A Report by the American Academy of Ophthalmology Technology Assessment Committee Glaucoma Panel: Anna K. Junk, MD,1 Philip P. Chen, MD,2 Shan C. Lin, MD,3 Kouros Nouri-Mahdavi, MD,4 Sunita Radhakrishnan, MD,5 Kuldev Singh, MD, MPH,6 Teresa C. Chen, MD7
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Objective: To examine the efficacy of various disinfection methods for reusable tonometer prisms in eye care and to highlight how disinfectants can damage tonometer tips and cause subsequent patient harm.
Methods: Literature searches were conducted last in October 2016 in the PubMed and the Cochrane Library databases for original research investigations. Reviews, non-English language articles, nonophthalmology articles, surveys, and case reports were excluded.
Results: The searches initially yielded 64 unique citations. After exclusion criteria were applied, 10 laboratory studies remained for this review. Nine of the 10 studies used tonometer prisms and 1 used steel discs. The infectious agents covered in this assessment include adenovirus 8 and 19, herpes simplex virus (HSV) 1 and 2, human immunodeficiency virus 1, hepatitis C virus, enterovirus 70, and variant Creutzfeldt-Jakob disease. All 4 studies of adenovirus 8 concluded that after sodium hypochlorite (dilute bleach) disinfection, the virus was undetectable, but only 2 of the 4 studies found that 70% isopropyl alcohol (e.g., alcohol wipes or soaks) eradicated all viable virus. All 3 HSV studies concluded that both sodium hypochlorite and 70% isopropyl alcohol eliminated HSV. Ethanol, 70% isopropyl alcohol, dilute bleach, and mechanical cleaning all lack the ability to remove cellular debris completely, which is necessary to prevent prion transmission. Therefore, single-use tonometer tips or disposable tonometer covers should be considered when treating patients with suspected prion disease. Damage to tonometer prisms can be caused by sodium hypochlorite, 70% isopropyl alcohol, 3% hydrogen peroxide, ethyl alcohol, water immersion, ultraviolet light, and heat exposure. Disinfectants can cause tonometer tips to swell and crack by dissolving the glue that holds the hollow tip together. The tonometer tip cracks can irritate the cornea, harbor microbes, or allow disinfectants to enter the interior of the tonometer tip.
Conclusions: Sodium hypochlorite (dilute bleach) offers effective disinfection against adenovirus and HSV, the viruses commonly associated with nosocomial outbreaks in eye care. Tonometer prisms should be examined regularly for signs of damage.
1 Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami; Miami Veterans Affairs Medical Center, Miami, Florida.
2 Department of Ophthalmology, University of Washington, Seattle, Washington.
3 Department of Ophthalmology, University of California, San Francisco, San Francisco, California.
4 Stein Eye Institute, Los Angeles, California.
5 Glaucoma Center of San Francisco, Glaucoma Research and Education Group, San Francisco, California.
6 Stanford University School of Medicine, Stanford, California.
7 Harvard Medical School, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary, Glaucoma Service, Boston, Massachusetts.