Contact Lens & Anterior Eye 35 (2012) 7176

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Contact Lens & Anterior Eye

journal homepage: www.elsevier.com/locate/clae

The signicance of hand wash compliance on the transfer of dermal lipids in

contact lens wear
Darren Campbell a, , Aisling Mann a , Olivia Hunt b , Lvia J.R. Santos c
a
Biomaterials Research Unit, Aston University, Aston, Birmingham B4 7ET, United Kingdom
b
Ophthalmic Research Group, Aston University, Aston, Birmingham B4 7ET, United Kingdom
c
CEMUC, Departamento de Engenharia Metalrgica e dos Materiais, Faculdade de Engenharia, Universidade do Porto, Portugal

a r t i c l e i n f o a b s t r a c t

Keywords: Aim: The aim of this study was to assess the impact of hand washing regimes on lipid transference to
Compliance contact lenses. The presence of lipids on contact lenses can affect visual acuity and enhance spoilation.
Contamination Additionally, they may even mediate and foster microbial transfer and serve as a marker of potential
Lens handling
dermal contamination.
Lipids
Methods and materials: A social hand wash and the Royal College of Nursing (RCN) hand wash were inves-
Dermal
tigated. A no-wash regime was used as control. The transfer of lipids from the hand was assessed by Thin
Layer Chromatography (TLC). Lipid transference to the contact lenses was studied through uorescence
spectroscopy (FS).
Results: Iodine staining, for presence of lipids, on TLC plates indicated the no-wash regime score averaged
at 3.4 0.8, the social wash averaged at 2.2 0.9 and the RCN averaged at 1.2 0.3 on a scale of 14. The
FS of lipids on contact lenses for no washing presented an average of 28.47 10.54 uorescence units
(FU), the social wash presented an average of 13.52 11.12 FU and the RCN wash presented a much lower
average 6.47 4.26 FU.
Conclusions: This work demonstrates how the method used for washing the hands can affect the concen-
tration of lipids, and the transfer of these lipids onto contact lenses. A regime of hand washing for contact
lens users should be standardised to help reduce potentially transferable species present on the hands.
2011 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Compliance can be dened as the process of complying with a
regimen of treatment [1]. In the context of contact lens wear, Mor-
gan [2] denes compliance as a wearer correctly adhering to the
instructions provided by the contact lens practitioner with respect
to optimum lens wear and care. A compliant patient is one that acts
accordingly with respect to lens wearing schedule, case care and
overall hygiene when handling lenses. Hand washing has a pivotal
role in contact lens compliance. It helps to prevent lens contamina-
tion by microbes and lipids present on the skin. Lack of compliance
among contact lens users is a perennial problem [35]; for exam-
ple a 1986 study [6] showed that up to 74% were non compliant
with (at least one aspect of) lens care. Hand washing has been
identied as a problem within compliance and poor hand wash-
ing can result in additional risks to the lens wearer [7]. The lack
of, or inefcient, hand washing could increase the occurrence of
sight-threading infections and inammation episodes.
Corresponding author. Tel.: +44 0121 204 3404; fax: +44 0121 204 3679.
E-mail address: d.campbell1@aston.ac.uk (D. Campbell).
The nature of the skins surface must be considered when dis-
cussing the handling of contact lenses. The skin is covered by the
acid mantle; which is an oily layer composed of sebaceous lipids
(sebum) and sweat. It normally has a pH of 45.5 which helps to
protect the skin from potentially harmful invading bacteria and
fungi, while providing a suitable environment for the commen-
sal species. Sebum on the surface of the skin is a mixture of lipids
secreted from the sebaceous glands. The composition of lipids at
the time of secretion and at the surface of the skin can be dif-
ferent. Sebum is made up of 25% wax esters, 2.5% sterol esters,
43% triacylglycerides and 16% free fatty acids. There are only trace
percentages of cholesterol and phospholipids present [8]. Meibo-
mian gland secretion composition is described at approximately
42.8% wax esters, 27.8% sterol esters, 12.9% triacylglycerides, 9.2%
free fatty acids, 6.1% phospholipids and 1.2% cholesterol [810],
although there is still controversy over its exact composition. In
addition to sebum there are lipases, these are enzymes which break
down lipids and proteins. The lipases which are present in the der-
mal environment are not present in the tear lm.
There are also commensal microorganisms and potential
pathogens present on the surface of the skin such as; bacteria,
viruses, protozoa, fungi, parasites and prion proteins. These are

1367-0484/$ see front matter 2011 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.clae.2011.11.004
72 D. Campbell et al. / Contact Lens & Anterior Eye 35 (2012) 7176
collectively known as the microora. These microorganisms gen-
erally live in harmless association with their accommodating host.
The nature and composition of this resident microora is depen-
dent on a variety of circumstances; inuenced by external factors
(e.g. light, temperature, humidity and use of detergent or cos-
metics) and/or host factors (e.g. gender, age, hygiene, pH, salinity,
immune status, diet and personal habits). The type and concentra-
tion of microora is also dependent on anatomical location and may
be either transient or constant. The number of bacteria resident on
the skin approximates 1012 [11] and some of the most commonly
found microorganisms on the skin are the aerobic and/or facultative
anaerobic gram positive cocci; Staphylococcus sp. and Micrococcus
sp., the gram positive rods; Corynebacterium sp. (facultative anaer-
obe), propionibacteria (facultative anaerobe or anaerobe) and the
aerobic gram negative cocci; Acinetobacter sp. [12,13]. Commensal
bacteria under normal conditions reside on the skin under almost
mutually benecial conditions; however under specic conditions
these so called friendly bacteria can overcome the host protective
barrier and initiate pathogenic effects.
The potential transfer of bacteria from the hands onto the lens
and into the ocular environment should not be overlooked. Micro-
bial contamination of contact lenses is very serious and bacteria
have long been implicated with adverse corneal complications.
Contact lens related microbial infections include the serious
sight threatening microbial keratitis. This can be caused by a num-
ber of bacterial species, including the gram positives Streptococcus
pneumoniae and Staphylococcus aureus, and the gram negatives
Pseudomonas sp., Acinetobacter sp. and Escherichia coli [14]. While
not readily identied on skin Acanthamoeba species (protozoa) are
present in the nose and throat of healthy people. They live freely in
a diverse range of environments including soil [15], seawater [16]
and tapwater [17]. Contact with humans is accidental and associ-
ated diseases appear to be rare and opportunistic. However ocular
related acanthamoeba disorders are prevalent. Acanthamoeba ker-
atitis which has been recognised in association with contact lens
wear [18,19] remains one of the most difcult corneal diseases to
manage successfully.
Ultimately the necessity for lens handling during insertion and
cleaning regimes can result in the lens acting as a vector for skin-
originating lipids and microorganism into the ocular environment.
Thus even the insertion of a new contact lens can provide a means
of microbial transfer and ocular contamination. The importance of
handwashing and the implication of hands in the transfer of disease
is well established and handwashing has been identied as the sin-
gle most important means of preventing the spread of infection in
hospitals [20].
The surface of contact lenses is known to form deposits after
exposure to the tear lm, a process known as spoilation [21]. Pro-
teins and lipids are perhaps the most studied species of the tear
lm which form deposits on contact lenses [22,23]. The adhesion
of species to the surface is a function of many parameters includ-
ing the physico-chemical properties of the adhering species and the
substrate. Adhesion of species is linked to the surface free energy of
the substrate [24]. Lipids are hydrophobic species and as such when
they deposit on a material they may increase the hydrophobicity
and reduce the surface free energy [25,26]. Bacteria must be able
to adhere, proliferate and invade the host in order to cause infec-
tion. Attachment of a microorganism is fundamental to its ability
to cause infection [27]. It is known that some bacterial species have
an afnity towards hydrophobic materials and that surface energy
affects their adhesion [28,29]. Contact lenses wear and the presence
of lens deposits have been shown to reduce material hydrophilic-
ity [28] and make the lens more prone to, or enhance, bacterial
adhesion [25,26,28,3032]. Bacterial adhesion has been shown to
be material dependant [36]. Work has been done which demon-
strated that bacterial adherence can also be unaffected by ocular
deposits [33], for example Pseudomonas aeruginosa has been shown
to be able to adhere to a range of clean unused conventional contact
lenses [34,35].
While the extent of microbial contamination and colonisation
over a range of contact lens materials and modalities has been
extensively studied, there is much less research on the effects of
the introduction of indigenous skin derived microora into the ocu-
lar environment. The ocular surface is already exposed to an array
of microorganisms but the introduction of a contact lens into the
ocular environment can further broaden the extent of the micro-
bial ora. It is obviously in patients best interest to reduce any
chances of bacterial adhesion to the material. The presence of lipid
transferred onto the lens through lens handling on insertion may
be one potential means of increasing bacterial transfer into the eye.
Lipids can also alter the contact lens surface properties which may
facilitate bacterial attachment and transfer. This study looks at the
effect of two different hand washing regimes on the transfer of der-
mal lipids from the hands onto contact lenses. It also looks at the
effects that these hand washing regimes have on the removal of
lipids from the hands.
2. Methods
2.1. Subjects
Ten subjects were recruited for this study. The cohort composed
of six female and four males. The age range was 2346 years (mean
33.3). All were white collar workers. The subjects were not trained
in any of the hand washing regimes prior to the study.
2.2. Hand washing regimes
The social wash (SW) is a type of wash that a subject would
typically use when washing the hands. The subjects were asked if
they could wash their hands. This type of wash has been shown
to frequently miss areas of the hands that are later used in handling
contact lenses, i.e. the nger tips and palms of the hands [37]. The
social hand wash takes on average eleven seconds to complete.
The Royal College of Nursing (RCN) hand wash [38] is a six point
hand washing technique used in medical elds (Fig. 1). The subjects
were instructed how to perform the RCN wash. This type of wash
has been shown to be effective in cleaning the areas frequently
missed by the SW regime [39]. The RCN takes on average thirty
four seconds to complete.
2.3. Contact lens and Thin Layer Chromatography (TLC) plate
handling
Contact lenses were handled in a manner typical of that used
before insertion into the eye. One set of contact lenses were handled
without hand washing. Two separate sets of contact lenses were
handled after the subjects had used the two different hand washing
regimes. Subjects were also instructed to apply their thumb, fore-
nger and index nger onto TLC plates after handling the lenses.
This gave three sets of contact lenses and TLC plates per subject.
The experiment used ten subjects.
In summary the procedure was:
handle rst TLC plate and CL
perform social hand wash
handle second TLC plate and CL
perform RCN hand wash
handle third TLC plate and CL
 D. Campbell et al. / Contact Lens & Anterior Eye 35 (2012) 7176
Fig. 1. Royal College of Nursing (RCN) hand wash.
2.4. Lipid detection
The presence of lipids on the contact lenses and on the TLC plates
was detected using uorescence spectroscopy (FS) and iodine stain-
ing respectively.
2.4.1. Fluorescence spectroscopy (FS)
Each individually handled lens was analysed by uorescence
spectroscopy. The method utilises a modied Hitachi F4500 uo-
rescence spectrometer, excitation wavelengths of 360 and 450 nm
and respective emission wavelengths of 280 and 340 nm were used
[23,40]. The FS method produces intensities which give an indica-
tion of the relative amount of lipid present on the contact lenses.
The intensity of lipid is reported in uorescence units (FU).
2.4.2. Iodine staining of Thin Layer Chromatography (TLC) plate
Most lipids can be stained using iodine vapour and under con-
trolled conditions the intensity of staining is proportional to the
actual amount of lipid [41]. The TLC plates were placed into a sealed
73
Fig. 2. Thin layer chromatography plate showing dermal-lipid spots: no wash. Each
of the boxes in the image contains three spots where one subject had placed their
thumb, forenger and index nger separately onto the TLC plate.
glass trough which contained atmosphere of iodine for 3 min. The
iodine vapour causes spots to appear where they had been exper-
imentally handled as detailed below. Immediately upon removal
a digital image was captured of the TLC plates. Each of the sub-
jects touched the TLC plates with their thumb, forenger and index
nger as instructed.
When stained with iodine vapours these areas produced visible
spots, which were scored 14 according to the level of staining
present. Level 1 equated to no staining, i.e. no spots were present
and lipid deposition was low. Level 4 equated to heavy staining, i.e.
the level of lipid deposition was high. The scores from the thumb,
forenger and index nger were then averaged to give one score
per subject per plate.
3. Results
3.1. Hand washing and Thin Layer Chromatography (TLC) plate
iodine staining: lipid levels
Fig. 2 shows an example of iodine stained TLC plate after han-
dling prior to no washing of the hands. Fig. 3 shows an example
of iodine stained TLC plate after handling prior to using a social
wash. Each of the boxes in the image contains three spots which
came from where one subject had placed their thumb, forenger
and index nger onto the TLC plate. The TLC plate for the RCN wash
showed negligible iodine staining and thus it is not shown.
Fig. 4 shows the scores of the iodine stain spots on the TLC plates
(n = 10). The iodine stain of the spots for no washing score averaged
at 3.4 0.8. The average scores after the social wash were 2.2 0.9.
The RCN average scores 1.2 0.3. There is a statistically signi-
cant difference between no hand wash and social wash (ANOVA,
p = 0.006) and between social wash and the RCN wash regimes
(ANOVA, p = 0.004).
3.2. Hand washing and contact lens uorescence intensity (FS):
lipid levels
Fig. 5 shows the FS of lipids on contact lenses (n = 10).
The no washing pre handling presented an average FS of
28.47 10.54 FU. The social wash pre-handling presented an aver-
age FS of 13.52 11.12 FU. The RCN wash presented an average
74 D. Campbell et al. / Contact Lens & Anterior Eye 35 (2012) 7176
Fig. 3. Thin layer chromatography plate showing dermal-lipid spots: social wash.
Each of the boxes in the image contains three spots where one subject had placed
their thumb, forenger and index nger separately onto the TLC plate.
FS of 6.47 4.26 FU. There is a statistically signicantly differ-
ence between no hand wash and social wash (ANOVA, p = 0.01)
and between social wash and the RCN wash regimes (ANOVA
p = 0.0095).
The iodine stained spots on the TLC plates demonstrated that
dermal-lipid from unwashed hands could be easily detected. Hand
washing with either regime reduced the lipid concentration avail-
able for transferral to contact lenses; in addition the reduction in
this concentration for the RCN wash is signicantly different com-
pared to the social wash. This trend was also observed for the
washing regimes when contact lenses were handled, using the u-
orescence spectroscopy technique.
4. Discussion
This study demonstrates that the hand wash method used has
a signicant impact on the quantity of lipids transferred from the
hands. The use of the Royal College of Nursing (RCN) hand wash
Fig. 4. Scores of the iodine stained dermal-lipid spots on the Thin Layer Chromatography (TLC) plates after no wash, social wash and RCN (Royal College of Nursing) wash.
technique removed a greater quantity of lipids, resulting in fewer
lipids transferred to the contact lenses. The social wash removed
fewer lipids from the hands, and therefore the contact lens pre-
sented a greater amount of transferable lipids.
The potential implications of lipid transfer onto a contact lens
are numerous. Triacylglycerides and free fatty acids are present at
higher concentration in sebum than in the tear lm. If these lipids
contaminate the lens and are subsequently released their presence
in the tear lm could have a detrimental effect on tear lm stabil-
ity; compositional changes are known to affect tear lm stability
[42,43]. Dermal lipid transfer onto contact lens could also cause
nucleation points for the build up of deposits of lipids from the tear
lm, which ideally should be avoided in contact lens wear [44].
Additionally the presence of lipids on the surface of a contact lens
can change the hydrophilicity [25,26]. This may aid the adhesion of
other species to the lens surface, for example species such as the
skins commensal lipases and bacteria described in the introduc-
tion. Bacterial contamination of contact lenses can, of course, lead
to serious consequences. The presence of skin-derived lipases in
the tear lm may result in the hydrolysis of tear lm lipid species.
With contact lens wear there is an increase in the concentration of
free fatty acids present. This increase in concentration could be due
to the activity of lipases that are not normally present in the tear
lm. Crucially, the transfer of commensal bacteria of the skin to the
new surroundings of the tear lm can present the bacteria with the
potential to cause ocular infection.
It is easy to place responsibility for compliance on the patient but
the effect of the relationship between the practitioner and patient
on the compliant behaviour of a patient is often under estimated.
Patients may judge the attitude of a practitioner and the level of
individual interest projected [3]. Practitioners should display pos-
itive judgements towards specic compliance recommendations
[3]. This is particularly true in the area of hand washing because
patients will be aware of the need for good cleanliness in the hos-
pital and health care sector but may feel that this does not apply to
what is often perceived as a purely cosmetic device.
Patients should always be advised to wash their hands prior to
handling lenses for insertion and removal. They must also see their
practitioner, regularly doing the same in the consulting room. The
recommendation should be to use unperfumed, antibacterial soap,
followed by thorough rinsing and drying of the hands with paper
towels [45]. Patients should also be advised that their lenses should
not come into contact with tap water for any reason. Practitioners
 D. Campbell et al. / Contact Lens & Anterior Eye 35 (2012) 7176
Fig. 5. Fluorescence intensity (FI) of dermal-lipids on contact lenses after no wash, social wash and RCN (Royal College of Nursing) wash.
should also wash their hands both before and after each patient
episode. It should be noted that frequent hand washing in a busy
practice may be irritating and damaging to the skin and hence the
use of hand rubs (glycerine/alcohol-based) is often advocated [46],
however additional exposure of the hands to lipids may bring its
own problems.
Current guidelines on hand washing for contact lens users are
typically along the lines that patients should be advised always to
wash their hands prior to handling lenses. This is of course good
advice but the problem is precisely how a patient should wash
their hands prior to lens handling. The type of advice currently
used is similar to always wash and rinse your hands thoroughly
before handling your lenses [47] and sufcient written information
to enable the patient to be able to handle lenses appropriately and
comply with an appropriate lens care regime [45]. The patient needs
more thorough advice than is currently given or available. The RCN
washing regime provides efcient protection but is only aimed at
the practitioner and not the patient [38]. A regime of hand wash-
ing for contact lens users should be standardised to help reduce
the potentially transferable species present on the hands. The RCN
wash should be given to patients in a written form and patients
should be taken through the routine verbally. The RCN wash could
be committed to a one side yer and then dispensed with the lenses.
The RCN wash takes only approximately twenty seconds longer for
the patient to complete and should be completed prior to lens han-
dling. Using the RCN wash should reduce risk of infections and other
complications.
References
[1] The Medline Online Dictionary. http://www.merriam-webster.com/
medlineplus/Compliance.
[2] Morgan P. Contact lens compliance and reducing the risk of ker-
atitis. Optician 2007:205, http://www.opticianonline.net/assets/getAsset.
aspx?ItemID=2563.
[3] Claydon BE, Efron N, Woods C. Non-compliance in optometric practice. Ophthal
Physl Opt 1998;18:18790.
[4] Hickson-Curran S, Chalmers R, Riley C. Patients attitudes and behavior regard-
ing hygiene and replacement of soft contact lenses and storage cases. Cont Lens
Anterior Eye 2011;34:20715.
[5] Wu Y, Carnt N, Stapleton F. Contact lens user prole, attitudes and level of
compliance to lens care. Cont Lens Anterior Eye 2010;33:1838.
[6] Collins MJ, Carney LG. Patient compliance and its inuence on contact lens
wearing problems. Am J Optom Physiol Opt 1986;63:9526.
75
[7] Stapleton F, Keay L, Jalbert I, Cole N. The epidemiology of contact lens related
inltrates. Optom Vis Sci 2007;84:25772.
[8] Tiffany JM. The lipid secretion of the meibomian glands. In: Advances in lipid
research. Academic Press Inc.; 1987.
[9] Tiffany JM. Individual variation in human meibomian lipid compositions. Exp
Eye Res 1978;27:289300.
[10] Nicolaides N. Meibomian gland studies: comparison of steer and human lipids.
IOVS 1981;20:52236.
[11] Bacterial disease mechanisms. Cambridge: Cambridge University Press; 2002.
[12] Leyden JJ, McGinley KJ, Nordstrom KM, Webster GF. Skin microora. J Invest
Dermatol 1987;88:65s72s.
[13] Roth RR, James WD. Microbial ecology of the skin. Annu Rev Microbiol
1988;42:44164.
[14] Schein OD, Ormerod LD, Barraquer E, Alfonso E, Egan KM, Paton BG, et al.
Microbiology of contact lens-related keratitis. Cornea 1989;8:2815.
[15] Culbertson CG. The pathogenicity of soil amoebas. Annu Rev Microbiol
1971;25:23154.
[16] Sawyer TK, Visvesvara GS, Harke BA. Pathogenic amoebas from brackish and
ocean sediments, with a description of Acanthamoeba hatchetti, n.sp. Science
1977;196:13245.
[17] Kilvington S, Larkin DFP, White DG, Beeching JR. Laboratory investigation of
acanthamoeba keratitis. J Clin Microbiol 1990;28:27225.
[18] Moore MB, McCulley JP, Luckenbach M, Gelender H, Newton C, McDonald MB,
et al. Acanthamoeba keratitis associated with soft contact lenses. Am J Oph-
thalmol 1985;100:396403.
[19] Stehr-Green JK, Bailey TM, Visvesvara GS. The epidemiology of acanthamoeba
keratitis in the United States. Am J Ophthalmol 1989;107:3316.
[20] Garner JS, Favero MS. CDC guideline for handwashing and hospital environ-
mental control, 1985. MMWR Morb Mortal Wkly Rep 1988;37:24.
[21] Bowers RWJ, Tighe BJ. Studies of the ocular compatibility of hydrogels.
A review of the clinical manifestations of spoliation. Biomaterials 1987;8:
838.
[22] Maissa C, Franklin V, Guillon M, Tighe BJ. Inuence of contact lens material sur-
face characteristics and replacement frequency on protein and lipid deposition.
Optom Vis Sci 1998;75:697705.
[23] Jones L, Evans K, Sariri R, Franklin V, Tighe B. Lipid and protein deposition of
N-vinyl pyrrolidone-containing group II and group IV frequent replacement
contact lenses. CLAO J 1997;23:1226.
[24] Mittal KL. Contact angle, wettability and adhesion. VSP An imprint of BRILL;
2007.
[25] Nasso M, Tighe B. Surface wettability of worn and unworn contact lenses. Poster
presented at BCLA Annual Conference, Birmingham, UK; 2004.
[26] Davies J, Nunnerley CS, Brisley AC, Edwards JC, Finlayson SD. Use of dynamic
contact angle prole analysis in studying the kinetics of protein removal from
steel, glass, polytetrauoroethylene, polypropylene, ethylenepropylene rub-
ber, and silicone surfaces. J Colloid Interface Sci 1996;182:43743.
[27] Chiller K, Selkin A, Murakawa GJ. Skin microora and bacterial infections of the
skin. J Investig Dermatol Symp Proc 2001;6:1704.
[28] Bruinsma GM, van der Mei HC, Busscher HJ. Bacterial adhesion to worn silicone
hydrogel contact lenses. Biomaterials 2001;22:321724.
[29] Bayoudh S, Othmane A, Bettaieb F, Bakhrouf A, Ben Ouada H, Ponsonnet L.
Quantication of the adhesion free energy between bacteria and hydrophobic
and hydrophilic substrata. Mater Sci Eng C 2006;26:3005.
76 D. Campbell et al. / Contact Lens & Anterior Eye 35 (2012) 7176
[30] Willcox MDP, Harmis N, Cowell BA, Williams T, Holden BA. Bacterial inter-
actions with contact lenses; effects of lens material, lens wear and microbial
physiology. Biomaterials 2001;22:323547.
[31] Cook AD, Sagers RD, Pitt W. Bacterial adhesion to protein-coated hydrogels. J
Biomater Appl 1993;8:7289.
[32] Miller MJ, Wilson LA, Ahern DG. Effects of protein, mucin, and human tears
on adherence of Pseudomonas aeruginosa to hydrophillic contact lenses. J Clin
Microbiol 1988;26:5137.
[33] Dart JK, Badenoch PR. Bacterial adherance to contact lenses. CLAO J
1986;12:2204.
[34] Miller MJ, Ahearn DG. Adherance of Pseudomonas aeruginosa to hydrophillic
contact lenses and other substrata. J Clin Microbiol 1987;25:13927.
[35] Stapleton F, Dart JK, Matheson M, Woodward G. Bacterial adherence and gly-
cocalyx formation on unworn hydrogel lenses. J BCLA 1993;16:1137.
[36] Santos L, Rodrigues D, Madalena L, Oliveira ME, Oliveira R, Vilar EY-P, et al.
Bacterial adhesion to worn silicone hydrogel contact lenses. Optom Vis Sci
2008;85:5205.
[37] Taylor L. An evaluation of handwashing techniques. Nurs Times 1978:
545.
[38] http://www.rcn.org.uk/resources/mrsa/downloads/RCN Handwashing
Technique.pdf.
[39] www.leics.gov.uk/index/social services/general information/partners/
handwashing.htm.
[40] Franklin V, Jones L, Ma J, Sariri R, Singh-Gill U, Evans K, et al. Studies on
the interaction of ocular deposition on spoilation resistant materials. J BCLA
1994;17:153.
[41] Palumbo G, Zullo F. The use of iodine staining for the quantitative analysis of
lipids separated by thin layer chromatography. Lipids 1987;22:2015.
[42] Bron AJ, Tiffany JM, Gouveia SM, Yokoi N, Voon LW. Functional aspects of the
tear lm lipid layer. Exp Eye Res 2004;78:34760.
[43] McCulley JP, Shine W. A compositional based model for the tear lm lipid layer.
Trans Am Ophthalmol Soc 1997;95:7988, discussion 93.
[44] Larke JR. The eye in contact lens wear. 2nd ed. Buterworth Heinmann;
1997.
[45] Advice and guidelines on professional conduct for dispensing opticians.
www.abdo.org.uk.
[46] Sulley A. Compliance in contact lens wear Part 1. Optician 2005;229:2430.
[47] http://www.cclru.org/eye information/contact lenses.asp.