Recommendations for Ophthalmic Practice in Relation to the Human Immunodeficiency Virus
Amy Chomsky
Denis M. O’Day
In 1985, in response to growing concerns the National Society to Prevent Blindness, in cooperation with the American Academy of Ophthalmology, assembled a task force to examine the risk of becoming infected by human immunodeficiency virus (HIV) during eye examinations and treatment.1 The unanimous conclusion of this task force was that the risk was remote. Indeed, they believe that the potential consequences of a denial of eye care because of a fear of acquiring HIV infection posed a greater health risk.
In August 1987, the Centers for Disease Control (CDC) issued revised recommendations for the prevention of HIV transmission in a health care setting.2 This was followed 2 months later by a joint advisory notice from the Department of Labor and the Department of Health and Human Services -regarding the protection against occupational exposure to hepatitis B virus (HBV) and HIV.3 These documents address the risk faced by health care workers in the course of their duties and make broad recommendations entitled, “Universal Precautions,” which all health care workers should follow. However, neither document distinguishes the particular risks and needs of health care workers in ophthalmology.
In June 1988, the CDC further clarified their recommendations, particularly as they relate to the protection of health care workers, by stressing the greater risk of blood-borne viral infections, such as HIV and HBV, posed by blood and blood-contaminated body fluids than by other body secretions such as tears.4
In view of the apparently low level of risk in ophthalmology compared with other more hazardous health care occupations and the lack of any published evidence of the transmission of HIV in ophthalmic health care settings, the American Academy of Ophthalmology and the National Society to Prevent Blindness, in consultation with the Contact Lens Association of Ophthalmologists, jointly established a committee to consider specific measures that would provide adequate protection for the patient, for eye health workers, and for the ophthalmologist. In this chapter, these measures are addressed in three distinct areas of concern:
Procedures for protection of the patient
Procedures for protection of health care providers including ophthalmologists and staff
Responsibilities toward patients with known or suspected HIV infection
Protection of The Patient
Protection of patients from exposure to the HIV during examination and treatment of eye disorders incorporates the application of good public health principles and specialized precautions. In the nearly two and one half decades since the infection was first recognized, there has been no evidence to indicate that HIV has been transmitted through any of the diagnostic or surgical procedures performed in the practice of ophthalmology. According to the CDC, the likelihood of transmission through contact with tears is remote.4 However, because the virus is potentially lethal, may be present in surface epithelia in the eye, is in tears of certain infected individuals, and can (at least in theory) be transmitted through mucous membranes, public health officials recommend that reasonable precautions be taken. Further, because many HIV carriers may be unaware of their infection and show no sign of the disease, the following recommendations should be routinely used for all patients. These guidelines represent good, general ophthalmic technique, because they also reduce the risk of transmitting other blood-borne and surface infectious agents (e.g., HBV, herpes virus, adenovirus) that are likely to be encountered in patients presenting for eye examinations.
Hand Washing
Hand washing represents one of the most effective ways to avoid transmitting or acquiring infections during examination. Hands should be washed with soap and water and thoroughly dried by fresh or disposable towels between examinations. Increasingly, patients have come to expect and often request that this be done. If an open wound or weeping lesion is present on the health care worker’s hands, disposable gloves should be worn. (Procedures to protect health care providers are discussed later.)
Gowns and Masks
Gowns and masks are unnecessary for the usual ophthalmic examination.
Instrument Disinfection Procedures
Although the risk of transmitting HIV through contact with tears is low, disinfecting instruments that come in contact with the tear film is essential to maximize patient safety not only in regards to HIV but also hardier viruses such as adenovirus and HBV
There is proven efficacy of 70% isopropyl alcohol against HIV;5 however, laboratory studies have shown 70% isopropyl alcohol and 3% hydrogen peroxide to be ineffective against adenovirus.6,7 For this reason, practitioners may choose to follow an alternative disinfection process as recommended by the CDC or the manufacturer, such as chlorine bleach. It is important to mention, however, that the study demonstrating that isopropyl alcohol and hydrogen peroxide are ineffective against adenovirus was done in vitro and may not translate to the clinical setting. Because of the delicate nature of the instruments, in many cases prolonged soaking with possibly corrosive agents is not possible. Therefore, the disinfecting process of these instruments needs to be considered separately.
Goldmann-Type Tonometer
When using a 70% isopropyl alcohol sponge, ideally the tip should be cleaned immediately after use and allowed to dry for at least 1 to 2 minutes before being used again. Care must be taken to cleanse the entire tip and to dry the tonometer surface thoroughly so that no alcohol is transferred to the ocular surface. An alternative method also proven to eliminate HIV infectious agents as well as adenovirus and HBV includes wiping the instrument clean and then disinfecting it with a bleach solution. The entire prism should be removed from the tonometer, wiped clean, and placed in a suitable receptacle, which allows the applanating surface and adjacent 2 to 3 mm of the tonometer to be immersed in a 1:100 dilution of household bleach. The 1:100 dilution is a broad-spectrum germicide. It is highly effective and rapidly acting, provided gross debris is removed from the tip before disinfection. Using a 1:10 concentration is unnecessary in most situations. One method uses a Petri dish with small holes drilled in the lid, sized to permit the tonometer tip to be partially immersed in the solution.8 After a 5-minute period of soaking, the tip should be washed under running water and dried before use. Corneal burns have resulted from incomplete rinsing of tonometer tips. Two tonometer prisms should be available so that one can be used while the other is being disinfected. Soaking the entire tip eventually removes the coloring of the etched calibration marks. This disinfecting solution should be changed at least once daily.
3% hydrogen peroxide may be used in a similar disinfecting procedure. This solution needs to be changed at least twice daily.
Schiotz Tonometer
The tonometer should be disassembled between each use; the barrel should be cleaned with two pipe cleaners (the first soaked in alcohol or an alternative solution as described previously, the second dry), and the footplate cleaned with an alcohol swab. All surfaces must be dried before reassembly.
Digital Pneumotonometer
Tips of pneumotonometers should be cleaned with an alcohol sponge, taking care that the surface is dry before placing it in contact with the cornea. These tips can also be changed between patients.
Noncontact Tonometers
The noncontact tonometer does not make contact with the cornea or tears and therefore is an ideal instrument for measurement of intraocular pressure in patients suspected of having any contagious viral condition. The front surface may be wiped with an alcohol-soaked sponge, because it occasionally can touch the eye or be splashed by tears.9
Tonopen
Since the tonopen has disposable covers, it is ideal for preventing viral spread in the office. The hand held surface can be wiped clean with an alcohol sponge as needed.
Diagnostic Contact Lenses (Gonio Lens, Macular Lens)
The lens is inverted so that the contact lens surface is uppermost. The outer casing and inner surface of the lens then is wiped with an alcohol sponge.
For added protection, the inner cup may be filled to the rim with a fresh 1:100 dilution of household bleach. After 5 minutes, the bleach is removed and the device is briskly irrigated with running water and dried. This method allows cleansing of the outer surface as well as the contact portion without exposing the glue, which cements the antireflective coating to the operator surface of the contact lens.
Other Patient Contact Instruments
Routine cleaning with alcohol of all instrument surfaces (e.g., slit lamp) after each patient is impractical and unnecessary because HIV is a fragile virus, and there is no evidence of casual spread from surfaces. However, other viruses, such as adenovirus, may persist for many hours on a dry surface and, thus, could be transmitted to other patients.10 Because patients may be carrying infectious disease without clinical features, it is prudent to wipe clean surfaces of the slit lamp that have contact with skin between patients.
Trial Fitting Contact Lenses
After each use, trial fitting contact lenses must be cleaned and then disinfected with a commercial product licensed by the U.S. Food and Drug Administration (FDA). Chemical disinfection with a hydrogen peroxide system can be used for trial hard, rigid gas permeable and soft contact lenses. Some hard and soft contact lenses also can be disinfected with a standard heat system.1 The use of disposable soft lenses eliminates the need for disinfection. Although many of the newer products on the market have not been included in the CDCs 1985 recommendations,1 the FDA requires that these products are virucidal against at least one strain of herpes simplex type I.11 Because HIV is considered a more easily inactivated virus and studies have shown many of these to be effective against HIV, it can be presumed that these are safe to use as well.11,12,13
Routine cleaning with a surfactant cleaner, rinsing, and disinfection essentially eliminates the possibility of transmitting HIV.11
Tissue Transplantation
Corneal and scleral tissue that is used for transplantation should be screened for HIV and HBV in accordance with guidelines provided by the Eye Bank Association of America.14
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