence other sources of organisms are likely.
Bacteria may be spread from other regions in
the body, such as the upper respiratory tract,
the skin or gastro-intestinal tract, or from
exogenous environmental sources. The exter­
nal environment may cause micro-organism
contamination, via the lens care materials
(Cooper & Constable, 1977; Galentine et al.,
1984; Mayo et al., 1987), eye drops or
make-up (Wilson & Ahem, 1977). Most lens
case contamination is thought to arise from
the fingers when inserting and removing the
contact lens from the storage case. Other
routes for environmental contamination
arise from the fingers when inserting the
lenses (Cooper & Constable, 1977; Wilson et
al., 1981b; Adams et al., 1983; Hart & Shih,
1987), by rubbing the eyes or from airborne
contaminants. Lens disinfection aims to
reduce the potential for microbial inocula­
tion to the cornea.
Lens surface wettability is an important
consideration for the maintenance of good
lens comfort and optical properties. Poor lens
wetting may lead to tear resurfacing disor­
ders, reduced acuity, irritation and corneal
surface abnormalities.
25.2 LENS CARE SYSTEMS
The licensing of all contact lens solutions is
regulated in the UK and in the USA. To gain
a product licence, manufacturers must pro­
vide information on the quality, including
stability, efficacy and safety of the product.
This must also include data on toxicity of the
product, its compatibility with lenses, other
solutions and solution containers, and its
microbiological efficacy (see Meakin, 1984,
for review and history of licensing in the
UK).
Desirable properties of contact lens care
solutions include:
1. The solution should be manufactured
sterile with means of minimizing chance
microbial contamination when in use.
2. It should cause minimal effect on the
ocular tissues.
3. There should be compatibility with lens
materials, inducing no significant lens
parameter changes.
4. There should be compatibility with
other solutions used.
5. The solution must have a product
licence, and be labelled with an expiry
date two years from the date of manufac­
ture.
25.2.1 CLEANING SYSTEMS
During wear and handling, lenses are subject
to the accumulation of mucus, protein, lipid
and inorganic salts from the tear film, and
exogenous debris such as nicotine, cosmet­
ics, micro-organisms and atmospheric pol­
lutants. Hydrophobic surfaces on lenses tend
to attract debris. Daily cleaning of lenses
prior to lens disinfection removes organic
debris likely to inactivate antimicrobials (see
Martindale, 1989a, for a review), and has
been shown to reduce the numbers of viable
organisms recoverable from a lens (Shih et
al., 1985). Routine daily cleaning is a prophy­
lactic measure for all types of lenses and does
not restore lenses to their original unworn
state (Fowler & Allansmith, 1981).
Daily cleaners
Cleaning solutions may include surfactants,
preservatives, chelating agents, buffering
agents, purified water and sodium chloride.
Surfactants are surface active detergents
which solubilize debris and emulsify lipids.
Surfactants lower the interfacial tension

between two immiscible phases. Molecules
contain two localized regions, one hydro­
philic in nature and the other hydrophobic.
Surfactants form a surface monolayer with
the hydrophobic region of the molecule ori­
entated towards the surface of the lipid (Phil­
lips, 1980). Since the hydrophilic region is
water soluble, lipids may be emulsified.
Surfactants used for their cleaning capabil­
ity, may be non-ionic, anionic or amphoteric.
Non-ionic molecules have no charge or ion­
ization of the molecule, and are generally
compatible with anionic and cationic sub­
stances. Surfactants for use with hydrogel
lenses are generally non-ionic to reduce
interaction with lens polymers. Non-ionic
and some amphoteric surfactants also have
low ocular irritancy. Anionic surfactants dis­
sociate in aqueous solution, to form an
anion, which is responsible for the surface
activity and a cation; devoid of surface prop­
erties. Conversely, cationic dissociate to form
a surface active cation and non-active anion.
Amphoteric surfactants contain anionic and
cationic groups on the molecule, and can
behave with anionic, non-ionic or cationic
properties depending on the pH of the solu­
tion. Cationic surfactants such as benzalko­
nium chloride, which are used only as
antimicrobial agents and not for cleaning
purposes, may become bound to ionic com­
ponents of lens materials.
Preservatives are incorporated to prevent
chance contamination of the solution once
opened. Rigid lens cleaners may contain
benzalkonium chloride at a concentration
between 0.004 and 0.02 %. Both rigid and soft
lens cleaners use thiomersal at a concentra­
tion of 0.001-0.004% and chlorhexidine at
0.002-0.006%. Sorbic acid or potassium sor­
bate may be used in hydrogel lens cleaners at
a concentration of 0.1-0.25%, as an alterna­
tive to thiomersal and chlorhexidine. Alco­
hols such as isopropyl alcohol (20%) may be
incorporated as preservatives in hydrogel
lens cleaners. These have an additional
action as lipid solvents.
Lens care systems 531
Chelating agents, usually ethylene
diamine tetra-acetic acid (EDTA) or its salts,
are incorporated to bind divalent metal ions
such as calcium or magnesium. Removal of
such divalent ions from solutions prevents
their use in intracellular and cell wall
metabolism by micro-organisms.
Phosphate or borate buffers are incorpo­
rated to maintain pH less than 7.4 since
certain formulations become less stable
above pH8.
Sodium or potassium chloride is incorpo­
rated to maintain the tonicity of the solution.
Certain daily cleaners or multipurpose solu­
tions are formulated hypertonic to enhance
their cleaning action.
Rigid lens cleaners have also been formu­
lated containing 10% sodium tridecylether
sulphate and silicon or polymeric beads as
friction agents to enhance the cleaning activ­
ity. It is thought that the surfactant emulsi­
fies deposits, reduces surface tension, and
subsequently the polymeric beads serve to
shear the protein build up and lipid com­
plexes from the lens surface. This type of
formulation is not suitable for surface coated
lenses or silicon rubber lenses.
Cleaning solutions are generally used with
manual rubbing of the lens followed by rins­
ing with sterile saline or the disinfecting
solution. Mechanical devices such as
sponges or turbulent cleaning and storing
cases may be used when the wearer has poor
lens handling or poor manual dexterity.
Enzyme treabnents
Tear film proteins are derived mainly from
the lacrimal gland and include albumin,
globulin and lysozyme. Proteinaceous
deposits on contact lenses are predominantly
lysozyme (Sack et al., 1987), which is selec­
tively adsorbed to the lens surface. The pro­
tein layer formed on ionic hydrogel lenses
has been shown to be thicker compared with
that formed on non-ionic lenses (Sack et al.,
1987). Bound protein is not removed by daily
532 Contact lens care systems and solutions used by the practitioner
surfactant cleaning (Kleist & Thorson, 1978)
and is thought to contribute to allergic and
inflammatory conditions in hydrogel lens
wearers (Allansmith et al., 1977) and in rigid
lens wearers (Allansmith et al., 1978). The
removal of protein is an important step in
contact lens care regimes, and has been
shown to reduce or alleviate symptoms of
lens associated papillary conjunctivitis (Korb
et al., 1983). Protein removal is usually per­
formed using enzyme treatment. Enzymes
are biochemical catalysts which are usually
specific for single chemical reactions. Pro­
teases hydrolyse proteolytic deposits to
soluble peptide residues. Contact lens care
systems require broad spectrum proteases,
which cleave protein molecules at multiple
sites, for more effective protein removal, and
which ideally act rapidly without interacting
with lens polymers.
Proteases fall into two main groups (Huth,
1987).
1. Sulphydryl proteases. These are based
on the amino acid cystein, and are deac­
tivated by heat or hydrogen peroxide,
for example papain.
2. Serine proteases. These are based on the
amino acid serine, and maintain their
proteolytic activity in heat or hydrogen
peroxide, for example subtilisin or sub­
tilisin A. Maintaining proteolytic activ­
ity in hydrogen peroxide enables
simultaneous disinfection and protein
removal for hydrogel lenses. It has been
suggested that combination of protease
and peroxide increases disinfection effi­
cacy over peroxide alone, and improved
protein removal compared with protease
alone.
These two types of protease have been com­
pared in a clinical study (Larcabal et al.,
1989). Subtilisin A was found to be more
effective at removing light deposits, whereas
papain was more effective for medium to
heavy deposits.
Multiple enzyme treatments may also be
used. These generally contain a protease,
lipase (for the hydrolysis of lipids) and an
amylase (for the hydrolysis of polysaccha­
rides). Multiple enzymes such as pancreatin or
pronase, are useful where lens wearers are
sensitive to papain (Carmichael, 1983; Davis,
1983). The effectiveness of papain for the
removal of protein was compared with pancre­
atin in a clinical study (Kurashige et al., 1987).
Papain was found to be more effective in the
removal of heavy proteinaceous deposits,
although both treatments were equally effec­
tive at removing light deposits. Similar results
were shown for heavily deposited lenses in a
laboratory study (Kjellsen et al., 1984).
In summary, it appears that papain is a
more effective means of protein removal for
moderate to heavy protein deposition on
hydrogel lenses, but that subtilisin A and
pancreatin are more effective at removing
light to moderate protein deposition. Pancre­
atin is a useful choice where lens wearers are
sensitive to papain, and subtilisin A gives
effective protein removal when combined
with peroxide. This simultaneous action may
encourage patient compliance. Regular use of
enzyme treatment appears to reduce the
build-up of proteinaceous deposits on both
rigid and hydrogel lenses.
Professional cleaners
These are intensive oxidative cleaners for pro­
fessional use only. Sodium perborate may be
used in conjunction with heat (50-60 "C) and
agitation for 2-4 hours, evolving reactive oxy­
gen. In addition to the cleaning effect, sodium
perborate has limited antimicrobial activity,
due to the generation of hydrogen peroxide.
This type of aggressive lens cleaning is now
less frequently carried out due to the current
use of disposable or frequently replaced lenses.
25.2.2 DISINFECTION SYSTEMS
All micro-organisms can exist as viable veg­
etative cells; in some cases they are able to
form dormant spore forms, which are much

more resistant to the lethal effect of heat and
chemicals. Sterilization is the destruction of
all viable forms including spores. Disinfec­
tion processes will destroy vegetative cells,
but spores frequently survive. Contact lens
care systems aim for disinfection of lenses
and not sterilization, so all spores are
unlikely to be destroyed.
Disinfection systems can be divided into
physical and chemical agents:
Physical agents
These depend upon generating sufficient
energy to cause lethal protein denaturation
and cell changes.
Heat
Disinfection of vegetative organisms
requires heating in the presence of water at
80°C for 10 min. Disinfection may also be
achieved with heating between 60-80 °C for
longer periods of time, for those lens materi­
als which are unstable at higher tempera­
tures. However, effective disinfection of
Acanthamoeba cysts has been shown to
require temperatures above 65°C (Kilving­
ton, 1989). Sterilization for complete removal
of viable organisms requires autoclaving at
121°C for 15 min. Moist heat is effective at
lower temperatures than dry heat, and
destroys organisms by coagulating and
denaturing cell protein.
Thermal disinfection correctly performed,
is an effective method of disinfection against
the majority of micro-organisms (Tregakis et
al., 1973b; Busschaert et al., 1978; Ludwig et
al., 1986a). Repeated exposure of high water
content hydrogel lenses to thermal disinfec­
tion is thought to damage lens materials,
however low water content lenses have
shown little change in lens parameters
(Reidhammer & Falcetta, 1980). Heat dena­
tures tear protein, and results in increased
deposition and reduced lens life. Another
consideration is that the lens storage case
Lens care systems 533
must also be able to withstand the thermal
process (Amos & Ward, 1988).
Ultraviolet radiation
The emission spectrum from ultraviolet (UV)
radiation from low pressure UV lamps, typi­
cally used for sterilization, has a peak at
260 nm, which is close to the absorption
maximum of DNA and RNA. Airborne
organisms are very susceptible to destruction
by UV radiation. However the efficacy of UV
radiation in destroying organisms on dirty
surfaces is questionable. One study per­
formed in the USA has found that ultraviolet
disinfection of lenses contaminated with a
small range of pathogens, was able to rapidly
reduce the concentration of viable organisms
(Dolman & Dobrogowski, 1989), and that
lenses were able to survive up to 8 h of
exposure. Recent studies however, have
been unable to demonstrate satisfactory con­
tact lens disinfection with devices currently
available (Palmer et al., 1991).
Microwave radiation
Microwave disinfection of contact lenses has
been suggested as a rapid, effective, inex­
pensive and convenient method for hydrogel
lenses (Rohrer et al., 1986). Microwave radia­
tion produces an antimicrobial effect due to
destruction of cellular constituents, and may
achieve this with both thermal and non­
thermal effects (see Harris et al., 1989a for a
review). Rohrer et al., (1986) evaluated a
700 W microwave against an inoculum of 106
organisms/ml for seven common bacterial
pathogens, two fungi and two viruses. Com­
plete sterilization was achieved in 8 min,
however lenses were dehydrated during this
procedure and needed to be subsequently
rehydrated. Harris et al., (1989a) showed that
90 s of exposure in a 600 W microwave was
effective for disinfection of a limited range of
organisms. Microwave disinfection may
prove to be an effective future means for the
534 Contact lens care systems and solutions used by the practitioner
disinfection of hydrogel trial lenses. A fur­
ther study by Harris et al., (1990) demon­
strated rapid kill times for contaminated lens
storage cases. However, there have been few
controlled studies to determine optimal
exposure times for a range of organisms and
the long-term effects on lens polymers are
unknown. A preliminary study performed
on 32 hydrogel lenses exposed to one micro­
wave disinfection cycle (Hatch & Paramore,
1990) showed no significant change in lens
parameters measured.
Ultrasound radiation
Ultrasound refers to sound waves with a
frequency higher than 16-20 Hz. It is an
effective means of surface disinfection, and
this may make it suitable as a contact lens
cleaning and disinfection system. Ultra­
sound cleans by cavitation, whereby sound
waves produce frictional forces in the liquid
medium, which generates heat and bubble
formation. The bubbles then dissolve almost
immediately, causing implosion or cavita­
tion. The disinfection ability of ultrasound is
partly due to cavitation within bacterial cells,
mechanical pressure generated on the cell
walls and as a result of the heat generated.
There is limited information on the use of
ultrasound with deposited or contaminated
lenses. but one study evaluating a single unit
with a small number of patients has shown
that ultrasound has limited antimicrobial
activity (Phillips et al., 1989). Fatt (1991)
evaluated the physical limitations of ultra­
sonic cleaning and has shown that effective
cleaning of high water content hydrogel
lenses requires high levels of sonic energy.
Although units could be designed with such
a high output, this level of surface energy
dissipation would damage low water content
hydrogel or gas permeable lenses. Efron et
al., (1991) demonstrated similar results for an
ultrasonic cleaning unit, which was effective
for cleaning soiled low water content hydro­
gels, but was less effective for gas permeable
or high water content hydrogel lenses.
Chemical agents
Chemical disinfection systems must be suffi­
ciently cytotoxic to eliminate viable micro­
organisms, but must have minimum toxicity
to ocular tissues. This often requires removal
of active components from the lens prior to
lens insertion, either by degradation, rinsing
or neutralization. Solution formulation has
an important role in the antimicrobial effi­
cacy and human cytotoxicity. Consequently,
increasing the concentration of the active
agent will not necessarily increase the anti­
microbial efficacy or toxicity.
Fresh disinfecting solutions should be
used each time lenses are returned to the
storage case.
Chemical systems may be divided into two
groups:
Preserved systems
These contain active antimicrobial agents
(which also act as preservatives), a chelating
agent, buffering agent, purified water and
sodium chloride, with or without potassium
chloride.
Antimicrobials Antimicrobials in rigid lens
disinfection systems are often the same as in
the respective cleaning solution. However,
concentrations are higher in disinfection
solutions as the major function is not to deal
with chance contamination but to destroy
organisms on lenses. In rigid lens systems,
benzalkonium chloride, (usually at a concen­
tration of 0.004-0.02%), and chlorhexidine
gluconate (0.006%) dissolve lipid from the
cell membrane of bacteria and fungi. Preser­
vatives such as organic mercurials bind to
enzyme groups and denature proteins. Anti­
microbials such as benzalkonium chloride
and chlorhexidine gluconate show reduced
antimicrobial activity in the presence of ionic
molecules. Non-ionic agents such as glycerol

or propylene glycol may be incorporated to
increase the antimicrobial efficacy (Meakin,
1989).
Combinations of chlorhexidine gluconate
(0.002~.006%), thiomersal (0.001~.OO25%)
and EDTA (0.1~.128%) are commonly used
for the disinfection of hydrogel lenses. The
bactericidal strength of these solutions tends
to be lower compared with those for rigid
lenses as hydrogel lenses may act as a reser­
voir for solutions which elute from the lens
onto the eye (Refojo, 1976). Antimicrobials
may be absorbed by or adsorbed onto lenses,
which may act as haptens, causing a local
delayed hypersensitivity response (Wilson et
al., 1981c). Interactions between these com­
pounds, the contact lens surface and
adsorbed surface mucoproteins may contrib­
ute to toxic and hypersensitivity responses
(Binder et al., 1981; Mondino et al., 1987).
Partly reversible binding of chlorhexidine
gluconate to hydrogel lenses has been
reported (Plant et al., 1981). This preservative
binding is thought to be enhanced by pro­
tein deposition on lenses (Kaspar, 1976) and
an animal model has demonstrated toxic epi­
thelial responses associated with chlorhexi­
dine gluconate (Green et al., 1980). There is
less binding of preservatives to rigid lenses
and solution related disorders are less com­
mon. Interactions between rigid lens materi­
als and benzalkonium chloride have been
reported, although there have been consider­
able differences in the reported levels of
preservative adsorption. Using fluorescence
spectroscopy, laboratory studies have sug­
gested that benzalkonium chloride uptake
occurs with silicone/acrylate molecules as a
result of charged binding of the preservative
with the lens surface (Rosenthal et al., 1986).
In one clinical study, using similar method­
ology, attributed to electrostatic interaction
of the molecule with silicone acrylate copoly­
mers (Herskowitz, 1987). However, this
methodology has been criticized, and using
an alternative assay, minimal uptake ot ben­
zalkonium chloride with CAB (Richardson et
Lens care systems 535
al., 1980) and silicone acrylate materials
(Wong et al., 1986) has been shown. Using a
radioactive tracer technique, adsorption and
release of benzalkonium chloride has been
demonstrated for both rigid and hydrogel
materials (Chapman et al.,1990). In this
recent comparative study of rigid lens mate­
rials, greatest uptake and release of benza­
lkonium chloride was found to occur for
fluorosilicone acrylate polymers (Chapman et
al., 1990).
Other combinations of antimicrobials and
preservatives in hydrogel lens disinfection
systems include:
1. Alkyltriethanol ammonium chloride
(0.013%), which is chemically similar to
benzalkonium chloride, but is less cyto­
toxic to both micro-organisms and
human cells, is used in conjunction with
thiomersal (0.002%).
2. Chlorhexidine-based tablet, containing
0.4 mg of chlorhexidine gluconate, for
use with 10 ml of potable tap water,
resulting in a chlorhexidine concentra­
tion of 0.004%. The resulting solution
contains a sequestering agent to remove
polyvalent metal ions which may be
present in tap water, and is buffered
with malic acid (Davies et al., 1990a). The
formulation of this tablet purifies the tap
water in the lens storage case (Anthony
et al., 1991). As the antimicrobial efficacy
of chlorhexidine is reduced in the pres­
ence of ionic molecules, this system is
contraindicated for use with Type IV
hydrogel lenses.
Chelating agents These are incorporated to
enhance the antimicrobial activity of certain
disinfectants, such as EDTA, which enhances
the activity of benzalkonium chloride (see
page 000).
Buffering agents Buffering agents are incor­
porated to maintain optimal solution pH for
enhanced antimicrobial efficacy.
536 Contact lens care systems and solutions used by the practitioner
Sodium chloride, with or without potas­
sium chloride is incorporated into solutions
intended for carry over to the eye. This
maintains the solution tonicity equivalent to
that of tears, at 0.9% sodium chloride.
Antimicrobial activity Solution formula­
tions which are highly toxic to micro­
organism cells are also toxic to human cells.
Less toxic formulations may be offset by a
longer recommended disinfection period.
The benefits of faster kill rates must be
balanced against the incidence of toxic or
allergic responses.
Cleaning solutions and those for rinsing or
wetting lenses are formulated to deal only
with chance contamination. It has been well
established that cleaning and rinsing lenses
reduces the microbial load on lenses. Using
an initial inoculum of 106 , cleaning and rins­
ing lenses is found achieve an 3.7 log unit
reduction in the number of organisms recov­
erable. Individually cleaning and rinsing
reduce by 1.9 log units each (Houlsby et al.,
1984).
All available solutions have passed licens­
ing requirements for antimicrobial efficacy,
however, under current UK regulations, con­
tact lens disinfecting units do not require a
product license from the Medicines Control
Agency. Microbiological efficacy of disinfec­
tion systems can be compared by using D
values (Decimal reduction time), which is the
time taken to achieve a 1 log cycle reduction
in the inoculum. Where the destruction rates
are non-linear, plots of the log survivors
against time gives the total log reduction
achieved during the disinfection period, fol­
lowing a fixed challenge.
Studies using different testing procedures
have compared the efficacy of different dis­
infecting solutions (Penley et aI., 1981a,b;
Houlsby et al., 1984; Reinhart et al., 1990).
The antimicrobial activity of solutions can be
very dependent on several formulation fac­
tors, such as pH, the presence of ionic mol­
ecules, temperature and whether lenses have
been cleaned and rinsed prior to disinfec­
tion. Chemically preserved solutions appear
to show good antimicrobial activity against
bacteria under laboratory conditions, but
appear to be less good against fungi.
Houlsby et al, (1984), have demonstrated
slow kill rates for chemically preserved solu­
tions using a sensitive recovery test for
viable organisms. This study concluded that
solutions containing chlorhexidine (0.005%)
and thiomersal (0.001%) provide effective
disinfection of bacteria, but not for yeast and
fungi. A solution containing quaternary
ammonium chloride (0.013%) and thiomersal
(0.002%) was not found to provide effective
disinfection for any test organisms.
There has recently been concern for disin­
fection ability against Acanthamoeba species
and several studies have demonstrated inad­
equate kill times for either trophozoites or
cysts using disinfection systems containing
either quaternary ammonium compounds
(Lindquist et al., 1988; Brandt et al., 1989;
Penley et al., 1989) chlorhexidine/thiomersal
(Ludwig et al., 1986b; Brandt et al., 1989),
benzalkonium chloride (Penley et al., 1989)
and sorbate (Sylvany et al., 1990). However,
other studies using different methodologies,
have demonstrated effective antiacan­
thamoeba activity with systems containing
chlorhexidine alone (Anthony et aI., 1991) or
in combination with thiomersal (Sylvany et
al., 1990). Rigid lens disinfection systems
containing benzalkonium chloride were
found to be effective (Sylvany et al., 1990).
Unpreserved systems
Oxidative systems are frequently used to
eliminate toxic and hypersensitivity disor­
ders resulting from the carry over of preser­
vatives and antimicrobial agents to the eye.
Oxidative systems break peptide links in
proteins and reduce them to soluble amino
acid products. These depend on the chemical
breakdown of an active toxic agent to a
non-toxic product at physiological pH.

Hydrogen peroxide systems The antimicro­
bial efficacy of hydrogen peroxide is attribut­
able to the formation of hydroxyl radicals,
which form as an intermediary step in the
decomposition of hydrogen peroxide to
water and oxygen.
Peroxide disinfection of contact lenses is
carried out by a two-stage system. Disinfec­
tion in 3% hydrogen peroxide is followed by
an inactivation stage to remove any traces of
peroxide from the lenses prior to lens inser­
tion (see Lowe and Brennan, 1987, for a
review). Three percent hydrogen peroxide is
generally used in conjunction with stabiliz­
ers (sodium stannate or nitrate), and buffers
to maintain the acid pH (3-6) of the solution.
Increasing the percentage of peroxide does
not result in a significantly faster kill rate,
but neutralization takes longer. A lower con­
centration of peroxide is less toxic and
requires a longer exposure time to give effec­
tive antimicrobial activity. Inactivation or
neutralization may be carried out using a
catalytic, reactive or dilution system. All two­
stage systems involve an initial dilution
effect (see Lowe & Brennan, 1987, for a
review), as residual peroxide on the lens is
carried over into the neutralization stage.
This reduces the concentration of peroxide
from 3% to about 1 part per 1000. Final
neutralization may result in a residual perox­
ide concentration (If less than or equal to 50
ppm. However, sensitive individuals have
reported discomfort with levels of peroxide
less than 10 ppm (Ianoff, 1984). Rapid
removal of peroxide from a hydrogel lens at a
concentration of 50 ppm, during the first
minute of lens wear has been demonstrated
(Chalmers et aI., 1989). Topical application of
peroxide solutions at concentrations of 50
and 500 ppm were found to have no signifi­
cant effects on corneal permeability using a
fluorophotometric technique (McNally,
1990). Clinical studies have shown no corneal
staining with peroxide levels up to 800 ppm
(Paugh et aI., 1987), but subjective discomfort
has been reported where residual peroxide
Lens care systems 537
levels exceed 100 ppm. Toxic keratopathy has
been associated with increased residual per­
oxide levels, from platinum disc neutralized
systems (Epstein & Freedman, 1990).
Residual pH is also thought to be a relevant
factor in patient comfort, particularly if the
final pH is outside the ocular threshold of
6.~7.8 units (Harris et al., 1988). In summary,
after peroxide disinfection, the target for
residual peroxide is less than 50 ppm in any
solution left on or imbibed by the lenses.
Parameter changes have been reported
with peroxide disinfection of high water
content lenses, with base curve steepening,
reduction in overall size and increased nega­
tive power although these changes are
reversible once the lens has been returned to
buffered saline (Ianoff, 1984). More recent
studies have shown that ionic hydrogel
lenses, particularly high water content
hydrogels may require extended neutraliza­
tion to restore parameters (Bruce, 1989; Har­
ris et aI., 1989b; McKenney, 1990).
One study has reported hazing of high
water content ionic lenses following disin­
fection using hydrogen peroxide systems.
These lenses tend to become readily coated
with protein, mainly lysozyme during wear.
Hazing may occur if lenses are inadequately
cleaned and exposed to peroxide for
extended periods. It has been suggested that
hazing results from interaction between
lysozyme, stannate ions (used as a stabilizer
in peroxide systems) and methacrylic acid
groups on ionic hydrogels (Sack et aI., 1989).
Neutralization systems include:
1. Catalytic systems. These may either
involve metallic or enzyme catalysts,
Catalytic breakdown of peroxide results
in the production of water and oxygen,
and a vented storage case should be
supplied with this type of system. This
allows oxygen to escape, but prevents
micro-organisms from entering. Where a
platinum disc catalyst is used, neutral­
ization requires the peroxide molecules
538 Contact lens care systems and solutions used by the practitioner
to contact with the platinum disc via
diffusion. This results in an increased
reaction time compared with soluble
enzyme catalysts, such as catalase,
which are evenly distributed throughout
the neutralization solution. Studies of
residual levels of peroxide have shown
that catalase neutralization provides a
rapid and effective method (Gyulai et
al., 1987). A modification of the plati­
num disc catalyst system is a one-step
system, which avoids a second neutral­
ization step (this is not available at the
time of writing in the UK). However,
there have been reservations concern­
ing the anti-acanthamoebal data, since
inactivation of the peroxide occurs
immediately in the vicinity of the
platinum disc (Davies et al., 1990b).
However, unpublished disinfection
rate studies using bacterial test organ­
isms have proved satisfactory (B.}.
Meakin, personal communication).
2. Chemical reactive systems. These dif­
fer from catalytic systems in that the
catalysts are unchanged by the cherni­
cal decomposition, whereas reactive
systems use chemicals to achieve
decomposition through oxidation-
reduction reactions. This results in end
products in addition to water and oxy­
gen, such as sodium acetate, bicarbon­
athe , sulphates and hydrosulphates.
T ese residual products are not consid­
ered to be harmful. Chemical reactive
agents include sodium pyruvate,
sodium sulphite and sodium thiosul­
phate (Ogunbiyi, 1986).
3. Dilution systems. These depend on
osmotic extraction generally with pre­
served saline, and are not strictly neu­
tralisation systems. Higher levels of
residual hydrogen peroxide have been
reported using this type of system (Kelly
et al., 1990), and no systems of this type
are licensed in the UK at the time of
writing.
Antimicrobial activity
Hydrogen peroxide has been shown to be an
extremely effective antimicrobial agent.
(Penley et al., 1981a).Most systems recom­
mend 10-20 min of disinfection with 3%
peroxide, and 2 h if 0.6% peroxide is used,
however longer times have been recom­
mended to ensure adequate destruction of
fungi and Acanthamoeba (Penley et aI., 1985;
Davies et al., 1990b). Decimal reduction times
of 20 min have been shown for hydrogen
peroxide against Pseudomonas aeruginosa,
Serratia marcescens, Staphylococcus epidermi­
dis, Candida albicans and Aspergillus fumigatus
(Reinhart et al., 1990). A contact time of 4-8 h
with 3% hydrogen peroxide has been shown
to be capable of eliminating a large challenge
of Acanthamoeba cysts (Davies, et al., 1990b).
Effective disinfection of fungi requires a
minimum of 45 min in 3% peroxide (Penley
ei al., 1985).
Chlorine-based systems These are one-step
systems which do not - require a separate
inactivation step and have low toxicity. In
aqueous solution, hypochlorous acid and
hypochlorite ions are formed. Non-ionized
hypochlorous acid chlorinates cell proteins
and enzyme systems (Martindale, 1989a).
Two systems are currently available in the
UK, with the following active agents:
1. Di-isochlorocyanurate. Effervescent tab­
lets for use in hydrogel lens disinfection.
The tablets contain di-isochlorocyanurate
(0.065 mg/tablet). The tablet is dissolved
in 10 ml of unpreserved saline, releasing
4 ppm of available chlorine.
2. Dichlorosulphamoyl benzoic acid (halo­
zone). Soluble tablets for use in hydrogel
lens disinfection. The tablets contain
0.16 mg of halozone, and are used with
10 ml of unpreserved saline, releasing
8 ppm of available chlorine.
Both formulations contain available chlorine
at levels well below the ocular toxicity

threshold of 50 ppm. This type of disinfec­
tion system may be used with all types of
lenses and avoids potential toxic responses
which may be associated with the use of
peroxide.
Antimicrobial activity
Chlorine-based systems have a rapid brief
bactericidal action, effective against bacteria,
some viruses, fungi and yeasts. They are
ineffective against spores, and Acanthamoeba
cysts have been shown to be resistant to free
chlorine (De [onkheere & Van der Woorde,
1976). Low concentrations of free chlorine are
not effective against fungi (Penley et al.,
1981b). Organic debris has been shown to
inactivate chlorine based disinfection sys­
tems (Copley, 1989). The concentration of
available chlorine reduces throughout the
disinfection cycle, consequently if lenses are
not worn for more than 2 days, rinsing and
further disinfection should take place.
The two systems available in the UK have
been compared, and were found to have
equivalent antimicrobial activity (Copley,
1989). A clinical study has reported that chlo­
rine systems should not be used with pre­
served salines since the hypochlorite ion
may bind with the preservatives in the
saline, which may result in reduced antimi­
crobial activity (Levy & Gross, 1988).
25.2.3 WErnNG/REWEITING SOLUTIONS
Wetting solutions encourage even tear distri­
bution over the lens front surface and
improve the optical performance and comfort
of lenses. During rigid lens wear, the wetting
solution acts as a cushion during lens inser­
tion and as a lubricant between the lensl
cornea and lens/lids. The effect of wetting
solutions on in vivo lens wetting angles is
thought to be transient, lasting up to 15 min
only (Benjamin, 1987).
Wetting solutions contain wetting agents,
viscosity increasing compounds, preserva-
Lens care systems 539
tives, chelating agents, buffering agents,
purified water and sodium chloride.
Wetting agents are molecules with both
hydrophobic and hydrophilic components,
which orientate themselves with the hydro­
phobic components of the lens surface, and
are thus surface active. This results in the
hydrophilic component of the wetting agent
furthest from the lens surface, such that the
surface is rendered wettable, by reducing
surface tension. Non-ionic surfactants often
incorporated include polyvinyl alcohol, poly­
vinyl pyrrolidone or polysorbate 80.
Viscosity building agents such as methyl­
cellulose and hypromellose are incorporated
to increase the contact time of the solution at
the eye and to enable the solution to adhere
to the lens.
Preservatives in wetting solutions are gen­
erally similar to those used in the respective
cleaning and disinfection solutions, but are
often incorporated at a lower concentration
than in the latter, as their function here is to
deal with chance contamination. Rigid lens
wetting solutions contain benzalkonium
chloride at a concentration between 0.004
and 0.01%.
Rewetting drops to maintain lens wetting
during wear may be used with both hydrogel
and rigid lenses. Toxic and allergic consider­
ations also apply with wetting solutions and
benzalkonium chloride should be avoided
with hydrogel lenses. Single dose unpre­
served lubricating solutions are available,
containing Poloxamer 407 (a non-ionic sur­
factant), hydroxyethylcellulose (a thickener
and stabilizer) and borate buffer in hyper­
tonic solution, which may be used for rigid
or soft lenses.
25.2.4 SALINE SOLUTIONS
Saline comprises 0.9% sodium chloride or
equivalent, which may also contain buffers. It
may be used in thermal disinfection systems,
enzyme treatments, certain peroxide neutral­
ization systems and in rinsing of lenses.
540 Contact lens care systems and solutions used by the practitioner
1. Preserved salines. These may be preser­
vatived with thiomersal (0.001%), alkyl­
triethanol chloride and sorbic acid or
sorbate. Buffering agents, and EDTA at
0.1% are also generally incorporated.
2. Unpreserved salines. These are formu­
lated in either unit dose or pressurized
spray form. Buffering agents such as
borate, phosphate or bicarbonate are
often incorporated.
3. Home made saline. In the past patients
have been instructed to prepare saline
from salt tablets and distilled or purified
water, for use in thermal disinfection or
with enzyme tablets. The use of home­
made saline has been linked with bacte­
rial (Mayo et al., 1987) and acanthamoebic
(Moore et al., 1987) infections, and should
not be used with any type of lenses.
25.2.5 MULTIPURPOSE SOLUTIONS
Multipurpose solutions, combining cleaning
and disinfection solutions in one, are occa­
sionally used, particularly where wearers
omit one or more steps in the lens hygiene
system. Multipurpose solutions represent an
improvement for these less than compliant
wearers, but there is thought to be some
compromise in either cleaning or disinfec­
tion efficiency of these solutions.
25.3 FAILURE OF DISINFECTION SYSTEMS
IN USE
The disinfection systems for use in the UK
have passed stringent Medicines Control
Agency licensing regulations, regarding
antimicrobial efficacy for the disinfection
cycle. However, several studies have shown
that significant microbial contamination of
the lenses and lens storage cases occurs fre­
quently in asymptomatic lens wearers in
addition to those who develop suppurative
keratitis. Bacterial contamination of the lens
storage has been shown to occur in approxi­
mately 50% of asymptomatic wearers (Pitts &
Krachmer, 1979; Callender et al., 1986b;
Donzis et al., 1987). Bacterial contamination
has also been reported despite good compli­
ance with a prescribed hygiene regime
(Donzis et al., 1987). Fungi have also been
isolated from lens storage cases in asymp­
tomatic rigid lens wearers (3%) (Pitts &
Krachmer, 1979) and hydrogel lens wearers
(8-14%) (Pitts & Krachmer, 1979; Donzis et
al., 1987). Fungal contamination of hydrogel
lenses has been estimated at 2-5% (Wilson &
Ahern, 1986). Acanthamoeba species were
isolated from 7% of lens storage cases from
71102 asymptomatic wearers (Larkin et al.,
1990), 6/7 of the storage cases were also
heavily contaminated with bacteria. The
presence of bacteria frequently found in
association with Acanthamoeba, suggests that
these organisms are important in the sur­
vival and growth of amoebae.
Several factors may be relevant including:
25.3.1 PATIENT COMPLIANCE WITH LENS
CARE REGIMES
Compliance with contact lens care regimes is
thought to be low; only 26 of 100 wearers
were fully compliant with hygiene instruc­
tions in one study (Collins & Carney, 1986).
Several studies have suggested a link
between poor patient compliance with a lens
hygiene regime, and a longer duration of
lens wear. Compliance with a prescribed
wearing and hygiene system has been evalu­
ated in daily wear lens users (Chun & Weiss­
man, 1987). A higher rate of bacterial
contamination of lens storage cases was
found to correlate with a duration of lens
wear of longer than 1 year. Data collected
from 200 asymptomatic lens wearers sampled
at a University clinic, showed that compli­
ance with a prescribed lens hygiene regime
amongst lens wearers reduces significantly
after 6 months wear (Wilson et al., in press).
Compliance with a prescribed hygiene
regime has been analysed using a health
belief model (Sokol et al., 1990). Non­

compliance was found to be associated with
wearers aged less than 30 and with those
using lenses for cosmetic indications.
With a demonstrated reduction in compli­
ance over time, there is a strong case for
continuing patient education to improve
hygiene compliance. Frequent lens storage
case cleaning and regular case replacement is
fundamental in reducing the frequency of
case contamination.
25.3.2 INAPPROPRIATE USE OF SOLUTIONS
Inadequate or omitted surfactant cleaning
may result in organic debris remaining on
the lens surface, which may subsequently
bind to antimicrobial agents or inactivate
oxidizing agents in the disinfecting solution.
There may also be some reduction in antimi­
crobial activity if surfactant cleaner residues
are carried over into the disinfection system.
Certain antimicrobials, particularly chlo­
rhexidine, may become bound to protein
deposits on lenses, such that their antimicro­
bial efficacy is reduced. Mixing of solutions
may potentially result in an incorrect pH for
some antimicrobial agents (e.g. sorbic acid),
or there may be potential incompatibility,
where cationic molecules interact with
anionic ones. Similarly certain antimicrobial
agents may interact with ionic lens polymers.
The use of preserved saline with chlorine
release systems may result in preservatives
becoming bound to hypochlorous ions, with
a reduction in antimicrobial efficacy.
25.3.3 MICRO-ORGANISM FACTORS
In an environment such as a lens storage
case, where nutrients may be limited, bacte­
ria may evolve specific physiological strate­
gies for survival (see Caroline & Campbell,
1990, for a review). These may include strate­
gies whereby cells become more efficient at
metabolizing low levels of nutrient within a
hostile environment. Cell morphology and
respiration may alter, such that outer walls
Disinfection of trial lenses 541
become rougher and more hydrophobic plus
surface area increases to enable organisms to
adhere to surfaces. Bacterial adherence to
surfaces provides a more efficient means of
uptake of nutrients.
It is also well established that bacteria in
natural ecosystems are surrounded by a
polysaccharide containing matrix of fibres or
glycocalyx, outside the cell wall (Costerton et
al., 1978). This glycocalyx mediates bacterial
adherence and colonization of surfaces. It
provides an protective and nutritive envi­
ronment for enclosed bacteria. Bacteria
enclosed within such a biofilm are signifi­
cantly more resistant to antibiotics compared
with free organisms in solution (Govan &
Fyfe, 1978). A study investigating bacterial
biofilm on hydrogel lenses, has shown that
bacteria in this mode of growth, are more
resistant to antimicrobials in lens disinfec­
tion systems (McCulloch et al., 1988). The role
of bacterial colonization and biofilm forma­
tion in lens and lens storage case contamina­
tion is unknown, but may be a factor in the
persistence of organisms in spite of good
lens hygiene.
25.4 DISINFECTION OF TRIAL LENSES
The requirements for disinfection of trial
lenses differ from those of overnight disin­
fection of lenses worn on a daily basis. Trial
lens disinfection ideally requires effective
continuous antimicrobial activity if lenses
are to be stored for long periods of time.
A further consideration is the possibility
of transferring micro-organisms through
inadequately disinfected trial lenses. Viruses
and viral antigens which have been isolated
from human tears include hepatitis B, her­
pes, adenovirus and HIV. The majority of
viruses do not have unusual resistance to
lens disinfection regimes. Thermal disinfec­
tion for hydrogel lenses or hydrogen perox­
ide for rigid lenses is effective for the
elimination of HIV (Moore, 1987), adenovi­
rus or Herpes simplex. Chlorine release sys­
542 Contact lens care systems and solutions used by the practitioner
. against
terns are effective . th e HIV VIruS.
. 25•5 FUTURE SYSTEMS
Following surfactant cleaning, thermal dis-
infection is a very- effective technique for the
disinfection of hydrogel lenses, and is gener-
ally appropriate for the disinfection of
hydrogel trial lenses. Deterioration of rubber
seals on lens vials with time may allow the
entry- of micro-organisms. Not all hydrogel
lenses are amenable to heat, particularly
high water content lenses or tinted lenses
which may undergo material and parameter
changes. For lenses unable to withstand heat,
hydrogen peroxide is an effective temporary-
contact lens disinfectant, however hydrogel
lenses stored in peroxide for long periods
may undergo parameter changes and may
require prolonged neutralization (Harris et
al., 1989b). A neutralized solution either
unpreserved or weakly preserved, has lim-
ited antimicrobial activity (Tse et al., 1987;
Rosenthal et al., 1988). Storage of hydrogel
trial lenses in chemically preserved solutions
ensures some continuous antimicrobial
activity, although systems containing rnercu-
rials may break down to leave toxic decom-
position products. Storage of trial lenses in
chemically preserved solutions may cause
toxic or allergic complications as described.
Base curve and diameter changes have been
described where hydrogel lenses have been
stored in chemically preserved solutions,
which have reportedly been due to pH
changes occurring with time, as the antimi-
crobial agents interact with the lens poly-
mers (Walker, 1981).
For rigid lenses, surfactant cleaning fol-
lowed by 10 min soaking in peroxide, prior
to either storing dry- or in preserved soaking
solutions, is an effective means of trial lens
disinfection. Small changes in base curve
have been found when storing rigid gas
permeable lenses dry. No correlation has
been found between the amount of base
curve change and the Dk/L for the material
(Snyder et al., 1990).
These considerations for trial lenses also
apply where patients store spare lenses.
To encourage patient compliance, future sys­
terns aim to reduce the complexity and cost,
but to maintain effective lens cleaning and
disinfection
In Europe and USA new preservatives, at
low concentrations, have been incorporated
into chemical systems. These are large mol­
ecules which do not readily penetrate the
hydrogel lens matrix and are thought to
result in fewer toxic and allergic responses
(e.g. 0.00005% polyaminopropyl biguanide
(Polyhexamide) (Dymed) and 0.001%
polyquaternium (Polyquad)). It has been
suggested that the antimicrobial sa.fety mar­
gin may be lower with thes~ r~glme~ and
that surfactant cleaning and nnsmg pnor to
disinfection is essential. The antimicrobial
efficacy of disinfection systems preserved
with these compound has been questioned
(Penley et al., 1989; Davies et al., 1990b; Shih
et al., 1991).
Unit dose disinfection systems avoid poten­
tial contamination problems which may arise
where the solution use after opening is
restricted. This is likely to be beneficial where
lenses are worn only occasionally. Future sys­
terns are likely to consist of tablet based disin­
fecting agents, which may contain buffer and
tonicity agents, which may be dissolved in
sterile/potable water. This concept has been
employed in a chlorhexidine based tabl~t ~y.s­
tern (Anthony et al., 1991), and may be In
future one step peroxide systems (Meakin,
1989). Catalase tablets for peroxide neutraliza-
tion, which dissolve in peroxide after the dis­
infection cycle have been described (Gyulai et
al., 1989), and clinical findings have been
promising (Courtney et al., 1990)
25.6 SOLUTIONS USED BY THE
PRACflTIONER
Drugs can be used by the practitioner for
diagnostic, topical anaesthesia and prophy­
lactic reasons.

25.6.1 DIAGNOSTIC STAINS
The two main diagnostic stains used by the
practitioner are fluorescein and rose bengal.
Fluorescein
Fluorescein is a sodium salt and is available in
three forms. It is presented in 20% concentra­
tion as eye drops (preserved), as sterile paper
strips or in unpreserved unit dose containers.
It is a water soluble compound, is yellow in
colour, has poor lipid solubility and will not
penetrate intact cell membranes. It can gain
access to Bowman's membrane, and into the
stroma and aqueous if the epithelium is dam­
aged (Wolff, 1976; O'Connor-Davies et al.,
1989; Stewart-Jones et al., 1990). Fluorescein
can be used to:
1. Demonstrate the integrity of the corneal
epithelium and conjunctiva prior to, and
following, contact lens fitting.
2. Detect foreign bodies.
3. Check the fit of contact lenses (PMMA,
GP, silicone rubber).
4. Check the patency of lacrimal drainage
channels into the nose and throat.
5. Assist the appearance of the split ring in
applanation tonometry.
Fluorescein should not be used with hydro­
philic lenses as it will be absorbed by the
material and cause permanent damage.
Sodium fluorescein has a molecular weight
of 376. Fluorexon has been suggested for use
with and after the wearing, of hydrophilic
lenses as it has a larger molecular size (710).
Any remaining fluorexon dye can be boiled
out of such lenses.
Rose bengal
Rose bengal is a brownish red, fat soluble
dye and is available in 1 % sterile, single dose
units. Its action is different to that of fluores­
cein in that it will stain dead, or devitalized
tissue red when viewed under white light. It
Solutions used by the practitioner 543
may be used to locate degenerate tissue in
the sclera, cornea and conjunctiva. The pres­
ence of facial skin conditions such as sebor­
rhoeic eczema, acne rosacea and various
form of dermatitis may indicate that the
cornea has been affected. Rose bengal may
help to establish whether the ocular tissues
are involved, which will influence lens fit­
ting and subsequent lens tolerance, for
example in the pathological dry eye.
Rose bengal is very irritating to the eye
and care should be taken to instil only the
smallest amount possible. The dye will also
stain the lids and facial tissues and is rela­
tively persistent.
Mucus is also stained by rose bengal and
can be differentiated by instilling one drop
of 1 % alcian blue, which differentially stains
mucus blue.
25.6.2 LOCAL ANAESTHETICS
Local and topical anaesthetics are used in
contact lens practice to reversibly block pain
sensation. They produce surface anaesthesia
of the cornea and conjunctiva by reducing
the sensitivity of their sensory nerve endings
(O'Connor-Davies et al., 1989).
Anaesthetics in contact lens practice are
used for:
1. Impression techniques (sclera! mould­
ing).
2. Tonometry.
3. Diagnostic lenses for evaluation of best
visual acuity if the patient is very intol­
erant to contact lenses.
4. Removal of foreign bodies.
5. Gonioscopy.
Local anaesthetics should have:
1. Rapid onset of action.
2. Adequate depth of anaesthesia.
3. Short duration (reversible).
4. No toxic effects.
5. No irritant effects and no allergic reac­
tions.
544 Contact lens care systems and solutions used by the practitioner
6. No discomfort when effect wears off.
7. No other action such as mydriasis, etc.
8. Compatibility with other topical drugs
and their preservatives.
9. Stability in solution and during steril­
ization.
The depth and duration of the anaesthesia
depends on the strength of the drug used
and the number of drops instilled. All these
preparations have some effect on the corneal
metabolism and increase its permeability to
other drugs. This is due to the desquamation
of the superficial epithelium.
Anaesthetics available to the contact
lens practitioner are: amethocaine,
proxymetacaine, benoxinate and lignocaine
(see British National Formularu],
All cause initial stinging and should be
kept away from direct sunlight.
25.6.3 ANTIMICROBIAL AGENTS
Antimicrobials are used prophylactically in
contact lens practice following superficial
trauma to the cornea after tonometry, contact
lens fitting, gonioscopy, etc.
The application of one drop at a single
instillation is probably ineffective and there
is the risk of a resistance to the drug being
built up with prolonged use (Martindale,
1989b).
The sulphonamides
These synthetic drugs were the most widely
used by the optometrist. They have a struc­
ture similar to para-aminobenzoic acid
(PABA).
When a bacterial cell is exposed to a sul­
phonamide the synthesis of folic acid is
blocked. Some bacteria require PABA for
growth and multiplication. These bacteria
use the PABA to synthesize the vitamin folic
acid.
Sulphonamides have a relatively broad
spectrum and are effective against Gram-
positive, as well as Gram-negative, bacteria.
Sulphacetamide sodium was the sulpho­
namide most widely used by the optometrist
but is now, in the UK, only available in a
10% concentration. It is soluble in water and
alkaline in solution. It will soon be less freely
available as several companies may choose
not to renew their product licence. There are
far more effective, modem drugs, now avail­
able.
Propamidine and dibromopropamidine
isethionate (Brolene eye drops and
ointment)
These agents have good antibacterial activ­
ity, particularly against Staphylococcal spe­
cies and even some strains of Pseudomonas
aeruginosa (Martindale, 1989b). They are use­
ful in the treatment of blepharitis and also
have fungistatic action. They have recently
been found to be useful in the treatment of
Acanthamoeba keratitis where it is used in
conjunction with neomycin (Wright et at.,
1985).
Dibromopropamidine isethionate is
soluble, 1:2, in water and a 5% solution has a
pH of 5.7. The commercially available prepa­
ration is a 0.15% cream (Brolene). Propami­
dine isethionate is similar, but less soluble in
water, 1:5, and is commercially available as a
0.1 % solution (Brolene eyedrops).
Antibiotics
The most commonly used topical antibiotics
in ophthalmology are chloramphenicol, neo­
mycin, framycetin, gentamicin, polymixin,
tetracycline, penicillin, erythromycin and
tobramycin (Martindale, 1989b).
Framycetin sulphate was the first antibi­
otic available to the optometrist in the UK. It
has a broad spectrum of activity and has
similar properties to neomycin. Framycetin
sulphate is effective against Staphylococcus
aureus and most Pseudomonas strains, but in
the UK is of little value to the optometrist as

it is a prescription only medicine, and can
therefore only be used in the practice and not
given to the patient.
Neomycin has a broad spectrum of activ­
ity. It is available in 0.5% drop and ointment
form. It is also available in conjunction with
other antibiotics.
Chloramphenicol can be supplied to the
patient by a written order from the optom­
etrist to the pharmacist. It is effective against
most bacterial pathogens but not against
Pseudomonas aeruginosa. It is available as
0.5% eye drops (multi- or unit dose) and in
1 % ointment form. Chloramphenicol can
cause transient stinging. Rare cases of aplas­
tic anaemia have been reported (Martindale,
1989b).
25.6.4 DECONGESTANT, ANTI-ALLERGIC
AND ANTI-INFLAMMATORY DRUGS
Decongestants
Sympathomimetic mydriatic drugs may be
used as decongestants. Peripheral blood ves­
sels (i.e. in the conjunctiva) receive post­
ganglionic innervation. The action of these
nerves results in vasoconstriction due to the
release of noradrenalin and its interaction
with alpha-receptors (O'Connor-Davies et
al.,1989).
Adrenalin, phenylephrine and ephedrine
cause vasoconstriction when applied topi­
cally to the eye.
Other drugs such as antazoline and xylom­
etazohne hydrochloride are used as decon­
gestants but de not cause mydriasis. They act
directly on the alpha receptors. Otrivine
Antistine eyedrops contain antazoline sul­
phate 0.5% and xylometazoline hydrochlo­
ride 0.05%.
Decongestants are sometimes used in con­
tact lens work to prevent vasodilation which
may occur during impression moulding
which would produce irregularities in the
mould.
Prolonged use of vasoconstrictor drugs is
Solutions used by the practitioner 545
not recommended because of the danger of
masking the underlying cause. Prolonged
use can also cause a rebound hyperaemia.
Anti-allergic drugs
Antihistamine drops are drugs which com­
pete with the histamine which is released
during an allergic reaction, thereby antago­
nizing its action. A number of antihistamine
drugs are available but are mostly formulated
for oral administration for the systemic relief
of allergic conditions.
Sodium cromoglycate (Opticrom, Fisons
UK) preparations are used prophylactically
in the treatment of seasonal and perennial
allergic rhinitis, allergic conjunctivitis and
giant papillary conjunctivitis (Martindale,
1989c). It acts differently to an antihistamine
drug, and its precise mode of action remains
unsure. Mast cell degranulation in the target
organ, in nasal mucosa or the palpebral con­
junctiva has been widely assumed to be
responsible for most of the common disor­
ders in the atopic subject. The hypothesis is
that sodium cromoglycate acts as a mast cell
stabilizer and inhibits the release from sensi­
tized mast cells of histamine and other
inflammatory mediators (Martindale, 1989c).
Sodium cromoglycate is available as eye­
drops (2% and 4%) and in ointment form
(4%).
Anti-inflammatory drugs
These drugs are able to suppress and prevent
all signs of inflammation such as redness,
swelling, etc. Anti-inflammatories prevent
the signs but do not prevent the underlying
cause.
These drugs include the naturally occur­
ring adenocortical steroids and synthetic
derivatives developed from naturally occur­
ring compounds. Because of the danger of
masking a serious condition, corticosteroids
should only be used under medical supervi­
sion.
546 Contact lens care systems and solutions used by the practitioner
ACKNOWLEDGEMENTS
We would like to thank Dr B Meakin and
Professor EG Woodward for reviewing this
manuscript. Thanks also to Ross Grant of
Ciba Vision, Roger Amass of Alcon, Ron
Loveridge of Pilkington Barnes-Hind and
Howard Griffiths of Bausch and Lomb for
their help with product information.
GLOSSARY
MERCURIAL COMPOUNDS
Thiomersal is a light-sensitive organic mer­
cury compound often added to chlorhexidine
systems as a preservative to broaden the
antimicrobial spectrum and provide greater
antimicrobial efficacy against fungi. Thi­
omersal is an anionic preservative with a
wide bacteriostatic effect.
Phenylmercuric salts such as nitrate
(PMN) or acetate are organic mercury com­
pounds with a similar action to thiomersal.
The salts dissociate slightly to give phenyl
mercuric cations. Phenylmercuric ions bind
to sulphated glycoproteins in micro­
organism cell walls. Mercuric compounds
alone have limited microbial efficacy
against bacteria, but have good efficacy
against fungi.
QUATERNARY AMMONIUM COMPOUNDS
These disinfectants have properties typical of
cationic surfactants. These surfactants fully
dissociate in aqueous solution into a cation,
which is responsible for the surface activity,
'md an inactive anion. Quaternary ammo­
nium compounds have emulsifying and
detergent properties associated with surfac­
tants, plus bactericidal activity against
Gram-positive bacteria, and at higher con­
centration some Gram-negative bacteria.
These compounds have variable antifungal
properties, are ineffective against bacterial
spores and are relatively ineffective against
viruses.
Benzalkonium chloride is a surface-active
antimicrobial that dissolves lipid from cell
membranes of bacteria and fungi. It has a
wide range of activity, usually in concentra­
tions of 0.004-0.01%, often combined with
EDTA (synergistic action) to enhance the
antimicrobial action. Benzalkonium chloride
is a cationic preservative which may bind
ionically with lens polymers, and can be
inhibited by anionic and non-ionic surface
active agents and protein.
Alkyl triethanol ammonium chloride is a
quaternary ammonium antimicrobial agent
with surfactant properties. It has weaker
action against Gram-negative bacteria,
yeasts and fungi, compared with benzalko­
nium chloride. It is usually combined with
0.001-0.002% thiomersal to enhance the
spectrum of activity. In its free form, it
readily penetrates hydrogel contact lenses,
hence it is formulated in a semi-bound
form by the addition of surfactant (micelle
interaction). In solution, the micelle bound
form of the molecule is in equilibrium with
the free form. This allows the preservative
effect to be manifest, but reduces penetra­
tion into the lens matrix, when used at a
concentration of 0.013%.
Cetrimide is combined with 1.5% chlo­
rhexidine gluconate in Savlon (ICI Pharma­
ceuticals, UK).
ALCOHOLS
Alcohol-based preservatives are rarely used
alone in disinfecting solutions, but are found
in cleaning solutions to eliminate chance
contamination. Alcohols have an additional
cleaning effect as lipid solvents.
Chlorbutol is a chlorinated alcohol bacteri­
cide usually used in conjunction with benza­
lkonium chloride in rigid lens solutions at a
concentration of 0.5%. It becomes unstable at
pH values above 6.
Benzyl and phenyl alcohols are both similar

to chlorbutol in activity, but more stable in
solution.
Isopropyl alcohol is incorporated at 20%
concentration.
Ethanol is also used.
OTHER ANTIMICROBIAL
AGENTS/PRESERVATIVES
EDTA (ethylene diamine tetra-acetic acid)
potentiates the action of quaternary ammo­
nium disinfectants against Gram-negative
but not Gram-positive organisms. It removes
divalent cations like magnesium and calcium
from the outer cell envelope of Gram­
negative organisms, resulting in the removal
of those molecules which compete with pre­
servative molecules for active sites on the cell
walls.
Chlorhexidine gluconate is a wide ranging
disinfectant, effective against Gram-positive
and Gram-negative organisms. It is effective
against Acanthamoebae when correctly for­
mulated, and is often combined with 0.001­
0.002% thiomersal to increase the spectrum
of antimicrobial efficacy. The activity of chlo­
rhexidine is reduced in the presence of ionic
molecules, particularly inorganic salts.
Sorbic acid is a compound with limited
antimicrobial activities. It is used as a means
of preventing chance contamination in clean­
ing solutions, re-wetting agents and saline.
Its antimicrobial activity is very dependent
upon pH and is limited in the range of most
contact lens care products. Toxic and allergic
responses are seen infrequently with sorbic
acid. Lens discoloration with sorbic acid pre­
served solutions has been reported infre­
quently (Iosephson & Caffery, 1986}, except
where lenses are heated with sorbic acidl
sorbate preserved saline (Sibley, 1984).
BUFFERING AND TONICITY AGENTS
Agents such as borate, bicarbonate and
phosphates are added to solutions to provide
pH < 8 for certain antimicrobial agents and
References 547
to allow the solution to adjust to tear pH
quickly. Normal tear pH varies with the
individual and with contact lens wear.
Sodium chloride or potassium chloride
may be incorporated to render the solution
isotonic with tears (0.7-1.2% NaCl equiva­
lent).
WETTING AGENTS
Polyvinyl alcohol (PVA) is a non-ionic poly­
mer used as a wetting agent and lubricant,
which increases solution viscosity and con­
tact time at the eye. The PVA molecule has
hydroxyl groups which render the lens sur­
face hydrophilic.
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Rosenthal, R.A, McNamee, L.S. and Schlech, B.A . Tregakis, M.P., Brown, 5.1. and Pearce, D.E.
(1988) Continuous antimicrobial activity of con­ (1973b) Bacteriological studies of contamination
tact lens disinfectants. Contact Lens Forum, 13 associated with soft contact lenses. Am. f. Oph­
(11),72-5. thalmol., 75, 496-9.
Sack, RA. Jones, B. Antignani, A. Libow, R. and Tripathi, R.C and Tripathi, B.J. (1984). Lens spoil­
Harvey, H. (1987) Specificity and biological age. In Contact Lenses: The CLAO Guide to Basic
activity of the protein deposited on the Science and Clinical Practice (2nd edn) (ed. a.H.
hydrogel surface. Invest. Ophthalmol. Vis. Sci. Dabezies), Little, Brown & Co, Boston, MA, pp.
28,842-9. 299--334.
Sack, R.A, Harvey, H. and Nunnes, I. (1989) Tse, L.S., Callender, M.G. and Charles, AM.
Disinfection associated spoilage of high water (1987) Antimicrobial effectiveness of some soft
content ionic matrix hydrogels. CL.A.O./., contact lens care systems. Am. f. Optom. Physiol.
15(2), 138-45. Optics, 64 (11), 824-8.
Shih, KL. Hu, J. and Sibley, M. (1985) The micro­ Walker, P.J. (1981) Do storage solutions affect soft
biological benefit of cleaning and rinsing con­ lens parameters? Contact Lens Review. The
tact lenses. Int Contact Lens Clin 12(4): 235--242. Ophthalmic Optician, 21 (8), 240-2.
Shih, KL., Raad, M.K. Hu, J.C, Gresh, W.J., Jones, Weissman, B.A, Mondino, B.J., Pettit, T.H. and
5.1., Caldwell, L.J. and Bergamini, M.V.W. Hofbauer, J.D. (1984) Corneal ulcers associated
(1991) Disinfecting activities of non-peroxide with extended wear soft contact lenses. Am. f.
soft contact lens cold disinfection solutions. Ophthalmol., 97, 467-81.
CL.A.O./., 17 (3), 165--8. Wilhelmus, KR., Robinson, N.M., Font, R.A.,
Sibley, M.]. (1984) Contact lens solution incompat­ Hamill, M.B. and Jones, D.B. (1988) Fungal
ibilities. Contact Lens Forum, 9 (5), 67-71. keratitis in lens wearers. Am. [, Ophthalmol.,
Smolin, G., Okumoto, M. and Nosik, R.A. (1979) 106,708-14.
The microbial flora in extended wear soft Wilson, L.A and Ahern, D.G. (1977) Pseudomonas
552 Contactlens care systems and solutions used by the practitioner
induced corneal ulcers associated with con­ Wilson, C.R, Woodward, E.G. and Stapleton, F.
taminated eye mascaras. Am. J. Ophthalmol., (1993) Contact lens compliance in a university
84(1), 112-19. population. J. Br, Contact Lens Assoc., in press.
Wilson, L.A and. Ahem, D.G. (1986) Association Wolff, E. (1976) Anatomy of the eye and orbit (7th
of fungi with extended wear soft contact lenses. ed), Lewis, London, p. 226.
Am. J. Ophthalmol., 101, 434-6. Wong, M.P., Dziabo, AJ. and Kiral, RM. (1986)
Wilson, L.A, McNatt, J. and Reitschel, R. (1981a) Adsorption of benzalkonium chloride by rigid
Delayed hypersensitivity to thimerosal in soft gas permeable lenses. Contact Lens Forum, 11(5),
contact lens wearers. Ophthalmology, 88, 804-9. 25-32.
Wilson, L.A., Schlitzer, RL. and Ahem, D.G. Wright, P., Warhurst, D. and Jones, B.R. (1985)
(1981b) Pseudomonas corneal ulcers associated Acanthamoeba keratitis successfully treated
with soft contact lens wear. Am. J. Ophthalmol. medically. Br. J. Ophthalmol., 69, 778-82.
92,546-54.
APPENDIX 25.A: CARE PRODUcrS CURRENTLY AVAILABLE
Solution Suitability Active ingredients Comments

(Manufacturer) Rigid Hydrogel

Cleaning
Boston Cleaner Y N Sodium tridecylether sulphate 10% Not suitable with
(Polymer w/v surface coated lenses
technology) Polymeric beads (as friction
enhancing agent)
Cleaner No 4 N Y Octylphenoxy ethanol 1.0% w/v Contains a non-ionic
(Pilkington Thiomersal 0.004% w/v surfactant
Barnes-Hind) Disodium edetate 0.2% w/v Alkaline pH
Clens (Alcon) Y N Tergitol TMN 0.1% w/v
Tyloxapol 0.1% w/v
Benzalkonium chloride 0.02% w/v
Disodium edetate 0.1% w/v
Contactaclean y N Chlorhexidine gluconate
(Ciba Vision) 0.006% w/v
Benzalkonium chloride 0.004% w/v
Disodium edetate 0.128% w/v
Non-ionic surfactant
Daily cleaner N Y Sorbic acid 0.25% w/v
(Bausch & Lomb) Disodiurn edetate 0.5% w/v
Hydroclean (Ciba N Y Chlorhexidine gluconate 0.0025%
Vision) w/v
Thiomersal 0.0025% wi"
Disodium edetate 0.128% w/v
Non-ionic surfactant
Hydron Cleaning Y Y Chlorhexidine gluconate
(Allergan) 0.002% w/v
Intensive Cleaner y N Alkyl imidazoline dicarboxylate Weekly intensive
(Pilkington Alkyl carboxylic acid amine cleaner, containing a
Barnes-Hind) Polyoxyalkylene high concentration of
dimethylpolysiloxane surfactant cleaners
Thiomersal 0.001% w/v For use with turbulent
Disodium edetate 0.1 % w/v Hydra-Mat cleaning
case
 Appendix 25.A: Care products currently available 553
Solution Suitability Active ingredients Comments

(Manufacturer) Rigid Hydrogel

LC65 (Allergan) Y Y Miranol2% w/v New formulation ­

Disodium edate 0.127% w/v preservative free
Liprofin (Alcon) N Y Sodium perborate 2g Not for use by patient
Regular use with high
water content lenses
may cause altered
parameters
Miraflow (Ciba Y Y Isopropyl alcohol 20% w/v Preservative free
Vision) Poloxamer 407
Miranol H2M
02 Care (Ciba Y N Benzalkonium chloride 0.005% w/v Recommended for
Vision) Disodium edetate 0.128% w/v Menicon 02 RGP
lenses
Pliagel (Alcon) Y Y Poloxamer 407 15% w/v Not for use wi th
Sorbic acid 0.1 % w/v Menicon 02 RGP
Trisodium edetate 0.50% w/v lenses
Care with CAB lenses
Preflex (Alcon) Y Y Thiomersal 0.004% w/v
Disodium edetate 0.2% w/v
Prymeclean (Smith y y Pluronic L64 0.5% w/v
& Nephew) ChIorhexidine gluconate 0.002%
w/v
RGP Cleaner Y N Sodium tridecylether sulphate 10% Not suitable with
(Bausch & Lomb) Polymeric beads (as friction surface coated lenses
enhancing agent)
Soft lens daily Y Y Thiomersal 0.004% w/v
cleaner (Sauflon) Disodium edetate 0.1% w/v
Steri-clens Y Y Thiomersal 0.004% w/v
(Sauflon) Disodium edetate 0.1 % w/v
Titan (Pilkington Y N Ethoxylated polypropylene glycol Contains a non-ionic
Barnes-Hind) Benzalkonium chloride 0.02% w/v surfactant
Hydroxyethyl cellulose
Disodium edetate 2.0% w/v
Transclean (Smith y N Pluronic 64 0.5% w/v
& Nephew) Benzalkonium chloride 0.01 % w/v
Disodium edetate 0.1% w/v
Soaking
Ami-10 (Abatron) Y Y Thiomersal 0.001 % w/v ~w formulation
Chlorhexidine gluconate
0.005% w/v
Disodium edetate
Contactasoak (Ciba y N Chlorhexidine gluconate
Vision) 0.006% w/v
Benzalkonium chloride 0.004% w/v
Disodium edetate 0.128% w/v
Non-ionic surfactant
554 Contact lens care systems and solutions used by the practitioner
Solution Suitability Active ingredients Comments

(Manufacturer) Rigid Hydrogel

Flexcare (Alcon) N Y Chlorhexidine gluconate Disinfection and

0.005% w/v rinsing solution
Thiomersal 0.001 % w/v High water content
Disodium edetate 0.1% w/v lenses may have
increased CHX
uptake
Flexsol (Alcon} N Y Chlorhexidine gluconate 0.005% Disinfection solution;
w/v lenses must be rinsed
Thiomersal 0.001% w/v with saline
Disodium edetate 0.1% w/v subsequently
Hexidin N Y Povidone Disinfection and
(Pilkington Octylphenoxy ethanols rinsing solution
Barnes-Hind) Chlorhexidine gluconate
0.003% w/v
Thiomersal 0.002% w/v
Disodium edetate 0.1% w/v
Hydrocare N Y Alkyl triethanol ammonium Cleaning and
Cleaning and chloride 0.03% w/v disinfection solution
Soaking Thiomersal 0.002% w/v
(Allergan)
Hydron Soaking N Y Chlorhexidine gluconate Rinsing and
(Allergan) 0.002% w/v disinfection solution
Hydrosoak (Ciba N Y Chlorhexidine gluconate Disinfection and
Vision) 0.0025% w/v storage
Thiomersal 0.0025% w/v
Disodium edetate 0.128% w/v
Normol (Alcon) N Y Chlorhexidine gluconate Rinsing and storage
0.005% w/v solution; buffered
Thiomersal 0.001% w/v multidose saline
Disodium edetate 0.2% w/v
OptimEyes N Y Chlorhexidine gluconate 0.004% Tablet containing
Disinfection Tablet w/v 0.4 mg chlcrhexidine.
(Bausch & Lomb soluble in 10 ml tap
water
Contraindicated for
class IV lenses
Prymesoak N Y Chlorhexidine gluconate 0.002%
(Smith & w/v
Nephew)
Softlens N Y Alkyl triethanol ammonium Disinfection solution
Soaking chloride 0.03% w/v
(Bausch & Lomb) Thiomersal 0.002% w/v
Soquette y N Polyvinyl alcohol
(Pilkington Benzalkonium chloride 0.01% w/v
Barnes-Hind) Disodium edetate 0.2% w/v
Steri-Sal2 N Y Thiomersal 0.002% w/v
(Sauflon) Chlorhexidine gluconate
0.002% w/vl
Disodium edetate 0.1 % w/v
 Appendix 25.A: Care products currently available 555
Solution Suitability Active ingredients Comments
(Manufacturer) Rigid Hydrogel

Sterisoak y N Chlorbutol 0.4% w/v

(Sauflon) Benzalkonium chloride 0.002% w/v
Disodium edetate 0.1 % w/v
Transoak Y N Benzalonium chloride 0.02% w/v
(Smith & Disodium edetate 0.2% w/v
Nephew)
Wetting solutions and re-uieiting solutions
Clerz (Ciba Vision) y y Poloxamer 407 Preservative and
Hydroxyethylcellulose enzyme free. Unit
dose
Contactasol (Ciba y N Chlorhexidine gluconate Contains non-ionic
Vision) 0.006% w/v surfactant
Benzalkonium chloride 0.004% w/v
Wetting agents
Disodium edetate 0.128% w/v
Hydron Comfort N Y Chlorhexidine glucontae
(Allergan) 0.0025% w/v
Thiornersal 0.0025% w/v
Disodium edetate 0.1 % w/v
Hydrosol (Ciba N Y Chlorhexidine gluconate
Vision) 0.0025% w/v
Thiomersal 0.0025% w/v
Wetting agents
Disodium edetate 0.128% w/v
Liquifilm Y N Polyvinyl alcohol 2% w/v
(Allergan) Methyl cellulose 0.35% w/v
Benzalkonium chloride 0.004% w/v
Disodium edetate 0.127% w/v
Transdrop (Smith Y N Polyvinyl alcohol 1.4% w/v Comfort drop
& Nephew) Hydroxyethyl cellulose
Benzalkonium chloride 0.004% w/v
Transol (Smith & Y N Polyvinyl alcohol 2% w/v
Nephew) Benzalkonium chloride 0.004% w/v
Hydroxyethyl cellulose
Disodium edetate 0.02% w/v
Wetting Solution y N Polyvinyl alcohol 2% w/v
(Pilkington Benzalkonium chloride 0.004% w/v
Barnes-Hind) Disodium edetate 0.02% w/v
Combined solutions
Boston Wetting & y N Chlorhexidine gluconate Disinfection and
Soaking (Polymer 0.006% w/v wetting
Technology) Disodium edetate 0.05% w/v
Cleaning & Y N Benzalkonium chloride 0.01 % w/v Cleaning and
Soaking Disodium edetate 0.2% w/v disinfection
(Pilkington
Barnes-Hind)
Clean-N-Soak y N Phenylmercuric nitrate 0.004% w/v Cleaning and
(Allergan) Disodium edetate 0.127% w/v disinfection
556 Contact lens care systems and solutions used by the practitioner
Solution Suitability Active ingredients Comments

(Manufacturer) Rigid Hydrogel

Complete Care y y Benzalkonium chloride 0.1% w/v

Disodium edetate 0.05% w/v
Poloxamer 407
Lipid solubilizer
One solution Y N Ethanol 0.035% w/v Cleaning, disinfection
(Pilkington Polyvinyl alcohol 0.5% w/v and wetting
Barnes-Hind) Benzalkonium chloride 0.01% w/v
Disodium edetate 0.1 % w/v
RGP Wetting & Y N Chlorhexidine gluconate Disinfection and
Soaking (Bausch 0.006% w/v wetting
& Lomb) Disodium edetate 0.05% w/v
Soaclens (Alcon) Y N Polysorbate 80 0.005% w/v Disinfection and
Benzalkonium chloride 0.01% w/v wetting
Disodium edetate 0.1% w/v
Total (Allergan) y N Polyvinyl alcohol 2.5% w/v Cleaning, disinfection
Benzalkonium chloride 0.004% w/v and wetting
Disodium edetate 0.127% w/v
Wetting and y N Oxyphenoxy ethanols Contains non-ionic
Soaking Polyvinyl alcohol surfactant
(Pilkington Benza!konium chloride 0.005% w/v
Barnes-Hind) Disodium edetate 0.1 % w/v
Salines
Aerosol Salette y y Sodium chloride 0.9% w/v Unpreserved
(Alcon) Phosphate buffer Use with Softab
Aerosol Saline y y Sodium chloride 0.9% w/v Unbuffered
(Alcon) unpreserved
Use with Softab
Aerosol Saline y y Sodium chloride 0.9% w/v Unbuffered
(Bausch & Lomb) unpreserved
Aerosol Saline y y Sodium chloride 0.9% w/v Unpreserved
(Sauflon) Phosphate buffer Use with Aerotab
Amidose saline y y Sodium chloride 0.9% w/v Unit dose unpreserved
(Abatron)
Hydron Saline B Y Y Sodium chloride 0.762% w/v Unpreserved
(Allergan) Sodium phosphate 0.22% w/v
Hydron Solusal y y Sodium chloride 0.9% w/v Unbuffered
(Allergan) Sodium phosphate 0.22% w/v unpreserved
Lens Plus Y Y Sodium chloride 0.9% w/v Unbuffered
(Allergan) unpreserved
Lensrins (Ciba y y Sodium chloride 0.85(;/0 wiv Neutralization stage
Vision) Thiomersal 0.001 % w Iv for Septicon peroxide
Disodium edetate 0.1 % w/v system
Buffers
Softmate Saline y y Sodium chloride 0.4% w/v Unpreserved
(Alcon)
Borate buffer
Solar Saline (Ciba y y Sodium chloride 0.66% w/v Unpreserved
Vision) Borate buffer
 Appendix 25.A: Care products currently available 557

Solution Suitability Active ingredients Comments

(Manufacturer) Rigid Hydrogel

Oxidative systems
Peroxide
Oxysept System N Y Disinfection; Catalytic
(Allergan) 3% w/v hydrogen peroxide decomposition of
stablizer peroxide
Neutralization; Vented storage case
Catalase
Miranol2% w/v
Disodium edetate 0.127% w/v
Oxysept One Step N Y Disinfection; Coated catalase tablet
(Allergen) 3% w/v hydrogen peroxide added to peroxide
stabilizer
Neutralization;
Catalase 0.1 mg/tablet
10-10 Cleaning & N Y Disinfection; Chemical
Disinfection 3% w/v hydrogen peroxide decomposition of
(Ciba Vision) stabilizer peroxide
Neutralization;
Sodium pyruvate 0.5% w/v
Disodium edetate 0.1 % w/v
Sodium chloride
Buffers
Lensept/Lensrins N Y Disinfection; Catalytic
(Ciba Vision) 3% w/v hydrogen peroxide decomposition using
stablizer Septicon disc
Neutralization;
Sodium chloride 0.85% w/v
Thiomersal 0.001% w/v
Disodium edetate 0.1 % w Iv
Perform System N Y Disinfection; Use with Hydromat
(Pilkington 3% w/v hydrogen peroxide Chemical
Barnes-Hind) case stablizer decomposition of
Neutralization; peroxide
Sodium thiosulphate 0.5% w/v
Sodium chloride
Borate buffer
Chlorine release
Aerotab System N Y Halozone (Dichlorosu phamoyl Use with unpreserved
(Sauflon) benzoic acid) 0.16 mg tablet saline, produces
8 ppm of available
chlorine
Softab System N Y Di-isochlorocyanurate 0.065 mg Dissolve in 10 ml
(Alcon) effervescent tablet unpreserved saline,
produces 4 ppm of
free chlorine
558 Contact lens care systems and solutions used by the practitioner

Solution Suitability Active ingredients Comments

(Manufacturer) Rigid Hydrogel

Enzyme cleaners
Amiclair Triple Y Y Protease Removal of protein,
Enzyme (Abatron) Lipase lipid mucin and
Pronase calcium
Disodium edetate Does not contain
papain
Clen-Zym N Y Pancreatin BP 2.5 mg Multiple enzyme
(Alcon) treatment
Not licensed for GP CL
Fizzy Protein Y Y Stabilized papain
Tablets (Bausch &
Lomb)
Hydrocare Fizzy y y Stabilized papain 10 mg 15 min exposure for
(Allergan) high water content
lenses
Protein Remover Y Y Stabilized papain
Tablets (Sauflon)
Prymecare (Smith Y Y Stabilized papain
& Nephew)
Ultrazyme N Y Subtilisin A 0.4 mg Serine protease use
(Allergan) with Oxysept 1