Reader and Industry Forum
Hand Washing: A Slippery Slope
BY SAMANTHA KRONISH & ETTY BITTON, OD, MSC, FAAO, FBCLA
Noncompliance has been at the heart of reported contact lens-related problems. These include poor adherence to replacement schedules, lack of proper case hygiene, inadequate cleaning regimen, and poor hand washing, among others (Dumbleton et al, 2010; Wu et al, Aug. 2010; Hickson-Curran et al, 2011; Wu et al, Jan. 2010; and others. Full list available at www.clspectrum. com/references.asp). Even hand washing, a well-established basic hygiene step, has shown to be poor in both patients and healthcare professionals alike (Boyce and Pittet, 2002; Khan et al, 2013; Morgan et al, 2011; McMonnies, 2013; and others).
Some report that up to one in four patients fail to wash their hands prior to contact lens handling (Eisenberg, 2012). Others have found that a little over half—56 percent of the surveyed population (12 to 39 years of age)—wash their hands prior to contact lens handling (Hickson-Curran, 2012).
The Centers for Disease Control and Prevention (CDC) recommends 20 seconds of hand rubbing, with no specific details or recommendations for contact lens wearers (CDC, 2013). Other agencies such as the American Optometric Association (AOA) and the World Health Organization (WHO) provide similar nonspecific recommendations (AOA Clinical Practice Guideline, 2006; WHO website, accessed 2013).
What Is Hand Washing?
The term "hand washing" can be defined as "cleansing of the hands with water/liquid, with or without the inclusion of soap or other detergent, for the purpose of removing soil or microorganisms" (Reference.MD). An improved definition would include three steps: cleansing, rinsing, and drying. As can be expected, the less time contact lens wearers spend on any of these steps, the greater the potential for residual debris or bioburden on the hands. These can subsequently be transferred to contact lens surfaces during handling and application, with the potential to affect vision, comfort, and risk of infection.
A study by Campbell et al (2012) revealed that poor or no hand washing left dermal lipid residue on hands, which was subsequently transferred to contact lenses.
A more stringent six-point technique of approximately 30 seconds proposed by the Royal College of Nursing (RCN) (RCN.org PDF), and traditionally reserved for medical professionals, succeeded in reducing the dermal lipid residue. Nonetheless, no specifics relating to each step of the process were enumerated.
Contact lens lipid deposits can come from many sources including the skin (Campbell et al, 2012), makeup and creams (Srinivasan et al, 2012), and possibly even hand soaps (Shakir, 2012). Some practitioners have suspected that the type of hand soap may be a contributing factor in contact lens lipid-type deposits, leading to poor vision and discomfort in their patients (Shakir, 2012).
A pilot study evaluated the amount of lipid deposit on contact lenses after hand washing for variable amounts of time and with different soap conditions (Bitton and Kronish, 2013).
Latex-gloved hands were lathered for five seconds with one of three soap conditions (no soap, clear-based soap, and cream-based soap). Randomized rinsing times were chosen to reflect shorter (zero, three, and five seconds) versus longer (10, 15, 20, and 30 seconds) times prior to manipulating a new contact lens. Some of the lenses were treated with a lipid-specific stain (Oil Red O). Others were evaluated for any changes in surface wettability by measuring the contact angle (CA).
Not surprisingly, preliminary findings revealed increasing lipid deposits with shortened rinsing times, but more so using the cream-based soap. Also, the CA values with the cream-based soaps were significantly higher (Figure 1), thereby indicating reduced wettability, as compared to the other soap conditions (p<0.001).
Figure 1. Contact angle (CA) by type of soap for short (zero to five seconds) and long (10 to 30 seconds) rinsing times. The cream-based soap had significantly increased CA (p<0.001), suggesting poorer wettability.
Education Is Always Key
A larger study is needed to corroborate these results, but these findings should remind practitioners to re-emphasize the importance of hand washing techniques, including specifics about lathering, rinsing, and drying, at every follow-up visit. If lipid deposits are unusual for patients (and tear lipid issues have been ruled out), consider the type of hand soap used. The lipid deposits may be a factor in symptoms of poor vision and/or contact lens discomfort, which can lead to contact lens dropouts and eventually affect practices' bottom lines. Although recommendations on hand washing are available (WHO website, accessed 2013), we, as well as our patients, need to do a better job of complying with them. CLS
For references, please visit www. clspectrum.com/references.asp and click on document #217.
Dr. Bitton is an associate professor, director of the Clinical Externship Program, and director of the Dry Eye Clinic at the École d'optométrie, Université de Montréal. Her research interests include tear film evaluation, dry eye, and contact lens wear. She has received funding from Alcon Canada and Allergan Canada and has been a consultant for or received honoraria from Alcon, Allergan Canada, B+L Canada, Ciba Vision, and J&J. Ms. Kronish is a college student who has interests in health sciences. She participated in this project as a student intern working with Dr. Bitton.