Continuous Wear, Continuous Care

At a recent Symposium, Brien Holden, on behalf of CCLRU, LVPEIand CCLR colleagues and teams, gave some of the suggestionsand measures that have been drawn up to minimise the risk ofmicrobial keratitis and, if such an event arises, to treata suspected MK event.

Though this is preliminary information that may form the basisof a publication or publications on the issue, we thought itwould be of value to pass the information on in this form.

Desmond Fonn and Debbie Sweeney

MK Diagnosis

The accurate diagnosis of Microbial Keratitis (MK) is vital,as significant delay in treatment or inappropriate treatmentcan seriously affect the visual outcome.
CCLRU and LVPEI have developed a differential diagnosis protocolto assist practitioners in the diagnosis of CLPU and MK. CLPUis often mistaken for MK, and this guide will provide practitionerswith a clear analysis of the different signs and symptoms, anda step by step checklist to guide diagnosis.

This guide, shown here, will soon be available from CCLRU.

Differential Diagnosis of CLPU v MK

MK:Treatment Strategy

MK treatment should immediately follow diagnosis. The initialempiric antibacterial treatment options for typical causativeorganisms(Pseudomonas aeruginosa, staphylococcus species,Streptococcus Pneumoniae)are:

1. Topical Fluroquinolone (e.g. ciprofloxacin 0.3%, ofloxacin0.3%) monotherapy (not in documented or suspected streptococcalkeratitis)
   - 2 drops/15min for 6 hours
   - 2 drops/30 mins for 18 hours
   - 2 drops/60 mins for 24 hours
   - 2 drops/2hours for days 3 and 4 (day only)
2. Topical Fluroquinolone (eg ciprofloxacin 0.3%, ofloxacin0.3%) + topical fortified Cefazolin (50mg/ml) (preferredagent for Gram positive coverage: if there is a possibilityof streptococcuspnueumoniae, or resistant Gram positive organisms)
3. As above

MK:Therapeutics
Initial treatment should be topical fortified Tobramycin (13.6mg/ml)+ topical fortified Cefazolin (50mg/ml) (preferred agent forGram positive coverage):

1. Give first doses (a “loading dose”): 1drop every minute for 5 minutes
2. Use topical fortified antibiotic A every hour (on the hour)
3. Use topical fortified antibiotic B every hour (on the halfhour).
4. After 36-48 hours:
   - reduce therapy if clinical improvement occurs
   - use topical fortified antibiotic A every 2 hours
   - topical antibiotic B is either discontinued or used every 2 hours,5 minutes after antibiotic A.
5. After 48-72 hours:
   - use topical fortified antibiotic A every 3 to 4 hours
   - use antibiotic ointment at bedtime
   - discontinue medication after bedtime.
6. After 96+ hours:
   - change to regular-strength antibiotic drops and slowly taperoff this medication
   - continue antibiotic ointment at night for approximately 1 week.

In the Practice

To protect your patients and your practice, it is importantthat standard operating procedures are followed for infectioncontrol. Typical guidelines for such procedures can be foundat:

• http://www.health.nsw.gov.au/
  
• http://www.cdc.gov/

The following guidelines should be standard procedures withinany practice to help to prevent infection. These should be followedas a matter of course, not just in the case of MK or other adverseevent.

Handwashing
Within the practice and for the patient, handwashing is stillthe MOST important procedure to stop the spread of infections.

• Hands must be washedpriorandpostto seeing any patient
• Hand wash should take at least 10 seconds
• Remove jewelry
• Use running water and 2% chlorhexidine gluconate
• Use friction/rubbing action
• Wash all areas
• Hands are to be rinsed well and dried completely with lintfree ‘tissues
• Use non-perfumed, hypo-allergenic hand creams to avoid crackingof skin or dermatitis.

Gloves
Gloves should be used whenever there is contact with tears orcontact lenses:

• Hands must still be washedbeforegloves are worn andafterthey have been removed
• Use non powdered gloves
• Vinyl gloves may be used. Ensure these fit well.

Instruments
Clinical facilities must also be kept clean and free from infection.

• Work benches must be cleaned using a neutral soap solution.
• Instruments that do not come into direct contact with a patient’seye (e.g. chin rests) should be cleaned between patients,using a neutral soap solution.
• Instruments that do come into contact with eyes (e.g. tonometer)should be disinfected. Tonometer prisms disinfected by a 5-minutesoak in 3% hydrogen peroxide (or 70% isopropyl alcohol or a1:10 dilution of sodium hypochlorite) are adequately disinfected againstmost ocular pathogens, with the exception of Acanthamoeba.

Lenses

• Autoclave any lens that is to be re-used OR
• Disinfect with a 2-hour soak in 3% hydrogen peroxide.
• After disinfection, rigid lenses should be stored dry, and softlenses should be stored in a sterile, preserved solution.
• Repeat disinfection should be routinely performed at 1-monthintervals to prevent regrowth of organisms.

Infection Control
Particular care should be taken with ALL adverse reaction/redeye patients:

• All staff (Optometrists, Clinical Assistants and anyother staff coming in direct contact) should use gloves for entireconsultation, disinfecting or discarding procedures.
• A designated room should be used for any adverse event patients.
• Any patient presenting with a red eye should be seated in thisroom rather than being asked to wait in waiting area (if practical).
• Disinfect / discard any items handled by adverse event patients.

Patient Management

Aftercare Visits
Regular checks of all contact lens patients will ensure timelyidentification of any problems, and will also remind patientsof the care schedules and procedures, and of the importanceof daily checks of their eyes.

New lens patients should be seen:

• after one week
• after first month
• after three months
• then every three to six months.

Management of Adverse Ocular Responses

For the practitioner, accurate diagnosis of adverse events iskey to their appropriate management, identification of risks,and prevention.

For the patient, it is important that they:

• are aware of how to minimise the risk of adverse events
• check their eyes daily and can recognise warning signs
• seek help promptly if any problems arise.

Patient education should continue at every practice visit toreiterate these points.

Minimising The Risk Of Adverse Events

Hygieneand general lens care should also be emphasized at everyvisit.

• If a contact lens is out of the eye for any time, itshould be disinfected before replacement in the eye, or a newlens should be used.
• Patients should be encouraged to use lubricants (a sterile unitdose), particularly in the morning upon waking, and in the evening.

Most recently,swimmingin contact lenses has been identifiedas a risk factor in MK. Practitioners should recommend to theirpatients that they wear goggles whenever they swim. An informationand reminder sheet is availableherefor downloading and printing,for distribution to your contact lens patients.

One of the most important guidelines for patients is:
Don’tsleepwith the lenses on when:

• The eye is red
• The eye is sore or irritated
• You are generally unwell/sick
  - sore throat
  - influenza
• Or if you have others sick in your household

Checking Their Eyes Daily

Each day, patients should check to see if their eyes:

• Look good
• Feel good, and
• See well.

Patients should be told that if their vision is blurry, or ifthere is any irritation, they should:

1. Remove the lens
2. Rub and rinse
3. Return the lens to eye
4. If there is no improvement
5. Try a spare lens
6. If there is no improvement
7. CONTACT THE CLINIC

Patients should be encouraged to always have an up-to-date sparepair of spectacles to use.

Contacting The Practitioner Promptly

Patient should be encouraged to contact their practitioner IMMEDIATELYthere is a problem.

This will be important to ensure accurate diagnosis and treatmentof any problems.

Wherever possible practitioners should provide 24 hour emergencyphone numbers.