Contact Lens & Anterior Eye 31 (2008) 1316 www.elsevier.

com/locate/clae

Tonometer prism sterilisation: A local and UK national survey

Aman Chandra a, Allon Barsam b, Christopher J. Hammond a,*
a

West Kent Eye Centre, Princess Royal University Hospital, Farnborough, Kent BR6 8ND, UK b Department of Ophthalmology, Queen Marys Hospital, Sidcup, Kent DA14 6LT, UK

Abstract Purpose: First to audit local adherence to a protocol of use of an alcohol wipe for each tonometry, and secondly to assess current practice nationally in the UK. Method: The audit was carried out at two units: The West Kent Eye Centre at the Princess Royal University Hospital (Orpington, UK) and Queen Marys Hospital (Sidcup, UK). The standard set for this audit was 100% sterilisation. During a 1-week period in November 2005, the number of alcohol wipes was counted in each consultation room after outpatient clinics, with the doctors being assessed blind to the survey. The number of Goldman applanation tonometry intra-ocular pressures recorded by each clinician was counted by inspection of the medical records of patients seen. Secondly, departments listed in the UK Directory of Training Posts were contacted by telephone and the senior nurse was interviewed. They were asked directly about their departments tonometer prism sterilisation and management. Results: The local audit showed only 54% of tonometry measurements were associated with sterilisation using an alcohol-impregnated wipe. The national survey included 140 of the 152 UK training departments. Thirty-three (23.6%) departments used disposable tonometer prisms routinely. The remaining 107 (76.4%) used non-disposable prisms. Eighty-ve (60.7%) departments provided sodium hypochlorite for prism sterilisation, with 69 (81.2%) of these departments providing more than one prism/clinician to allow full exposure to the disinfectant. Twentytwo (15.7%) departments used alcohol wipes. Only 8 (7.5%) of the 107 departments using non-disposable prisms tracked these prisms, despite Royal College of Ophthalmologists guidelines that they should be. These same 8 (7.5%) departments replaced the non-disposable prisms as per manufacturer guidelines. 19.3% of charge nurses were aware of a policy for tonometry in patients with, or at risk of, prion disease. Conclusions: This study highlights that sterilisation of tonometer prisms was inconsistent in a local audit. Nationally, practices were varied. The majority of ophthalmology departments continued to use non-disposable tonometer prisms, but few seemed aware of the Royal College of Ophthalmologists recommendation that disposable prisms are used in patients at risk of prion disease, and few track tonometer heads or replace them according to manufacturers guidelines. Use of disposable tonometer prisms would seem to reduce concerns about sterilisation, as well as prevent spread of common pathogens. # 2007 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
Keywords: Tonometer; Prisms; Sterilisation; Audit; Survey

1. Introduction Tonometer prisms are an integral part of ophthalmic examination. They are known to be a potential vector in iatrogenic transmission of pathogens [1]. Prion disease such as CreutzfeldJacobs Disease (CJD) is of particular concern, and applanation tonometer prisms have been suggested as a possible source of infection [2]. As the United Kingdom may be an area of relatively high risk, the Royal College
* Corresponding author. Tel.: +44 1689 865682; fax: +44 1689 863329. E-mail address: chammond@btopenworld.com (C.J. Hammond).

of Ophthalmologists (RCOphth) guidance advises use of disposable tonometers for patients either diagnosed, at risk of, or suspected of prion disease, but fall short of recommending disposable tonometer prisms for all patients. It is suggested that non-disposable prisms should be wiped and disinfected between use, and should not be moved between individual clinical stations so any outbreaks may be tracked easily [3]. Manufacturers recommend that their tonometer prisms be replaced after 100 uses, though the extent of adherence to this guidance is not known. The aim of this study was twofold. The rst aim was to audit the rate of sterilisation of non-disposable tonometer

1367-0484/$ see front matter # 2007 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clae.2007.07.004

14

A. Chandra et al. / Contact Lens & Anterior Eye 31 (2008) 1316

prisms in two District General Hospital (DGH) ophthalmology departments. The second aim was a national survey of UK ophthalmology departments to assess current sterilisation practice, to identify policies regarding tonometer prisms, and in particular whether there were local policies in place for patients with possible CJD.

number of patients who had their IOPs measured without the use of alcohol wipes was at least 93 (46%) (Fig. 1). This differed between different grades of doctors. The non-consultant grade doctors measured 165 patients GAT intra-ocular pressures and used 79 alcohol wipes (47.9%). Consultants measured 38 patients GAT intra-ocular pressures and used 27 alcohol wipes (71.1%). 3.2. National survey For the survey, interviews were conducted with the senior nurse in 140 (92%) of the 152 ophthalmology departments listed in the Directory of Training Posts. With regard to their methods of sterilisation, 107 (76.4%) departments used non-disposable tonometer prisms routinely. Sodium hypochlorite was used in 85 (60.7%) departments and 69 (81.2%) of these departments provided more than one prism/clinician to allow full exposure to the disinfectant. Alcohol wipes were used in 22 (15.7%) departments. Non-disposable prisms were tracked by eight departments (7.5%). These same 8 (7.5%) departments replaced their prisms as per guidelines. Disposable tonometer prisms were used in the remaining 33 (23.6%) departments (Fig. 2). Twenty-seven (19.3%) of the surveyed were aware of a protocol for prion risk patients.

2. Method The two DGH departments included in the audit recommend wiping the tonometer head after each Goldmann applanation tonometry (GAT) with a single 70% isopropyl alcohol-impregnated swab, followed by wiping the prism with a dry tissue. The West Kent Eye Centre at the Princess Royal University Hospital (Orpington, UK) has around 25,000 ophthalmology outpatient attendances per annum, and Queen Marys Hospital (Sidcup, UK) sees similar numbers of patients. The standard set for this audit was 100% tonometer prism sterilisation. During a 1-week period in November 2005, the number of alcohol wipes was counted in each consultation room after outpatient clinics, with the doctors being assessed blind to the survey (to avoid change of practice during the audit). The number of GAT intra-ocular pressures recorded by each clinician was counted by inspection of the medical records of patients seen during the session. Results of individual doctors were anonymised, but the grade of clinician was recorded. It was assumed that alcohol wipes were only used for the purpose of cleaning tonometer prisms. Doctors involved in the clinics were asked about this after the week of data collection, and none could recall any other occasion they had used these. For the second part of the survey, departments listed in the UK Directory of Training Posts were contacted by telephone and an interview with the senior nurse manager in charge of the clinic was arranged at a time convenient to him/her. Four direct questions were asked:  What is your departments method of tonometer prism sterilisation?  If you use non-disposable tonometer prisms, did you track them?  Do you replace your tonometer prisms as per manufacturer guidelines?  Are you aware of a local protocol for tonometry for patients with, or at risk of, CJD?

4. Discussion The local audit showed a very disappointing compliance with local guidance, as the number of alcohol swabs identied for only 54% of patient GAT measurements, assuming the number of alcohol wipes correlates with each disinfection. Although use of alcohol wipes for tonometer prism disinfection was not directly observed, the doctors audited did not recall any other reason for use, and we believe there were no missed swabs in the count, supporting the assumption. The results compare poorly to the Aizman et al. study [4], which showed 100% sterilisation with alcohol pads. While time constraints in busy clinics and ignorance of epidemiological principles may have played a role, these results have been reported to the clinicians, and a subsequent reaudit 6 months later (again, with clinicians

3. Results 3.1. Local audit The total number of patients who had had their intraocular pressures (IOP) measured was 203. The total number of alcohol wipes used was 110 (54% of IOPs). Therefore, the
Fig. 1. Local audit results showing the proportion of Goldmann applanation tonometry measurements when a 70% isopropyl alcohol-impregnated swab was used.

A. Chandra et al. / Contact Lens & Anterior Eye 31 (2008) 1316

15

Fig. 2. Methods of tonometer sterilisation used in UK national survey of ophthalmology departments.

blinded to the audit while it was under way) showed improved adherence to guidelines. In the UK national survey, almost a quarter of departments (23.6%) used disposable tonometer heads routinely. The remaining three quarters provided reusable GAT prisms, 60.7% of the departments sampled used sodium hypochlorite, and 15.7% of departments used disposable alcohol swabs between patient contacts. Tonometer prisms have been shown to be vectors for transmission of epidemic keratoconjunctivitis (EKC) [2]. Sterilisation of instrumentation abruptly ends EKC outbreaks [5]. Soaking GAT prisms in 500 parts per million of sodium hypochlorite (NaOCl) for 10 min has been shown to destroy adenovirus 8 [6], herpes simplex, enterovirus 70 and most bacteria [7]. Wiping tips with swabs impregnated with 70% isopropyl alcohol has also been shown to be effective in removing adenovirus 8 [6] and most other common ocular viral and bacterial pathogens [8]. Although Hepatitis C nucleic acid has been detected on tonometer tips after sterilisation with wiping with a 70% isopropyl ethanol swab, it is not thought to confer infectivity [9]. There is therefore ample evidence that these two methods of sterilisation are adequate alternatives in routine practice to prevent transmission of common pathogens. The majority (81.4%) of departments using hypochlorite conrmed that more than one tonometer prism was provided per clinician, to allow adequate exposure to the cleaning solution. Haag-Streit, the manufacturers of the tonometer prisms most widely used in the UK, recommends a maximum of 100 uses per prism. However only 7.5% of departments regularly monitored their tonometer head use, and therefore followed manufacturer instructions. Although this is most probably due to the nancial implications of regular tonometer replacement, this low gure may also reect ignorance of this guidance. Regarding prion disease, only 19.3% of charge nurses in this survey were aware of a departmental protocol in accordance with RCOphth recommendations that disposable tonometers are used for any patients at risk of CJD. While prion disease is rare, and there are no reported cases of prion disease transmission via GAT, the resistance of prions to conventional sterilisation methods is the reason for this cautious advice. Wadsworth et al. [10] found no detectable

concentrations of prion protein in the anterior segments of eyes from patients with sporadic and variant CJD-appreciable concentrations were found only in their retinae and optic nerves. The risk of transmission via tonometry therefore seems theoretical, but this survey suggests the majority of ophthalmology departments have poor knowledge of the guidance regarding those subjects at risk. Although charge nurses were surveyed in this study, rather than the medical staff, it seems likely that if the nurse in charge was unaware of a protocol, then the doctors would also have been unaware. In studies of residual epithelial cells on tonometer heads (which are increased in patients on topical medication), the biggest reduction is found by wiping the tonometer head with a tissue which should be performed for all nondisposable prism GAT, even when using sodium hypochlorite solution [11]. However, importantly, no method completely removed debris; and therefore none completely eliminated the risk from transmission of pathogens, including prion disease. Desai et al. [12]. showed close agreement between results using reusable tonometer and disposable prisms. An alternative method of using a disposable latex cover over the tonometer head has also been shown to give accurate results [13]. In busy clinics, this may however impinge unacceptably on time constraints. Disposable prisms would therefore seem the preferable alternative. As has been shown by this survey, there is incomplete sterilisation of tonometer prisms. Even if carried out, there is debate as to whether complete elimination of corneal epithelial debris occurs with any method. In addition, ophthalmology departments across the UK do not seem to adhere to manufacturer guidelines for tonometer heads. The use of disposable prisms currently seems the most effective method of reducing cross contamination. Although disposable prisms are currently recommended for use in patients at risk of prion disease, their real benet may lie in prevention of transmission of other, more common, pathogens. The majority of UK ophthalmology training departments do not seem to have a well-publicized policy for patients at risk of prion disease. A simpler recommendation for the use of disposable prisms in all clinical cases may be easier to follow, and have further reaching benets. Our survey has shown that 23.6% of UK training ophthalmic departments have incorporated such devices in their daily clinics. Perhaps the rest should follow suit.

References
[1] Warren D, Nelson K, Farrar J. A large outbreak of epidemic keratoconjunctivitis: problems in controlling nosocomial spread. J Infect Dis 1989;160:93843. [2] Ford E, Nelson KE, Warren D. Epidemiology of epidemic keratoconjunctivitis. Epidemiol Rev 1987;9:24461. [3] Royal College of Ophthalmologists, website: http://www.rcophth.ac. uk/docs/profstands/ophthalmic-services/DecontaminationJan006.pdf.

16

A. Chandra et al. / Contact Lens & Anterior Eye 31 (2008) 1316 [9] Segal W, Piranzar J, Arens M, Pepose J. Disinfection of Goldmann tonometers after contamination with hepatitis C virus. Am J Ophthalmol 2001;131(2):1847. [10] Wadsworth JD, Joiner S, Hill AF, Campbell TA, Desbruslais M, Luthery PJ, et al. Tissue distribution of protease resistant prion protein in variant CreutzfeldtJakob disease using a highly sensitive immunoblotting assay. Lancet 2001;358(9277):17180. [11] Lim R, Dhillon B, Kurian KM, Aspinall PA, Fernie K, Ironside JW. Retention of corneal epithelial cells following Goldmann tonometry: implications for CJD risk. Br J Ophthalmol 2003;87(5):5836. [12] Desai SP, Sivakumar S, Fryers PT. Evaluation of a disposable prism for applanation tonometry. Eye 2001;15(3):27982. [13] Hodkin MJ, Pavilack MA, Musch DC. Pneumotonometry using sterile single-use tonometer covers. Ophthalmology 1992;99(5):68895.

[4] Aizman A, Stein J, Stenson S. A survey of patterns of physician hygiene in ophthalmology clinic patient encounters. Eye Contact Lens 2003;29(4):2212. [5] Dawson C, Darrell R. Infections due to adenovirus type 8 in the United States: an outbreak of epidemic keratoconjunctivitis originating in a physicians ofce. N Engl J Med 1968;268:10314. [6] Threlkeld A, Froggatt J, Schein O, Forman M. Efcacy of a disinfectant wipe method for the removal of adenovirus 8 from tonometer tips. Ophthalmology 1993;100(12):18415. [7] Nagington J, Sutehall GM, Whipp P. Tonometer disinfection and viruses. Br J Ophthal 1983;67(10):6746. [8] Smith C, Pepose J. Disinfection of tonometers and contact lenses in the ofce setting: are current techniques adequate? Am J Ophthalmol 1999;127(1):7784.