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Use of Tap Water on Gas Permeable Lenses The International Society of Contact Lens Specialists 2015 Mindy Toabe, OD, FAAO, FSLS MetroHealth Medical Center/ Senior Clinical Instruction, Case Western Reserve University School of Medicine Corneal Gas Permeable Risk of Microbial Keratitis Stapleton, F., Keat, L., et al. The incidence of contact lens –related microbial keratitis in Australia. Ophthalmology. 2008 Oct;115(10):1655-62. Centers for Disease Control and Prevention(CDC) Study: Collier SA, Gronostaj, MP, et al. “Estimated burden of keratitis—United States, 2010.” Morb Mortal Wkly Rep. 2014 Nov;63(45):1027-30. Wu, Y., Wilcox, M., Stapleton, F. Contact lens hygiene compliance and lens case contamination: a review. Cont Lens & Ant Eye. 2015 British Contact Lens Association Corneal Gas Permeable Wearers and Microbial Keratitis Risk Factors 1.2 daily wear RGP wearers out of 10,000 developed CL related microbial keratitis Relationship between bacterial contamination and age of contact lens case Kuzman, T., Kutija, MB., et al. Lens wearers non-compliance-is there an association with lens case contamination? Cont Lens Anterior Eye. 2014 Apr;37(2):99-105. Scleral Lens Risk of Microbial Keratitis Zimmerman, Aaron B (01/2014). "Microbial keratitis secondary to unintended poor compliance with scleral gas-permeable contact lenses". Eye & contact lens (1542-2321), 40 (1), p. e1 Bruce, Adrian S (03/2013). "Acute red eye (non-ulcerative keratitis) associated with mini-scleral contact lens wear for keratoconus". Clinical and experimental optometry (0816-4622), 96 (2), p. 245. Fernandes, Merle (04/2013). "Polymicrobial and microsporidial keratitis in a patient using Boston scleral contact lens for Sjogren's syndrome and ocular cicatricial pemphigoid". Contact lens & anterior eye (1367-0484), 36 (2), p. 95. Primary Reason for Tap Water Use Change in routine “I went camping and lost my solutions so had to use water. It was really uncomfortable, but my fault.” Dumbleton, K., Spafford, M., et al. Exploring Compliance: A Mixed- Methods Study of Contact Lens Wearers Perspectives Optometry and Vision Science. 2013 Aug;90(8):898-908. Tap Water Risks “Do not expose your contact lenses to any water: tap, bottled, distilled, lake or ocean water. Never use non-sterile water (distilled water, tap water or any homemade saline solution). Exposure of contact lenses to water has been associated with Acanthamoeba keratitis, a corneal infection that is resistant to treatment and cure.” http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerPro ducts/ContactLenses/ucm062584.htm 2014 Pseudomonus Found in natural bodies of water, human body, distilled water, sewerage systems, and whirlpools Not found in drinking water but biofilms colonize in plumbing fixtures Mena K., Gerba, C. Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol. 2009;201:71-115. Tap Water and Storage Case Samples Tap Water Samples Bacteria (TAMB) - 68% Gram Negative Bacteria - 0% Pseudomonus - 0% Amoebae - 30% Fungi - 30% Storage Case Samples (soft and rigid) Bacteria (TAMB) - 90% Gram Negative Bacteria - 40% Pseudomonus - 4% Amoebae - 30% Fungi - 36% Üstüntürk, M., Zeybek, Z. Microbial contamination of contact lens storage cases and domestic tap water of contact lens wearers. The Central European Journal of Medicine. 2012 Oct 24:251. Microbial Keratitis Process Water touches contact lens Lens is inserted in the eye Mechanical effects of the lid increase adhesion of bacteria Bacteria binds to shedding epithelium and then to the lens deposits (lipids and proteins) Corneal epithelial integrity is comprom ised by a scratch Microbial keratitis occurs Case Contamination Gram–positive bacteria, gramnegative bacteria and fungal increases with tap water use, especially gram-negative bacteria levels Tap water rinses off the disinfecting solution in the case increasing the risk of biofilm formation Tilia, D., Lazon de la Jara, P., et al. The Effect of Compliance on Contact Lens Case Contamination. Optometry and Vision Science. 2014 Mar; 91(3): 262-271. Acanthamoeba Biology Causal Agents: Acanthamoeba spp. , are commonly found in lakes, swimming pools, tap water, and heating and air conditioning units. Several species of Acanthamoeba, including A. culbertsoni, A. polyphaga, A. castellanii, A. astronyxis, A. hatchetti, A. rhysodes, A. divionensis, A. lugdunensis, and A. lenticulata are implicated in human disease. Life Cycle: Acanthamoeba spp. have been found in soil; fresh, brackish, and sea water; sewage; swimming pools; contact lens equipment; medicinal pools; dental treatment units; dialysis machines; heating, ventilating, and air conditioning systems; mammalian cell cultures; vegetables; human nostrils and Parasites - Granulomatous Amebic Encephalitis (GAE); Acanthamoeba has throats; and- Acanthamoeba human and animal brain, skin, and lung tissues. Unlike N. fowleri, only two stages, cysts and trophozoites , in its life cycle. No flagellated stage exists as part of the Keratitis, http://www.cdc.gov/parasites/acanthamoeba/biology.html life cycle. The trophozoites replicate by mitosis (nuclear membrane does not remain intact) . The Exposure to Acanthamoeba Swimming, hot tub, natural spring Non-sterile wetting solutions, saliva, or chlorine disinfectants Tap, bottled or distilled water as wetting /storage solution contact lens wear CDC Acanthamoeba pathogenesis Minor trauma to corneal epithelium Contaminated water • contact lens Amebae adhere to contact lens •Biofilm on contact lens Keratitis •Biofilm protects ameba from lid action and tears Moore. M. Acanthamomeba Keratitis and Contact Lens Wear: The Patient Is at Fault. Cornea. 1990;9 Suppl 1:S33-S35;discussion S39-S40. Worldwide: Acanthamoeba Japan Watanabe, R., Ishibashi, Y., Acanthamoeba isolation from contact lens solution of contact lens wearers without keratitis. Nihon kanka Gakkai Zasshi. 1994 May;98(5):477-80. Seal, D., Kirkness, C. Acanthamoeba keratitis in Scotland: Risk factors for contact lens wear. Cont Lens Anterior Eye 1999;22:58-68. Radford, C., Minassian, D., et al. Acanthamoeba keratitis in England and Wales: Incidence, outcome, and risk factors. Br J Ophthalmol 2002;86:536-542. Jeong, H., Yu, H. The role of domestic tap water in Acanthamoeba contamination in contact lens storage cases in Korea. The Korean Journal of Parasitology. 2005 June;43(2):47-50. USA Shoff, M., Rogerson, A., et al. prevalence of Acanthamoeba and other naked amoeba in South Florida domestic water. J Water Health. 2008 Mar;6(1):99-104. Bonilla-Lemus P, Ramerirez-Bautista GA, Zamora-Munoz C, et al. Acanthamoeba spp. In domestic tap water in houses of contact lens wearers in the metropolitan area of Mexico City. Exp Parasitol. 2010 Sep;126(1):54-8. Elimination of Tap Water Use Cleaning lenses and cases with tap water leads to an increased risk of acanthamoeba keratitis NO tap water-no acanthamoeba and low risk of biofilm Seal DV, Dalton A, Doris D. Disinfection of contact lenses without tap water rinsing: is it effective? Eye(London) 1999 Apr;13 (Pt 2):226-30. Confusion with Tap Confusion exists between package inserts and doctor’s recommendations Legarreta JE, Nau AC, Dhaliwal, AC. Acanthamoeba keratitis associated with tap water use during contact lens cleaning: manufacturer guidelines need to change. Eye Contact Lens 2013 Mar;39(2):158-61. Confusion with Tap Water Patient education is the key to increasing compliance. Seal, D., Stapleton, F., et al. Possible environmental sources of Acanthamoeba spp in contact lens wearers. Br J Ophthalmol. 1992 Jul;76(7): 424-7. Effective Disinfectants 3% Hydrogen peroxide Chlorhexidine Benzalkonium chloride with edetate Moore, M. Acanthamoeba keratitis and contact lens wear: the patient is at fault. Cornea. 1990;9 Suppl 1:S33-5; discussion S39-40. Noncompliance Issues Ky W., Scherick, K., et al. Clinical survey of lens care in contact lens patients. CLAO J. 1998 Oct;24(4):216-9. Kuzman, T., Kutija, M., et al. Lens wearers non-compliance-is there an association with lens case contamination? Cont Lens Anterior Eye. 2014 April;37(2):96-105. Lens Care: Hand washing Wash hands with soap and water, not water only Dry hands completely Replace case every 30-90 days Lens Care Steps Clean Rinse Disinfect Store Seal DV, Dalton A, Doris D. Disinfection of contact lenses without tap water rinsing: is it effective? Eye(London) 1999 Apr;13 (Pt 2):226-30. Thakur DV, Gaikwad, UN. Microbial contamination of soft contact lenses and accessories in asymptomatic contact lens users. Indian J Med Res.2014 Aug;140(2):307-309. Leading the way to a healthier you and a healthier community through service, teaching, discovery and teamwork. Thank you [email protected]