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   Table of Contents      
REVIEW ARTICLE
Year : 2021  |  Volume : 69  |  Issue : 3  |  Page : 510-516

Chemical disinfectants in ophthalmic practice


Consultant, Shreeji Eye Clinic and Palak's Glaucoma Care Centre, Mumbai, Maharashtra, India

Date of Submission19-May-2020
Date of Acceptance29-Jul-2020
Date of Web Publication17-Feb-2021

Correspondence Address:
Dr. Rajul S Parikh
Shreeji Eye Clinic and Palak's Glacuoma Care Centre, Samrat Bldg, Andheri (E), Mumbai - 400 069, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1549_20

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  Abstract 


The instrumentation used in ophthalmic clinics can be a source of epidemics in health care set up. Contact tonometry with Schiotz or Applanation tonometer is associated with nosocomial epidemic keratoconjunctivitis outbreaks. Recently identified SARS-CoV-2 (COVID -19) spreads mainly via the respiratory route and fomites and can transmit through other body fluids, including tear film. Various ophthalmic instruments can become a common source of spreading cross infections. Chemical disinfection is one of the most common methods employed to decontaminate instruments and environmental surfaces and prevent transmission of infectious pathogens to patients through medical and surgical instruments. Various chemical disinfectants are available with a varied spectrum to work on a different group of organisms. In this article, we briefly cover commonly used chemical disinfectants in ophthalmic practice like Alcohol (Ethyl Alcohol, Isopropyl Alcohol), Chlorine-based solution (mainly Sodium Hypochlorite), Glutaraldehyde, Hydrogen Peroxide, Formaldehyde, Iodophors, and Quaternary Ammonium Compounds

Keywords: Chemical disinfectants, glutaraldehyde, isopropyl alcohol, ophthalmic practice, sodium hypochlorite


How to cite this article:
Parikh SR, Parikh RS. Chemical disinfectants in ophthalmic practice. Indian J Ophthalmol 2021;69:510-6

How to cite this URL:
Parikh SR, Parikh RS. Chemical disinfectants in ophthalmic practice. Indian J Ophthalmol [serial online] 2021 [cited 2021 Feb 28];69:510-6. Available from: https://www.ijo.in/text.asp?2021/69/3/510/309369



The instrumentation used + in ophthalmic clinics can be a source of epidemics in health care set up. Contact tonometry with Schiotz or applanation tonometer is associated with Nosocomial Epidemic Keratoconjunctivitis outbreaks. Recently identified SARS-CoV-2 (COVID -19) spreads mainly via the respiratory route and fomites and can transmit through other body fluids, including tear film. Various ophthalmic instruments can become a common source of spreading cross infections. Chemical disinfection is one of the most common methods used to decontaminate instruments and environmental surfaces and prevent transmission of infectious pathogens to patients through medical and surgical instruments. Various chemical disinfectants are available with a varied spectrum to work on a different group of organisms. In this article, we briefly cover commonly used chemical disinfectants in ophthalmic practice like Alcohol (Ethyl Alcohol, Isopropyl Alcohol), Chlorine-based solutions (mainly Sodium Hypochlorite), Glutaraldehyde, Hydrogen Peroxide, Formaldehyde, Iodophors, and Quaternary Ammonium Compounds.

The instrumentation used in the outpatient department (OPD) and operation theatres can be a source of an epidemic in health care set up. Contact tonometry with Schiotz or applanation tonometer is a known risk factor for epidemic keratoconjunctivitis (EKC) and also linked to nosocomial EKC outbreaks.[1],[2] other specialties have also documented similar incidences of nosocomial infection via instruments.[3],[4] Failure to properly disinfect or sterilize equipment carries the risk for person-to-person transmission (e.g., hepatitis B virus) and transmission of environmental pathogens (e.g., Pseudomonas aeruginosa).

We must understand the difference between sterilant and disinfectant, the terminologies used routinely and flexibly in practice. 'Sterilization' refers to a physical or chemical process that destroys or removes all microbial life, including spores.[5] Unlike sterilization, disinfection is not sporicidal. A few disinfectants can kill spores with prolonged exposure times (3–12 h); these are called 'chemical sterilants.'[5] At similar concentrations but with shorter exposure periods (e.g., 20 min for 2% glutaraldehyde), these same disinfectants can kill all microorganisms except large numbers of bacterial spores; they are called high-level disinfectants.[5] Low-level disinfectants can kill most vegetative bacteria, fungi, and some viruses in a reasonable time (=10 min). Prior cleaning of the object; the presence of organic and inorganic load; type and level of microbial contamination; concentration of and exposure time to the disinfectant; physical nature of the object (e.g., crevices, hinges, and lumens); temperature and pH of the disinfection process affects the efficacy of both disinfection and sterilization.[5]

SARS-CoV-2, the virus linked to the current pandemic, is an enveloped virus with an extraordinarily large single-stranded RNA genome ranging from 26 to 32 kilobases in length. It has a fragile outer lipid envelope that makes it more susceptible to disinfectants and heat than non-enveloped viruses such as Rotavirus, Norovirus, and Poliovirus.[6] It has already affected nearly 200 countries and territories.[7] This virus spreads mainly via respiratory route and fomites; reports also suggest conjunctivitis as one spectrum of its presentation and a high probability of virus being present in the body fluids including tear film.[8],[9]

Recently, AIOS-IJO Consensus statement and AIOS guidelines suggested incongruent concentrations of sodium hypochlorite (1% & 0.5% respectively) for sterilization of various ophthalmic instruments in OPD.[10],[11] Variability in guidelines may create ambiguity and apprehension among ophthalmologists. In the unacquainted pandemic, it is a physician's onus to prevent the spread of this virus through instruments from patient to patient. This article attempts to re-visit commonly used disinfectants in ophthalmic practice, which may formulate an evidence-based approach towards the use of chemical disinfectants. [Table 1] lists frequently used chemical disinfectants in ophthalmic practice.
Table 1: Summarizes commonly used Chemical disinfectants in ophthalmic practice with their known mechanism of action, microbicidal activity, common side effects, and special instructions

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  Alcohol Top


Ethyl Alcohol and Isopropyl Alcohol are commonly used solutions in the healthcare industry. Their cidal activity declines sharply below the dilution of 50% concentration, and the optimum bactericidal concentration is 60%–90% solutions in water (volume/volume). Its antimicrobial action is due to the denaturation of proteins. Its bacteriostatic effect is due to the inhibition of the production of metabolites essential for rapid cell division.[12] 60%–80% concentration of Ethyl alcohol is a potent virucidal agent that can inactivate all of the lipophilic viruses (e.g., Corona viridae, Herpes, Vaccinia, and Influenza) and many hydrophilic viruses (Adenovirus, Rotavirus). Isopropyl alcohol is not active against the non-lipid enteroviruses like Adenovirus but is active against the lipid viruses (e.g., Coronavirus group).[13],[14],[15] Alcohols based disinfectants can be used effectively for sterilization of various health care instrumentation.[17],[18],[19] Isopropyl Alcohol Swabs are used to disinfect Goldmann Applanation tips/Goniolenses/other non-contact lenses. However, the alcohol-based solution can damage the shellac mountings of lensed instruments, tend to swell and harden rubber and certain plastic tubing after prolonged and repeated use, bleach rubber and plastic tiles,[20] and damage tonometer tips (by the deterioration of the glue) after the equivalent of 1 working year of routine use.[21] Tonometer biprisms soaked in alcohol for four days developed rough front surfaces that potentially could cause corneal damage.[22] Corneal opacification is reported if IOP is measured immediately after cleaning tonometer tips with alcohol.[23] Alcohols are flammable and consequently must be stored in a cool, well-ventilated area. Food and Drug Administration of the United States of America (USFDA) does not approve Alcohol-based solutions as a chemical sterilant or high-level disinfectant.

Commonly used commercially available Alcohol products containing Ethyl Alcohol are Sterlium and Hexiprep-T, and those containing Isopropyl alcohol are BD Swab and Sterlomax.


  Chlorine and Chlorine Compounds Top


Hypochlorites, the most widely used of the chlorine disinfectants, are available as liquid (e.g., sodium hypochlorite) or solid (e.g., calcium hypochlorite). The most prevalent chlorine products are aqueous solutions of 5.25%–6.15% sodium hypochlorite, usually called household bleach. They have a broad spectrum of antimicrobial activity, do not leave toxic residues, are unaffected by water hardness, are inexpensive, and fast-acting,[24] Sodium hypochlorite at the concentration used in household bleach (5.25%–6.15%) can produce ocular irritation or oropharyngeal, esophageal, and gastric burns and chemical corneal injury.[25],[26],[27],[28],[29] It is corrosive to metals in high concentrations. The microbicidal activity of chlorine is attributed mostly to undissociated hypochlorous acid (HOCl). Hypochlorite solutions in tap water at a pH > 8 stored at room temperature (23°C) in closed, opaque plastic containers can lose up to 40%–50% of their free available chlorine level over one month.[30]

The microbicidal mechanism of chlorine involves a combination of factors like ring chlorination of amino acids, loss of intracellular contents, decreased uptake of nutrients, inhibition of protein synthesis, decreased oxygen uptake, breaks in DNA, and depressed DNA synthesis leading to protein inhibition.[31],[32] Sodium Hypochlorite is bactericidal at 25 ppm (0.025%), fungicidal at 0.02% (200 ppm), sporicidal and mycobactericidal at 1000 ppm (0.1%), virucidal at 200 to 500 ppm (0.02%-0.05%).[13],[31],[33],[34] It is effective against both lipophilic (including HIV) and hydrophilic groups of viruses.[35] Sterilization of applanation tip and spot-disinfection of countertops and floors can be done by 0.1% to 0.5% freshly prepared solution of Sodium Hypochlorite.[36],[37],[38],[39] However, one must remember that 0.5% solution of Sodium Hypochlorite is corrosive and reduces the prism life to maximum 100 cycles of 1 h each.[40] 0.5% solution of Sodium Hypochlorite is recommended only for high contamination or large spills of blood and body fluids (>10 mL).[41]

Alternative compounds that release chlorine and used in the healthcare setting include:

  • Demand-release chlorine dioxide
  • Sodium dichloroisocyanurate
  • Chloramine-T
  • Superoxidized water.


The advantage of these compounds over the hypochlorites is that they retain chlorine longer and hence exert a bactericidal effect, and USFDA has approved them as a high-level disinfectant. However, we require specialized equipment to produce the super-oxidized water with perfect parameters such as pH, current, and redox potential. Super-oxidized water should have a pH of 5.5–7.0 and an oxidation-reduction potential (redox) of >900 mV.” We need to prepare it fresh as its effectivity reduces with time.[42],[43],[44]

Commonly used commercially available products in India are Dakin's Solution (Sodium Hypochlorite 0.25% & 0.5%) and Hypocin Eyelid Cleaner (Super-oxidized solution).


  Glutaraldehyde Top


Glutaraldehyde is a saturated dialdehyde. The antimicrobial activity of the solution depends on the duration of dilution, its concentration, and organic stress. Its alkaline solution is sporicidal. The biocidal activity of glutaraldehyde results from alkylation of sulfhydryl, hydroxyl, carboxyl, and amino groups of microorganisms, which alters RNA, DNA, and protein synthesis.[45],[46] ≥2% aqueous solutions of Glutaraldehyde, buffered to pH 7.5–8.5 with sodium bicarbonate is bactericidal in less than 2 min; mycobactericidal, fungicidal, virucidal in <10 min; and sporicidal in 3 h.[45],[46],[47],[48],[49],[50] It is effective against both lipophilic and hydrophilic groups of viruses. A solution of 2.4% and 3.4% glutaraldehyde and combined solution of 1.12% glutaraldehyde with a 1.93% phenol/phenate is approved as a high-level disinfectant. Glutaraldehyde is non-corrosive and commonly used as a high-level disinfectant for medical equipment such as endoscopes, anesthesia equipment, and various medical instruments.[50],[51],[52],[53],[54],[55] Bacillocid Special Solution, which contains Glutaraldehyde, can be used to clean Goldmann Applanation tips and Goniolenses. Once diluted, this solution has a shelf-life of minimally 14 days.[55] As it is toxic and expensive, it should be avoided for cleaning of non-critical surfaces. If equipment's processing is done in poorly ventilated rooms, healthcare personnel can be exposed to high levels of glutaraldehyde vapor.[49] Acute or chronic exposure can result in skin irritation or dermatitis, mucous membrane irritation (eye, nose, mouth), epistaxis, allergic contact dermatitis, asthma, and rhinitis.[56],[57],[58],[59]

Commonly used commercially available products are Bacillocid Extra and Glutaraldehyde solution 2.45% by Glutradex.


  Formaldehyde Top


Formaldehyde is used principally as a water-based solution called formalin, which is 37% formaldehyde by weight. The aqueous solution is bactericidal, mycobactericidal, fungicidal, virucidal, and sporicidal.[13],[60],[61],[62] It is a potential carcinogen, and standard should be set, limiting employee's exposure time to formaldehyde as per standard guidelines.[63] It inactivates microorganisms by alkylating the amino and sulfydryl groups of proteins and ring nitrogen atoms of purine bases.[64] It destroys a wide range of microorganisms at varying concentrations. It is virucidal at 2% except poliovirus requires 8% concentration,[13] mycobactericidal at 4%,[60] and bactericidal at 2.5%.[62] The sporicidal action of formaldehyde is slow and takes at least 2 h compared to only 15 min with Glutaraldehyde. Although formaldehyde-alcohol is a high-level disinfectant, its healthcare uses are limited by irritating fumes and pungent odor even at very low levels (<1 ppm). It mainly used as Fumigator in Operation Theater.

Commonly used commercially available products in India are Microtroniks Formaldehyde Solution (37-41% Formalin Solutions) and Daffodil's Formalin Solution (37%–41% W/V).


  Hydrogen Peroxide Top


Stabilized Hydrogen Peroxide is extensively used in health care set up and has got approval as a high-level disinfectant. Concentrations of hydrogen peroxide from 6% to 25% show promise as chemical sterilants. It works by producing destructive hydroxyl free radicals that can attack membrane lipids, DNA, and other essential cell components. Organisms that possess cytochrome systems can protect cells by degrading hydrogen peroxide to water and oxygen.[65],[66] It has bactericidal, virucidal, sporicidal, and fungicidal properties.[65],[66] However, it has limited action against hydrophilic viruses (e.g., Adenovirus). Concentrations ranging from 3% to 6% are used to disinfect soft contact lenses (e.g., 3% for 2–3 hrs)[58],[67],[68] tonometer biprisms,[22] and endoscopes.[65],[66],[67],[68] Improperly rinsed applanation tip prism can cause corneal damage.[69] As with other chemical sterilants, dilution of the hydrogen peroxide must be monitored by regularly testing the minimum effective concentration (i.e., 7.5%–6.0%). Hydrogen peroxide is exceptionally stable when stored in dark containers.

Commonly used commercially available products in India are Clorox Healthcare Hydrogen Peroxide and Hydrogen Peroxide 3% by National Peroxide Ltd.


  Iodophors Top


An iodophor is a combination of iodine and a solubilizing agent or carrier; the resulting complex provides a sustained-release reservoir of iodine and releases small amounts of free iodine in aqueous solution. The best-known and most widely used iodophor is povidone-iodine, a compound of polyvinylpyrrolidone with iodine. Iodine can quickly penetrate the cell wall of microorganisms and disrupt the synthesis of protein and nucleic acid. Iodophors are bactericidal, mycobactericidal, and virucidal but require prolonged contact times to kill certain fungi and bacterial spores.[33],[70],[71] Most commercially available iodophors are not sporicidal at their recommended use-dilution. Its use in Ophthalmology is limited to pre-operative cleaning of the surgical site and disinfecting medical instruments and endoscopes. They are not suitable for disinfecting hard surfaces. USFDA has not cleared any liquid chemical sterilant or high-level disinfectants with iodophors as the main active ingredient.

Commonly used commercially available products in India are BETADINE* 5% Sterile Ophthalmic Prep Solution and Wokadine 5% Solution.


  Quaternary Ammonium Compounds Top


The quaternary ammonium compounds are commonly used disinfectants. Their activity reduces in hard water; however, the newer quaternary ammonium compounds referred to dialkyl quaternary (e.g., didecyl dimethyl ammonium bromide) remain active in hard water.[44] It causes inactivation of energy-producing enzymes, denaturation of essential cell proteins, and disruption of the cell membrane. It is fungicidal, bactericidal, and virucidal against lipophilic (enveloped) viruses but ineffective against hydrophilic (nonenveloped) viruses.[44] This compound is less corrosive compared to sodium hypochlorite. Its use is common in environmental sanitation of non-critical surfaces, such as floors, furniture, and walls. It can also be used for disinfecting medical equipment that contacts intact skin (e.g., trial frame).

Commonly used commercially available products in India are D-125 (3rd generation twin chain quaternary ammonium compound), D-256 (5th generation twin chain quaternary ammonium compound) from Microgen.

[Table 1] summarizes commonly used Chemical disinfectants in ophthalmic practice with their known mechanism of action, microbicidal activity, common side effects, and special instructions. [Table 2] summarizes the suggested uses of the chemical disinfectants in ophthalmic OPD with the most commonly available commercial products.
Table 2: Summarizes the suggested uses of the chemical disinfectants in ophthalmic OPD

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  Conclusion Top


To conclude, we need to address the issues of cross-infection and the spread of the SARS-CoV-2 virus. As physicians, we have the onus to prevent or minimize the risk of spreading infection from patient to patient. As everyone is naïve to this pandemic, it becomes difficult to decide the type of disinfectant to choose from the current armamentarium of disinfectants. Proper knowledge of all available chemical disinfectants may help us in our decision making, and by making minor changes in our current protocols of disinfection, we shall be able to keep patients and ourselves on a safer side.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Alcohol
Chlorine and Chl...
Glutaraldehyde
Formaldehyde
Hydrogen Peroxide
Iodophors
Quaternary Ammon...
Conclusion
References
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