C L I N I C A L A N D E X P E R I M E N T A L

OPTOMETRY

GUIDELINES

Best practice contact lens care: A review of the

Asia Pacific Contact Lens Care Summit

Clin Exp Optom 2009; 92: 2: 78–89 DOI:10.1111/j.1444-0938.2009.00353.x

Deborah Sweeney*† BOptom PhD FAAO
Brien Holden*† BAppSc PhD Hon DSc
FAAO OAM
Kylie Evans*† BA(Comms)
Venice Ng§ MBA
Pauline Cho|| PhD FAAO FBCLA
*Vision CRC, University of New South
Wales, Sydney, Australia
†
Institute for Eye Research, University of
New South Wales, Sydney, Australia
§
Advanced Medical Optics, Singapore
||
School of Optometry, The Hong Kong
Polytechnic University, Hong Kong SAR,
China
E-mail: d.sweeney@ier.org.au
Submitted: 20 October 2008
Revised: 7 December 2008
Accepted for publication: 23 December
2008
Contact lens hygiene has long been recognised as key to the prevention of contact-lens
associated infection and inflammation. Microbial keratitis (MK) is the only serious and
potentially sight-threatening contact lens adverse event. International studies including
recent research in Asia Pacific show that MK is rare but, as the consequences can be
severe, it is important to minimise the risk factors. Studies continue to show that one of
the key risk factors is lens and lens case hygiene. Therefore, it is also useful to review the
behaviour of our patients, to see how closely they follow the recommended hygiene
practices. Recent studies in various regions have shown that patients’ lens care habits do
not meet a required standard.
Patients can become complacent and thus non-compliant with lens care instructions.
Furthermore, they do not understand the high risk of some behaviour and they are not
hearing the practitioner when instructions and reminders are given. Further education is
important to improve patient compliance and safety. The Asia Pacific Contact Lens Care
Summit held in Singapore urged the industry and practitioners to restore the emphasis
of proper lens care, including the ‘rub and rinse’ technique, and developed a new set of
guidelines to help eye-care professionals educate their patients on the importance of
proper contact lens care to avoid eye infections. The summit also presented the latest
research on how to avoid corneal staining, another important element of contact lens
care. This review provides a summary of the summit presentations and the science behind
these guidelines.

Key words: contact lenses, contact lens solutions, keratitis, patient compliance, patient education

The eye has a range of natural defence
systems, which very effectively protect the
eye’s tissues from inflammation and
infection. The placement of a contact
lens on the eye places an added burden
on these systems, which sometimes results
in an adverse response or event. Knowing
the risk factors for these events, typical
patient behaviour that might con-
tribute to these, and the best practice
care and management guidelines, will
help practitioners to improve patient
outcomes.
ADVERSE EVENTS
Microbial keratitis (MK) is the only serious
and potentially sight-threatening contact
lens adverse event and is the only infection
related to contact lens wear. All other
events are either inflammatory or physi-
ological in nature or are mechanically
induced. The inflammatory events such
as contact lens-induced peripheral ulcer
(CLPU), contact lens-induced acute red
eye (CLARE) or infiltrative keratitis (IK)
may be associated with the presence of
bacteria and their toxins on the eye, the
lids or the contact lens but are not sight
threatening.1

Clinical and Experimental Optometry 92.2 March 2009 © 2009 Institute for Eye Research
78 Journal compilation © 2009 Optometrists Association Australia

300
250
Annual incidence (per 10,000)
200
150
100
50
20.9 20.0
New USA
England 1991
1989
Figure 1. MK with EW: annual incidence rates
MK is caused by microbial infection of
the cornea. The presentation of MK can
vary, depending on the type and virulence
of the micro-organism and the stage at
which the patient presents. In general,
excavation of the corneal epithelium,
Bowman’s layer and the stroma is seen,
with serious necrosis and infiltration of
the underlying tissue.1 Anterior chamber
reaction is often observed in the active
stage. The patient will have moderate to
severe pain of rapid onset, with severe
redness of the eye, blurred or hazy vision,
discharge and photophobia. A key charac-
teristic of MK is that the symptoms and
signs worsen with time.
CONTACT LENS WEAR
Myopia is a rapidly growing epidemic. It is
estimated that the number of myopes in
the world will grow from 1.6 billion now to
2.5 billion by 2020.2 In Asia in particular, a
combination of heredity and changing
lifestyles is bringing about an increased
incidence of myopia. For example, in Sin-
gapore, a series of studies has shown an
increase in myopia in males aged 15 to
25 years, from 26 per cent in the late 1970s
to 83 per cent in the late 1990s.3,4 In
Taiwan, a nationwide survey showed that
© 2009 Institute for Eye Research
Journal compilation © 2009 Optometrists Association Australia
0.2% per year − all SCLs and SiHys
96.4
19.8
18.0
9.3
19.3
13.3
Sweden Holland Hong UK UK USA
1994 1999 Kong Morgan Morgan Schein
2002 2005 2005 2005
Hydrogels Silicone hydrogels
the prevalence of myopia among school-
children increased from 20 per cent at
seven years of age to 61 per cent at
12 years and 81 per cent at 15 years.5
With the increase in myopia throughout
the world and particularly in Asia, we are
also seeing an increase in contact lens
wear and thus unfortunately, an increase
in contact lens-related infections. Reports
of increased numbers of cases of infection
in countries in the Asia Pacific region have
been of concern to local practitioners.
Recent studies have examined the rates
of contact lens complications.6,7 In com-
paring rates of MK with extended wear
(EW) in different regions, it is clear that
while there may have been an increase in
the absolute number of cases in the Asia
Pacific, the rates per population remain
very low and are consistent between
regions and across all soft lens types
(Figure 1). Thus, what we are seeing inter-
nationally is reflected in the Asia Pacific
region.
One major study in the region, the
Australian and New Zealand Microbial
Keratitis Study,7 captured all new cases of
presumed MK identified between October
2003 and September 2004. This large-
scale collaborative research project was
designed to assess the incidence of MK
CL Care Summit Sweeney, Holden, Evans, Ng and Cho
with different contact lenses and modes of
wear, and to assess risk factors associated
with infection. The study involved surveil-
lance of all cases of contact lens-associated
keratitis presenting to private and
hospital-based ophthalmic practitioners
and a population-based telephone survey
of 30,000 households in Australia and
7,500 in New Zealand.
The study reaffirmed that contact lens-
related infections are rare, affecting ap-
proximately four in 10,000 daily wear and
18.0
20 in 10,000 extended wear contact lens
wearers annually.7
Australia
ARE INFLAMMATORY EVENTS
ASSOCIATED WITH AN INCREASED
RISK OF MK?
It has been suggested that inflammatory
events such as CLPU, CLARE and IK are a
markers of increased risk for the occur-
rence of MK or can progress to MK.8
Several authors8,9 have put forward an
argument that symptomatic contact lens-
related keratitis should be considered as a
part of a disease continuum encompassing
any event that aggregates inflammatory
cells in the cornea. It is also possible
that corneal inflammatory events could
provide the trauma or break in the epithe-
lium required to allow the microbes to
invade the epithelium and result in an MK
event. However, it is the bacterial type not
epithelial trauma that dictates inflamma-
tory versus infective events.10,11 Willcox
and colleagues11 used the corneal chal-
lenge of a needle scratch in a mouse
model and applied a range of inocula,
including Pseudomonas aeruginosa, Haemo-
philus influenzae, Serratia marcescens,
Stenotrophomonas maltophilia or Aeromonas
hydrophila isolated from human cases of
MK or CLARE. The results showed that
strains isolated from inflammatory events
such as CLARE did not cause infection,
although this may not exclude organisms
of low virulence causing less severe micro-
bial keratitis.
The recent Stapleton review of risk fac-
tors12 associated with sterile infiltrates in
silicone hydrogel EW identified the
following factors: history of prior lens-
related corneal inflammation, initial
Clinical and Experimental Optometry 92.2 March 2009
79
CL Care Summit Sweeney, Holden, Evans, Ng and Cho
period of adaptation, limbal redness,
corneal staining, younger age (under
25 years), older age (over 50 years),
smoking, high ametropia, shorter dura-
tion of EW and bacterial contamination of
the storage case. While inflammatory
events do not appear to be a risk factor for
events of MK, they are a risk factor for
further inflammatory events.
While of concern to patients and prac-
titioners, inflammatory events are self-
limiting and benign. In contrast, prompt
attention and aggressive treatment are
essential for suspected corneal infection,
as MK is a truly infectious process and dis-
plays rapid growth of bacteria in the
corneal tissue.13 In practice, any ulceration
of the cornea should be treated as though
it might be a true MK and appropriate
antibiotic therapy given. Indeed, failure to
appropriately treat MK rapidly has been
shown to be a major risk factor in develop-
ing severe disease.14
CAUSES AND RISK FACTORS
Some of the most important results of the
research into contact lens infections are
the identification of risk factors associated
with the disease.
The risk of microbial keratitis associated
with contact lens wear is increased with
overnight contact lens use.6,7,15–20 Closure
of the eye causes changes to the ocular
defences which parallel those seen with
contact lens wear, and sleeping in lenses
means the effects may be additive. An
important finding of the Australian and
New Zealand Microbial Keratitis Study7
and the parallel study carried out in the
UK21 is that overnight wear persists as the
major risk factor regardless of the soft lens
type worn.
Recent research showed that one in
three eye health problems suffered by lens
wearers is a direct result of improper lens
care and cleaning.22 Indeed, adverse
events in general, including both infective
and inflammatory conditions, are more
likely where there is contamination of
the lenses. Sankaridurg and colleagues23
found that colonisation of soft contact
lenses with pathogenic bacteria, especially
Gram-negative bacteria and S. pneumoniae,
Clinical and Experimental Optometry 92.2 March 2009
80
appears to be a significant risk factor
leading to inflammatory events. In the
Australian study, significant associations
were identified between MK and lens
hygiene practices, smoking, overnight
wear and male gender.22 This confirms
earlier epidemiological studies, which
have also highlighted lens and case
cleaning,6,12,19 smoking15,16,20 and male gen-
der12,15 as important risk factors. Socio-
economic status is also a factor, though
puzzlingly in the Australian study,24 high
socio-economic class was the risk factor,
while conversely, in other studies,18,21 it
was found to be low.
Also of concern is the contamination
of solutions. Commercially available pre-
served saline solutions became con-
taminated during normal use.25 The
contaminants were predominantly gram-
positive bacteria, representing normal
ocular or skin flora.
PATIENT BEHAVIOUR
Contact lens hygiene has long been
recognised as the key to the prevention
of contact-lens associated infection and
inflammation, however, as all practitio-
ners know, patients may become compla-
cent and thus non-compliant with lens
care instructions. Recent studies, such as
that conducted by Morgan,26 show that
compliance is an issue with many patients.
His survey of contact lens use in Europe
found that only 0.3 per cent of daily
wearers and 2.7 per cent of extended
wearers were fully compliant for all 14
steps identified for correct lens care. Many
wearers stretched the use of their contact
lens products by using lenses for too many
days, sleeping in lenses when daily wear
use only had been prescribed, sleeping in
lenses for too many nights in the case of
extended wear, and topping up solutions
rather than discarding the solution from
the lens case each time and refilling with
fresh solution. Only a minority of wearers
in the study cared for their contact lens
cases correctly and as this is a known risk
factor for ocular infection, the need for
much improved management of contact
lens cases is a key message. Similarly, a
survey by the US Contact Lens Council27
Journal compilation © 2009 Optometrists Association Australia
found that 44 per cent of patients always
or occasionally topped up their contact
lens solution and 54 per cent did not clean
their lens case after each use. In addition,
49 per cent wore lenses for longer than
recommended, although this has not been
confirmed as a risk factor for corneal
infection or inflammation.
Two recent Asia Pacific studies further
demonstrate current patient behaviour.
Hong Kong study
In Hong Kong, 101 young, university-
based, asymptomatic soft contact lens
wearers were recruited.28 All subjects were
interviewed regarding their contact lens
wearing history and hygienic practices
and the lenses, solutions and cases of
the subjects were tested for microbial
contamination.
In this study, the lens case was the most
frequently contaminated item and yielded
the widest range of bacterial isolates. This
may be because contact lens wearers
usually pay less attention to case hygiene
than lens hygiene. According to the inter-
views, over half of the subjects (58 per
cent) did not discard lens care solutions or
air dry their lens cases every time after use
(the recommended procedure), 68 per
cent cleaned their lens cases less than
once per week and 61 per cent did not
change their lens cases regularly (at least
every three months is recommended).
Lack of cleaning and replacement allows
the lens cases to become a stagnant envi-
ronment. Such an environment is more
favourable for the formation of biofilm
than contact lenses.29 This is of concern
because biofilm on the case surface
provides a reservoir for the adhesion
of further micro-organisms to lenses30
and physically protects bacteria from
disinfectants.31
Care of the lens case is of particular
relevance because non-compliance has
frequently been associated with contami-
nation of the case32,33 and even infection in
contact lens wearers.29 The ability of Acan-
thamoeba to survive in contaminated lens
cases has been reported by Cheng and
associates34 and failure to clean the lens
case adequately was cited as a risk fac-
© 2009 Institute for Eye Research

tor for infection with Acanthamoeba by
Houang and co-workers.35
Another interesting factor in lens care is
that the results of the Hong Kong study
show that contact lenses used by
occasional wearers were more likely to be
associated with ocular pathogenic micro-
organisms. This may be because contact
lenses that are left unused in the (probably
contaminated) case for a period provide a
favourable environment for the attach-
ment of micro-organisms and build-up of
biofilm. By contrast, a recent study has con-
firmed a dose-dependent effect of wear
showing that part-time (two days per week)
daily lens use has a lower risk of disease
compared with six or seven days.21
In the Hong Kong study, the patients
were university students and would be
expected to be well educated and thus
cognisant of the potential risk of poor lens
hygiene, yet the findings of this study dem-
onstrate that contact lenses and lens care
accessories are not well maintained by the
wearers. Therefore, regular reviews and
reinforcement of lens care procedures for
the use and care of contact lenses is essen-
tial to protect patients. In particular,
special care should be taken to instruct
patients on the importance of lens case
hygiene, as well as hygiene for the lenses
themselves.
Asia Pacific survey
In the second study, a major survey of Asia
Pacific markets was conducted to investi-
gate the disconnection between the beliefs
and attitudes of patients and eye-care
practitioners (ECP) on proper lens care
compliance.36
The research was conducted in October
2007 by an independent market research
company, Oracle-Added Value, in Austra-
lia, Singapore, Malaysia (Kuala Lumpar/
Petaling Jaya), Hong Kong, China
(Shanghai), Taiwan (Taipei) and South
Korea (Seoul). In each location, panels of
50 ECPs and 100 consumers were inter-
viewed: the ECP panels were put together
from a random sampling of local optom-
etrist associations or business directories,
and the consumer panels from a random
sampling based on the population
distribution.
© 2009 Institute for Eye Research
Journal compilation © 2009 Optometrists Association Australia
CL Care Summit Sweeney, Holden, Evans, Ng and Cho
The Asia Pacific survey shows that ECPs
are sceptical about consumers’ compli-
ance with cleaning instructions, with only
10 per cent of them believing consumers
were strictly compliant with cleaning
instructions, while 36 and 35 per cent of
the consumers claimed they were strictly
compliant with instructions from packag-
ing and ECPs, respectively. In reality, con-
sumers’ lens care habits are not up to
standard. Although consumers stated that
they devote 2.9 minutes per day to lens
care, which theoretically should be suffi-
cient, nearly 70 per cent of consumers did
not clean their lens case every day and 50
per cent of them kept their lens case
longer than three months.
Most (68 per cent) of the ECPs believed
consumers had not read the cleaning
instructions, whereas 90 per cent of the
consumers claimed they did read instruc-
tions. Most consumers (60 per cent) did
admit they only read the instructions the
first time they bought a new lens care
product.
SOLUTIONS
In November 2007, the Institute for Eye
Research (IER) conducted a series of tests
to evaluate the efficacy of various regimens
that might be recommended for hygienic
lens care.37
In regimen A, lenses were neither
rubbed nor rinsed before disinfection; in
regimen B, lenses were rinsed for five
seconds per lens surface before disinfec-
tion; and in regimen C, lenses were
rubbed and rinsed before disinfection.
Disinfection of the lenses followed the
manufacturers’ recommended minimum
disinfection time (four or six hours
depending on solution type). Solutions
tested included Complete MoisturePlus,
Opti-Free Replenish, AQuify and ReNu
MultiPlus. Challenge micro-organisms
were the standard panel of organisms,
which include Pseudomonas aeruginosa, Sta-
phylococcus aureus, Fusarium solani, Candida
albicans, as well as a strain of Acanthamoeba
polyphaga.
The International Organization for
Standardisation (ISO) has set up standard
disinfecting regimens that solutions must
Clinical and Experimental Optometry 92.2 March 2009
pass. Under one disinfection criterion
called the Stand Alone test and published
as ISO standard 14729,38 contact lens dis-
infecting solutions are required to reduce
the load of specific strains of microbes in
the solution by specific amounts (one log
unit reduction for Fusarium and Candida;
three log unit reduction for Pseudomonas
aeruginosa, Serratia marcescens and Staphylo-
coccus aureus) and there is no requirement
for a rub/rinse step. If solutions passed
this Stand Alone test, they did not have to
meet the ‘Regimen Criteria’ that required
the solutions to perform to certain stan-
dards (including reductions in microbe
numbers after rubbing and rinsing the
lenses). Under the regimen test, less than
10 colony-forming units of bacteria or
fungi are allowed to remain on the lens
surface.
Recently, there have been recalls of
some of these newer no-rub solutions due
to apparent lack of efficacy and conse-
quent increases in specific types of micro-
bial keratitis. In 2006 Bausch & Lomb
globally recalled its solution, ReNu Mois-
tureLoc,39 following epidemiological evi-
dence that this solution was linked to an
increase in microbial keratitis caused by
Fusarium sp., including outbreaks in Sin-
gapore40,41 and the USA.42 While ReNu
MoistureLoc met the ISO Stand Alone
disinfection criteria and was reported as
being very effective against bacterial
types,43,44 it appears that a combination of
the novel ingredients in MoistureLoc
and a certain amount of non-compliance
by users brought about this increase in
Fusarium keratitis.
Another recent recall of a MPS solution
was made due to an apparent increased
risk of acanthamoebic keratitis. Advanced
Medical Optics globally recalled Complete
MoisturePlus from sale in 2007, following
a report that demonstrated an increased
rate of acanthamoebic keratitis that was
associated with the use of Complete
MoisturePlus.45 No existing multipurpose
solutions in the current market are re-
quired by US FDA to be tested against
Acanthamoeba.
While contact lens manufacturers have
responded to market pressure by produc-
ing more easy to use, no rub solutions, this
81
CL Care Summit Sweeney, Holden, Evans, Ng and Cho
may not be the optimum lens care for lens
hygiene and ocular safety.
In the IER study across four solutions
and three lens types, in most cases, the
addition of the ‘rub and rinse’ step signifi-
cantly reduced the microbial load on the
lens. Compared to rinsing only:
1. Pseudomonas aeruginosa was reduced by
a further two to three log units with
‘rub and rinse’.
2. Staphylococcus aureus was reduced by at
least a further two log units with ‘rub
and rinse’.
3. Both fungi Fusarium solani and Candida
albicans were reduced by a further one
to two log units with ‘rub and rinse’.
4. Acanthamoeba polyphaga was reduced by
up to a further 0.5 log unit with ‘rub
and rinse’.
This study has demonstrated that
rubbing combined with rinsing and appro-
priate time for disinfection adds a signifi-
cant safety margin (up to 100,000 times).
In another study, Cho and colleagues46
compared the effectiveness of rub versus
no-rub cleaning of 300 soft contact lenses,
which were artificially contaminated with
serum albumin, hand cream and mascara.
Their results showed that cleaning the soft
lens without rubbing was ineffective in
removing loosely-bound deposits. Their
work supports the view that contact lens
wearers should be encouraged to rub their
lenses when cleaning. The US Food and
Drug Administration (FDA) Ophthalmic
Devices Panel of the Medical Devices Advi-
sory Committee has now recommended
the ‘rub and rinse’ technique as best prac-
tice in contact lens care.
Furthermore, at the 111th meeting of
the US FDA Ophthalmic Devices Panel on
June 10 2008,47 the panel concluded that
the current regimen test should be revised
to improve predictability of real world per-
formance, including testing a lens in the
case with the solution, without rubbing,
without rinsing and with biofilm. They
also recommended that a realistic ‘rub
and rinse’ time should be included in
labelling, along with explanations of the
reasons contact lens wearers should rub
and rinse.
While ‘rub and rinse’ is the primary rec-
ommendation, one alternative is the use
Clinical and Experimental Optometry 92.2 March 2009
82
of a solution with hydrogen peroxide.
Carnt and colleagues48 have shown that
the use of hydrogen peroxide is able to
reduce the risk of corneal inflammation
by a factor of 10 compared to MPS. More-
over, hydrogen peroxide is more effective
in killing rare organisms such as Acan-
thamoeba,49 although longer exposure time
to peroxide is required to fully eliminate
the cysts. It was suggested that the cysti-
cidal activity of hydrogen peroxide could
be improved if neutralisation were de-
layed.50 Hydrogen peroxide also offers
another benefit, as it is currently the only
solution to virtually eliminate solution-
induced corneal staining with silicone
hydrogel lenses.51,52
Corneal staining is an important
in-practice tool for evaluating the state of
the corneal epithelium. While minimal
corneal staining often occurs in contact
lens wear,53 moderate amounts of control-
lable staining should always be avoided,
especially given the links that have been
established between solution-induced
corneal staining or ‘SICS’ and low grade
corneal inflammation and discomfort. IER
researchers have previously shown that
SICS is associated with three times
increased risk of corneal inflammation54
and decreased comfort.55
The introduction of silicone hydrogel
contact lenses has had an unexpected
ocular consequence. About 2004, corneal
staining in response to particular silicone
hydrogel materials and solutions became
of concern56 and practitioners and pa-
tients had to be wary of possible ‘com-
bination’ effects. Unfortunately, lens/
solution interactions were not pre-
dictable according to preservative type
and concentration.57
Structurally, silicone hydrogel lenses are
more complex than conventional hydro-
gels, with fluorine and silicone for oxygen
permeability and other components and
surface treatments to improve lens wetta-
bility. At the same time, lens care solutions
are themselves complex, with buffers,
chelating agents, surfactants, isotonicity
agents, hygroscopic agents and pre-
servatives. Recently, we have also seen
the release of new, wetting, comfort-
enhancing multipurpose solutions, which
Journal compilation © 2009 Optometrists Association Australia
have other ingredients. Finally, solutions
interact with the complex tear film.
Understanding which combinations
may cause problems is important for prac-
titioners in providing appropriate advice
to their patients.
A number of studies examined the com-
binations to present lens/solution ‘grids’,
detailing the interactions. These include
Lyndon Jones,56 the Andrasko Staining
Grid (www.staininggrid.com) and the Itoi
Grid (www.staininggrid-japan.com), where
lenses were soaked overnight in a particu-
lar solution and the average percentage of
corneal staining (by area) after two hours
of wear the following day was recorded.
The Institute for Eye Research Matrix
Study, first published in the September
2007 issue of Contact Lens Spectrum51 and
updated in March 2008,52 examined five
leading brands of lenses used in combina-
tion with four brands of disinfecting solu-
tions (Table 1).
The study involved 800 experienced
and new contact lens wearers in 20 groups
of 40, who used each type of silicone
hydrogel lens bilaterally in conjunction
with each type of multipurpose solution
and were monitored over three months.
Clinicians indicated the presence of
SICS (Figure 2). The IER Matrix Study
defined SICS to avoid confusion with
other corneal staining phenomena. There
are two manifestations of solution-related
staining, ‘diffuse punctuate’ and ‘periph-
eral annular’ and they are easily differen-
tiated from corneal staining resulting
from other causes.
The study reveals that each solution-
silicone hydrogel lens combination pre-
sents a unique ocular situation; some
causing SICS in a high percentage of
wearers, others causing SICS in a low per-
centage of wearers, with hydrogen perox-
ide causing almost none (Table 2).
Multipurpose solutions
Opti-Free Express and Replenish were in
higher quartile ranges than were peroxide
and AQuify MPS for both Acuvue Oasys
and O2Optix.
Opti-Free Replenish was also in higher
quartile ranges than Opti-Free Express for
Acuvue Oasys and O2Optix.
© 2009 Institute for Eye Research
 CL Care Summit Sweeney, Holden, Evans, Ng and Cho

Contact lenses Composition

Acuvue Advanc 47% water, galyfilcon A, PVP, low water/ non-ionic (FDA I), Dk 60, Dk/t 86
(Johnson and Johnson Vision Care Inc)
Acuvue Oasys 38% water, senofilcon A, PVP, low water/ non-ionic (FDA I), Dk 103, Dk/t 147
(Johnson and Johnson Vision Care Inc)
O2Optix 33% water, lotrafilcon B, plasma, low water/ non-ionic (FDA I), Dk 110, Dk/t 138
(CIBA Vision)
PureVision 36% water, balafilcon A, plasma, low water/ ionic (FDA 3), Dk 91, Dk/t 110
(Bausch & Lomb)
Night and Day 24% water, lotrafilcon A, plasma, low water/ non-ionic (FDA I), Dk 140, Dk/t 175
(CIBA Vision)
Contact lens solutions Composition
AO Sept Plus Sodium chloride, phosphate buffer system, pluronic surfactant, phosphonic acid,
Clear Care hydrogen peroxide 3%,
(CIBA Vision)
AQuify MPS Sorbitol, tromethamine, dexpanthenol, pluronic F127 surfactant, sodium phosphate
Focus AQuify dihydrogen buffer, disodium edetate, polyhexadine 0.001%
(CIBA Vision)
Opti-Free Express Sodium chloride, sorbitol, AMP-95, boric acid/ sodium citrate buffer, tetronic 1304
(Alcon Laboratories Inc) surfactant, disodium edetate, 0.001% polyquad, 0.0005% aldox
Opti-Free RepleniSH Sodium chloride, sorbitol, AMP-95, boric acid/sodium citrate buffer, tetronic 1304
(Alcon Laboratories Inc) surfactant, disodium edetate, 0.001% polyquad, 0.0005% aldox

Table 1. IER Matrix Study lenses and solutions

AQuify MPS was in the higher quartile
range for PureVision.
Hydrogen peroxide
Hydrogen peroxide caused far less corneal
staining with silicone hydrogels than did
any of the multipurpose solutions (MPS)
(for all lens types combined, p < 0.001).
Lenses
PureVision demonstrated statistically sig-
nificant staining with MPS systems but not
hydrogen peroxide. (PureVision versus
other lens types with MPS, p < 0.001).
Acuvue Advance had the lowest fre-
quency of staining for MPS compared to
all other lens types (p < 0.001).
Night & Day is in the lowest quartile,
with Clear Care and AQuify in the highest
quartile range for both Opti-Free prod-
ucts, along with PureVision and Oasys.
PATIENT EDUCATION
While a hydrogen peroxide solution is very
effective in contact lens disinfection, a
further problem was demonstrated in the
Asia Pacific survey,36 in which 83 per cent
of the ECPs stated that they recommended
hydrogen peroxide to their patients but
only 31 per cent of the customers
believed they had ever received the
recommendation.
This confirms that instructions provided
by the ECP may not be registering with
patients. They can become complacent
and may not hear the instructions or
reminders provided. Also in the survey,
ECPs and consumers agreed on when and
how to provide lens care instructions but
ECPs believed the instructions on proper
lens care were actually given more fre-
quently than consumers perceived (ECP:
2.8 times versus consumers: 1.6 times per
annum) (Figure 3) and in more varied
ways (ECP: 2.7 ways versus consumers: 1.6
ways) (Figure 4).
Consumers are also insensitive to poten-
tial risk. In the survey, ECPs accurately
stated that ‘no rubbing and rinsing’ and
‘not cleaning the lens case’ are the most
common mistakes in hygiene, which may
lead to ocular infection, however, these
two forms of behaviour were regarded
by the consumers as the least common
factors causing infection (Figure 5). This
is a vital finding, showing that consumers
have taken these risk factors too lightly
and thus increased their exposure to risk.
It also demonstrates the need for con-
tinual education of patients by ECPs.
Non-compliance is a complex problem
that involves patient knowledge, attitudes
and beliefs and resources.58 Claydon59
found that most patients are unintention-
ally non-compliant, due to misunderstand-
ing, forgetfulness or poor instruction and
that only a small percentage were inten-
tionally non-compliant due to cost, incon-
venience, ignorance or denial of the risk.
Clearly, a better understanding of
wearers’ beliefs, behaviour and motiva-
tions may assist in developing effective
guidelines and patient communication
strategies. Claydon59 developed a model of
general guidelines to enhance compli-
ance, detailing three interdependent
areas comprising the contact lens patient,

© 2009 Institute for Eye Research Clinical and Experimental Optometry 92.2 March 2009
Journal compilation © 2009 Optometrists Association Australia 83
CL Care Summit Sweeney, Holden, Evans, Ng and Cho

the clinic and practitioner, and the lens

A B
care recommendations. While there has
been an emphasis on recommendations,
clear instructions must be combined with
an understanding of the knowledge, pref-
erences and expectations of the patient
and with enhancing the practitioner-
patient relationship. Good communica-
tion is essential for compliance.
While the practitioner can make a
major contribution to successful contact
C D lens wear by careful patient selection and
lens fitting, the patients must play their
part in monitoring and supporting their
ocular health.
Patients should check every morning
and night to ensure that their eyes ‘look
good, feel good and see well’.60 If there are
any problems, such as redness, watering,
discomfort or pain, patients should imme-
Figure 2. Solution-induced corneal staining differentiation diately remove their lenses and contact
A. Diffuse staining spread over most of the cornea. If severe, there can be linear areas their practitioner as soon as possible.
of coalescent punctate staining. Some patients may feel that if the lens
B. Peripheral staining, usually a continuous paralimbal/limbal annulus. We considered does not feel quite right, sleeping in lenses
staining peripheral when the average extent of staining in the peripheral zones was more may alleviate the discomfort or perhaps
than 0.5 of a unit higher than in the central zones. they just do not take the trouble to remove
C. Dehydration staining, located mainly inferiorly and contributed to by partial blinking their lenses. This must be avoided. Also
and lagophthalmos. It may also occur in the superior cornea adjacent to the upper lid importantly, patients should not sleep in
margin due to an unstable tear meniscus. It generally presents in bands and is located in lenses if they feel unwell, as they may be at
the mid-peripheral cornea. higher risk of adverse events such as
D. Limbal transition pooling. Circumferentially arranged radial spokes of fluorescein CLARE.61 If patients remove their lenses
pooling at the anterior edge of the limbal transition zone occurs in some patients.
for any time, they should be disinfected
before they are reinserted or be replaced
with new lenses.
The Australia and New Zealand MK
study7,62 found that those who developed
infections were more likely to have pur-
chased their contact lenses over the inter-
The IER Matrix Study: Corneal staining net, highlighting the need for professional
advice and education on contact lens
Solution-induced corneal staining per month with the combination*
prescribing.
Lens/solution Clear Care AQuify Opti-Free Express Opti-Free RepleniSH The importance of patient compliance
Acuvue Advance 0.0% 0.9% 0.0% 0.0% (2W) should be reiterated at every visit, as it
Acuvue Oasys 0.9% (2W) 2.6% (2W) 6.2% 7.1% (2W) has been shown that compliance levels
O2Optix 0.5% 3.2% 5.9% 6.7% decrease with experience, and reinstruc-
PureVision 0.9% 23.2% 11.3% 14.2% tion increases compliance levels.63 It is also
Night & Day 1.7% 0.9% 7.2% 6.7% a good idea if patients are given documen-
tation to take home with them. The
lower quartile inner two quartiles upper quartile documentation should provide clear in-
*percentage of patients per month showing lens care related staining in the first three months of structions in layman’s terms on guidelines
lens wear
to follow to avoid complications, informa-
2W = two-weekly replacement
tion on the support network available, and
a description of the possible repercussions
Table 2. IER Matrix including ‘night and day’ lenses (percentage of patients per month) of non-compliance. It is also important to

Clinical and Experimental Optometry 92.2 March 2009 © 2009 Institute for Eye Research
84 Journal compilation © 2009 Optometrists Association Australia
 CL Care Summit Sweeney, Holden, Evans, Ng and Cho

AP TOTAL
AP TOTAL
%
%
82 95
At first visit with new patient ECP talks to patient
49 70

71 42
At initial contact lens fitting
56 Promoter talks to patient 27

40 50
At annual eye exams Staff member gives demonstration
12 21

When patient picks up new 49 43

26 Patients receive written materials
contact lenses 19

When patient picks up 33 35

Sales staff talk to patients
replacement lenses 19 22

5 8
Some other time
- See/given video
1

Average: Average:
according to ECPs: 2.8 times according to ECPs: 2.7 ways
according to consumers: 1.6 times ECP Consumer according to consumers: 1.6 ways ECP Consumer

Figure 3. When proper lens care is discussed with patients Figure 4. Ways patients receive information about proper
care

AP TOTAL
ance, by providing the best possible prod-
ucts and by raising awareness of good lens
ECP perceptions of patient cleaning mistakes Behaviours causing risk of eye infection care practice among patients. The revision
% of the ISO standard will be an important
first step in improving products. As
Washing lens with
Not rubbing & rinsing 45 61 24 12 4 recommended by the FDA Ophthalmic
tap water

Devices Panel, the improvement of written

Not washing hands before
Not cleaning case 39 58 31 8 3
inserting/removing product instructions is already taking
place, for example, with the development
Topping up solution
Not washing hands 33 43 36 17 5
of an easy to use cautionary product state-
Topping up Not cleaning lens case ment to communicate the importance of
27 properly after every use 40 40 17 4
patient compliance by the US Contact
Washing lens with Not rubbing & rinsing Lens Institute, an association of
tap water 13 properly 32 40 24 5
manufacturers.
percentage rating the item top 3 boxes is shown definitely does not contribute
might or might not contribute
probably contributes ASIA PACIFIC CONTACT LENS CARE
definitely contributes
SUMMIT
Figure 5. Lens care behaviour leading to eye infection In 2007, the Asia Pacific Contact Lens
Care Summit was held in Singapore. Del-
egates, including leading eye health clini-
cians, researchers and academic experts,
foster patient loyalty so that patients will novel ways to engage with patients. Studies developed a new set of guidelines to
return for follow-up care and will contact by Claydon, Efron and Woods64 and Yung help eye-care practitioners educate their
the practitioner promptly if there is a and associates65 show that compliance patients on the importance of proper
problem. enhancement strategies, such as videos, contact lens care to avoid eye infections.
It must be noted that while the posters, a health care contract or free solu- The guidelines emphasise that contact
practitioner-patient relationship and com- tions, had little effect on compliance levels. lenses are safe if they are used properly,
munication are essential to compliance, Industry, too, plays a role in ensuring and offer instructions on their use, main-
practitioners do not need to find entirely contact lens patient safety and compli- tenance and storage.

© 2009 Institute for Eye Research Clinical and Experimental Optometry 92.2 March 2009
Journal compilation © 2009 Optometrists Association Australia 85
CL Care Summit Sweeney, Holden, Evans, Ng and Cho
GUIDELINES FOR THE SAFE AND
EFFECTIVE USE OF CONTACT
LENSES
We, the delegates at the 2007 Contact
Lens Care Summit, are strongly of the view
that contact lens care and its proper
implementation are critical to the safety
and efficacy of contact lens wear.
We make this statement in support of
improving safety for all contact lens
wearers and to encourage adoption of
these guidelines that are aimed at improv-
ing practitioner awareness and increasing
lens care efficacy and patient compliance.
We consider that:
1. Contact lenses are a safe and effective
way of correcting vision when used and
cared for properly.
2. Care and maintenance of contact
lenses and cases are of major impor-
tance in avoiding the very rare but
serious problem of corneal infection.
3. Contact lens care is critical in optimis-
ing the performance of contact lenses
and avoiding inflammation and other
side-effects.
4. Hydrogen peroxide, when used appro-
priately, has been shown to be a very
safe disinfection system and, thus
far, the system most conducive to
continued lens biocompatibility and
performance.
5. Rubbing and rinsing contact lenses
with a multipurpose solution is a very
important way of significantly reducing
the microbial challenge to the contact
lens wearing situation and ideally
should be used both before and after
lens disinfection and storage.
6. Contact lens cases are a major potential
source of infectious organisms. Practi-
tioners and corporations are urged to
consider every measure possible to
reduce potential contamination, inc-
luding supplying new cases with every
lens care pack, encouraging disposal of
‘old’ cases, producing contamination
resistant cases, encouraging the use of
cases that are easy to clean and giving
clear instructions on case hygiene and
storage, when the cases are not in use.
We urge practitioners and the industry
to restore emphasis to the importance of
Clinical and Experimental Optometry 92.2 March 2009
86
contact lens care for the sake of all contact
lens wearers.
We emphasise the role of the practitio-
ner in ensuring that patients are properly
informed and understand the details of
appropriate care of the lenses they pre-
scribe, including taking responsibility for
instructing patients in appropriate care
techniques for the lenses prescribed.
We ask that industry and practitioners
make all possible efforts to clarify and
simplify instructions for patients, so that
they are easy to understand and carry
out.
We ask all the organisations involved in
contact lens education, such as IACLE
(International Association Contact Lens
Educators), contact lens societies, eye
research institutes, university departments
and professional bodies, to revisit the issue
of contact lens care and to emphasise in all
educational programs that proper care
and maintenance are very important parts
of contact lens safety and success.
We suggest adoption of the following
guidelines for appropriate contact lens
care and maintenance.
Contact lens hygiene
fundamentals
1. Contact lens disinfection systems
should be effective against bacteria,
fungi, viruses and amoebae.
2. Every time a contact lens is handled, it
should be with clean, washed and
dried hands.
3. Any time a contact lens is removed
from the eye, it should be properly
disinfected.
4. Safety is enhanced significantly by
rubbing and rinsing contact lenses
both prior to and following storage.
5. Patients should never ‘top up’ that is,
add additional solution to the solution
already in the case.
6. When contact lenses have been stored
for more than seven days, regardless
of whether peroxide or multipurpose
solutions is used, lenses should be
effectively redisinfected before the
next use.
7. Hydrogen peroxide is considered to
be a very safe solution, however,
patients using hydrogen peroxide for
Journal compilation © 2009 Optometrists Association Australia
disinfection should be advised to use
unit dose sterile saline or other sterile
saline-based solutions for rinsing their
lenses prior to lens insertion.
8. Patients should be advised strongly
to adhere to the lens wearing and
replacement schedules prescribed by
their practitioners.
9. The industry and practitioners are
urged to make all instructions for
contact lens care systems simple, easy
to remember and effective.
10. Purchasing lenses over the internet
has been shown to have a higher risk
of infection, presumably because of
the absence of practitioner monitor-
ing and instruction.
11. Medical practitioners and associated
health care professionals should be
provided with up-to-date advice on
contact lens care and the latest treat-
ment imperatives for contact lens-
related complications.
Patient management
12. Patients should be told to wash their
hands every time they handle their
contact lenses or contact lens cases,
preferably with appropriate (non-
moisturising, non-residue) soap or
disinfectant and to dry their hands
with lint-free tissues or cloths.
13. Practitioners should note on their
records the type of contact lens care
system and instruction information
given to each patient, and this infor-
mation should be updated at each
visit.
14. Patient contact lens hygiene should be
monitored at repeat visits, by demon-
stration and observation and appro-
priate reinforcement of lens care
instructions.
Contact lens case hygiene
15. Contact lens case hygiene is extremely
important.
16. Contact lens cases should be cleaned
and dried after every use.
17. Contact lens wearers should be told
how to clean and disinfect contact
lens cases and to dry them with a clean
lint free cloth, if that is not contrain-
dicated for the type of case.
© 2009 Institute for Eye Research

18. The industry should be encouraged
to make contact lens cases that are
cleaned easily.
19. The industry is encouraged to con-
tinue development and use of
improved, anti-bacterial and dispos-
able contact lens cases.
20. Contact lens solution manufacturers
should make available a new case with
every bottle of contact lens disinfect-
ing solution and patients should
discard their old case and use the new
case every time a new bottle of disin-
fecting solution is used.
Tap water and other high risk
situations
21. Patients should be informed that
water is a very common source of very
infectious and potentially damaging
micro-organisms that can produce
sight-threatening infections and [be
advised] to never use tap water to
store, clean or rinse their contact
lenses.
22. Patients should also be reminded to
avoid splashing water directly into
their eyes, contact lenses or contact
lens cases.
23. Patients should be advised to close
their eyes firmly while showering or
washing their faces with water.
24. Practitioners should emphasise that
one of the highest risk occasions for
contact lens wearers is when on vaca-
tion and that an appropriate ‘travel
kit’ should be carried and used and
[patients should] be especially vigilant
with regard to contact lens care and
disinfection.
25. Manufacturers of contact lens care
systems should provide smaller bottles
of disinfectants that last a shorter time
and that comply with current travel
restrictions on solution container
volume.
26. Practitioners should advise patients
that exposing lenses to potential con-
tamination from swimming pool or
spa water is another high risk occasion
for contact lens wearers and that
goggles should be worn while swim-
ming. Care should be taken to avoid
spa or pool water being splashed
© 2009 Institute for Eye Research
Journal compilation © 2009 Optometrists Association Australia
CL Care Summit Sweeney, Holden, Evans, Ng and Cho
in the eyes. For emphasis, patients
should be advised that if they wish to
remove their lenses before or during
such activities, they must be properly
cleaned and disinfected before being
reinserted.
27. Practitioners should inform patients
that storing their contact lenses in
the bathroom carries a high risk of
airborne contamination and that
special care needs to be taken to
avoid atmospheric contaminants,
especially by avoiding leaving con-
tainers open.
28. Patients should never reuse the solu-
tion in a contact lens case.
Patients should be told never to refill
smaller contact lens solution containers
with solution from a larger container.
Smaller containers should be made diffi-
cult to refill.
Summit delegates
Professor Brien Holden, University of New
South Wales; CEO, Institute for Eye
Research (Chairman).
Professor Deborah Sweeney, CEO, Vision
CRC Limited, Australia; President,
International Association of Contact
Lens Educators.
Ms Wendy Ho, Private Practitioner,
Australia.
Ms Jyoti Dave, Private Practitioner, India;
Managing Trustee, Jyoticare Benevolent
Foundation
Professor Xiao Mei Qu, EENT Hospital,
Fundan University, China; Co-ordinator
of International Association of Contact
Lens Educators.
Dr Stan Isaacs, Private Practitioner;
President, Singapore Contact Lens
Society.
Professor Jai Min Kim, Head of Oph-
thalmic Optics Department, Keon Yang
University, Korea; Chairman, Korean
Ophthalmic Optics Society.
Dr Usman Husin, Private Practitioner,
Indonesia.
Dr Joseph Fung, Private Practitioner;
President, Hong Kong Optometric
Association.
Clinical and Experimental Optometry 92.2 March 2009
Dr Kah Meng Chung, Private Practitioner;
President, Association of Malaysian
Optometrists.
Associate Professor Pauline Cho, School
of Optometry, The Hong Kong Poly-
technic University, Hong Kong SAR,
China.
Dr Huey-Chuan Cheng, Director at the
Department of Ophthalmology, Mackay
Memorial Hospital, Taiwan.
Professor Pei-Ying Xie, Director of Peking
University, Optometry and Ophthalmol-
ogy Center; Director of Tianjin Eye Hos-
pital Contact Lens Centre.
Mr Kevin Siew, Private Practitioner; Presi-
dent, Malaysian Association of Practic-
ing Opticians.
Mr Alan Saks, Private Practitioner, New
Zealand.
Dr Wilfred Tang: Singapore Polytechnic,
Head of Singapore Polytechnic Optom-
etry Centre.
Assistant Professor Hsi-Ming Yang, Oph-
thalmology, Catholic FuJen University,
Taiwan.
CONCLUSION
Contact lenses are medical devices that
come into close contact with human
tissue and it is important that prac-
titioners and industry take all steps
necessary to optimise patients’ ocular
health.
For industry, new product standards
and communication in package instruc-
tions will help to improve outcomes.
Practitioners should be aware of the risk
of corneal staining with silicone hydrogel
lenses and ensure optimum combinations
of lens and solution for their patients.
They should also be aware that with sili-
cone hydrogels, hydrogen peroxide is cur-
rently the only solution that avoids corneal
staining.
Finally, while regional studies have
shown that contact lens-related infections
are very rare, proper lens care, which
includes hygiene, wear and replacement
schedules, is a key factor in ensuring the
safety of these devices. It is clear that lens
and lens case hygiene are inadequate in
many wearers. Therefore, regular reviews
and reinforcement of care procedures for
87
CL Care Summit Sweeney, Holden, Evans, Ng and Cho
contact lenses and lens care accessories are
essential to protect patients. The Guide-
lines for the Safe and Effective Use of
Contact Lenses provide a valuable res-
ource, providing the latest recommended
practice to ensure contact lens safety.
ACKNOWLEDGEMENTS
The contributions of the following people
are gratefully acknowledged: Professor
Fiona Stapleton, School of Optometry and
Vision Science, University of New South
Wales; and Nicole Carnt, Dr Vicki Evans,
Daniel Tilia, Dr Mark Willcox and Dr Hua
Zhu of the Institute for Eye Research, Uni-
versity of New South Wales.
SOURCES OF FUNDING AND CONFLICT
OF INTEREST
The Asia Pacific Contact Lens Summit and
the Asia Pacific survey were sponsored by
Advanced Medical Optics. The Institute
for Eye Research receives royalties from
the sale of certain contact lenses men-
tioned in this report. The Vision CRC is
supported by the Cooperative Research
Centres program of the Australian Federal
Government.
REFERENCES
1. Holden BA, Sankaridurg PR, Jalbert I.
Adverse events and infections: which ones
and how many? In: Sweeney DF, ed. Sili-
cone Hydrogels: The Rebirth of Extended
Wear. Oxford: Butterworth Heinemann,
2000. p 150–213.
2. IACLE—International Association of
Contact Lens Educators 2002.
3. Au Eong KG, Tay TH, Lim MK. Education
and myopia in 110,236 young Singaporean
males. Singapore Med J 1993; 34: 485–492.
4. Wu HM, Seet B, Yap EP, Saw SM, Lim TH,
Chia KS. Does education explain ethnic
differences in myopia prevalence? A
population-based study of young adult
males in Singapore. Optom Vis Sci 2001; 78:
234–239.
5. Lin LLK, Shih YF, Hsiao CK, Chen CJ, Lee
LA, Hung PT. Epidemiologic study of the
prevalence and severity of myopia among
school children in Taiwan in 2000. J Formo-
san Med Assoc 2001; 100: 684–691.
6. Lam DS, Houang E, Fan DS, Lyon D, Seal
D, Wong E. Hong Kong Microbial Keratitis
Study Group. Incidence and risk factors for
microbial keratitis in Hong Kong: compari-
son with Europe and North America. Eye
2002; 16: 608–618.
Clinical and Experimental Optometry 92.2 March 2009
88
7. Stapleton F, Keay L, Edwards K, Naduvilath
T, Dart JK, Brian G, Holden BA. The inci-
dence of contact lens-related microbial
keratitis in Australia. Ophthalmology 2008;
115: 1655–1662.
8. Cutter GR, Chalmers RL, Roseman M. The
clinical presentation, prevalence, and risk
factors of focal corneal infiltrates in soft
contact lens wearers. CLAO J 1996; 22:
30–37.
9. Efron N, Morgan PB. Rethinking contact
lens associated keratitis. Clin Exp Optom
2006; 89: 280–298.
10. Fleiszig SMJ. The pathogenesis of contact
lens-related keratitis. Optom Vis Sci 2006; 83:
E866–E873.
11. Willcox MDP. Pseudomonas aeruginosa infec-
tion and inflammation during contact lens
wear: A review. Optom Vis Sci 2007; 84: 273–
278.
12. Stapleton F, Dart JKG, Minassian D.
Risk factors in contact lens associated
suppurative keratitis. CLAO J 1993;19: 204–
210.
13. Wilhemus KR. Bacterial keratitis. In:
Pepose JS, Holland GN, Wilhemus KR, eds.
Ocular Infection and Immunity. St Louis:
Mosby, 1996. p 970–1032.
14. Keay L, Edwards K, Stapleton F. Referral
pathways and management of contact lens-
related microbial keratitis in Australia and
New Zealand. Clin Experiment Ophthalmol
2008; 36: 209–216.
15. Schein OD, Glynn RJ, Poggio EC, Seddon
JM, Kenyon KR. The relative risk of ulcer-
ative keratitis among users of daily-wear and
extended-wear soft contact lenses: A case-
control study. New Eng J Med 1989; 321:
773–778.
16. Poggio EC, Glynn RJ, Schein OD, Seddon
JM, Shannon MJ, Scardino VA, Kenyon KR.
The incidence of ulcerative keratitis among
users of daily-wear and extended-wear soft
contact lenses. New Eng J Med 1989; 321:
779–783.
17. Cheng KH, Leung SL, Hoekman HW,
Beekhuis WH, Mulder PG, Geerards AJ,
Kijlstra A. Incidence of contact-lens associ-
ated microbial keratitis and its related mor-
bidity. Lancet 1999; 354: 181–185.
18. Dart JKG, Stapleton F, Minassian D. Contact
lenses and other risk factors in microbial
keratitis. Lancet 1991; 338: 651–653.
19. Nilsson S, Montan PG. The hospitalised
cases of contact lens induced keratitis in
Sweden and their relation to lens type and
wear schedule: results of a three-year
retrospective study. CLAO J 1994; 20: 97–
101.
20. Matthews TD, Frazer DG, Minassian DC,
Radford CF, Dart JK. Risks of keratitis and
patterns of use with disposable contact
lenses. Arch Ophthalmol 1992; 110: 1559–
1562.
Journal compilation © 2009 Optometrists Association Australia
21. Dart JK, Radford CF, Minassian D, Verma S,
Stapleton F. Risk factors for microbial
keratitis with contemporary contact lenses:
a case-control study. Ophthalmology 2008;
115: 1647–1654.
22. ECP Research Report, ResearchLink, July
2007.
23. Sankaridurg PR, Sharma S, Willcox M,
Naduvilath TJ, Sweeney DF, Holden BA,
Rao GN. Bacterial colonization of dispos-
able soft contact lenses is greater during
corneal infiltrative events than during
asymptomatic extended lens wear. J Clin
Microbiol 2000; 38: 4420–4424.
24. Stapleton F, Keay L, Jalbert I, Cole N. The
epidemiology of contact lens related infil-
trates. Optom Vis Sci 2007; 84: 257–272.
25. Sweeney DF, Willcox MDP, Sansey N,
Leitch C, Harmis N, Wong R, Holden BA.
Incidence of contamination of preserved
saline solutions during normal use. CLAO J
1999; 25: 167–175.
26. Morgan P: Contact lens compliance and
reducing the risk of keratitis. http://
www.siliconehydrogels.com./editorials/.
27. Mack CJ. Contact lenses 2007. Contact Lens
Spectrum January 2008.
28. Yung MS, Boost M, Cho P, Yap M. Microbial
contamination of contact lenses and lens
care accessories of soft contact lens wearers
(university students) in Hong Kong. Oph-
thalmic Physiol Optics 2007; 27: 11–21.
29. McLaughlin-Borlace L, Stapleton F, Mathe-
son M, Dart JK. Bacterial biofilm on contact
lenses and lens storage cases in wearers with
microbial keratitis. J Appl Microbiol 1998; 84,
827–838.
30. Willcox MDP, Harmis N, Cowell BA, Will-
iams T, Holden BA. Bacterial interactions
with contact lenses; effects of lens material,
lens wear and microbial physiology. Bioma-
terials 2001; 2: 3235–3247.
31. LeChevallier MW, Cawthon CD, Lee RG.
Inactivation of biofilm bacteria. Appl
Environ Microbiol 1988; 54: 2492–2499.
32. Boost MV, Cho P. Microbial flora of tears
of orthokeratology patients and microbial
contamination of contact lenses and
contact lens accessories. Optom Vis Sci 2005;
82: 451–458.
33. Devonshire P, Munro FA, Abernethy C,
Clark BJ. Microbial contamination of con-
tact lens cases in the west of Scotland. Br J
Ophthalmol 1993;77: 41–45.
34. Cheng KH, Leung SL, Hoekman HW,
Beekhuis WH, Mulder PGH, Geerards
AJM, Kijlstra A. Incidence of contact-lens-
associated microbial keratitis and its related
morbidity. Lancet 1999; 354: 181–185.
35. Houang E, Lam D, Fan D, Seal D. Microbial
keratitis in Hong Kong: relationship to
climate, environment and contact-lens dis-
infection. Trans R Soc Trop Med Hyg 2001;
95: 361–367.
© 2009 Institute for Eye Research

36. Ng V. Lens care study key findings (Presen-
tation). Asia Pacific Contact Lens Care
Summit, Singapore, Nov 2007.
37. Zhu H, Bandara M, Kumar A, Masoudi S,
Wu D, Willcox MDP. Contribution of
regimen steps to efficacy of multipurpose
solutions used to disinfect silicone hydrogel
contact lenses. XVIII International Con-
gress of Eye Research, Beijing Sep 24–29,
2008.
38. Rosenthal RA, Sutton SV, Schlech BA.
Review of standard for evaluating the effec-
tiveness of contact lens disinfectants. PDA J
Pharm Sci Technol 2002: 56: 37–50.
39. Barry MA, Pendarvis J, Mshar P. Morbidity
and Mortality Weekly Report. 2006. May 26.
Update: Fusarium keratitis—United States
2005–2006: 55: 563–564.
40. Khor WB, Aung T, Saw SM, Wong TY,
Tambyah PA, Tan AL, Beuerman R et al.
An outbreak of Fusarium keratitis associated
with contact lens wear in Singapore. JAMA
2006; 295; 2867–2873.
41. Saw SM, Ooi PL, Tan DT, Khor WB, Fong
CW, Lim J, Cajucom-Uy HY. Risk factors for
contact lens-related Fusarium keratitis. Arch
Ophthalmol 2007; 125: 611–617.
42. Chang DC, Grant GB, O’Donnell K, Wan-
nemuehler KA, Noble-Wang J, Rao CY,
Jacobson LM et al. Multistate outbreak of
Fusarium keratitis associated with use of a
contact lens solution. JAMA 2006; 296: 953–
963.
43. Manuj K, Gunderson C, Troupe J, Huber
ME. Efficacy of contact lens disinfecting
solutions against Staphylococcus aureus and
Pseudomonas aeruginosa. Eye Contact Lens
2006; 32: 216–218.
44. Hume EBH, Zhu H, Cole N, Huynh C, Lam
S, Willcox MD. Efficacy of contact lens mul-
tipurpose solutions against Serratia marce-
scens. Optom Vis Sci 2007; 84: 316–320.
45. Bryant K, Chang T, Chen S. Morbidity
and Mortality Weekly Report. 2007. June 1.
Acanthamoeba keratitis Multiple States
2005–2007: 56: 532–534.
46. Cho P, Cheng SY, Can WY, Yip WK. Soft
contact lens cleaning—rub or no-rub? Oph-
thalmic Physiol Optics. In press.
47. Summary minutes, Medical Devices Advi-
sory Committee, Ophthalmic Devices
Panel, 111th Meeting, June 10 2008 http://
www.fda.gov/ohrms/dockets/ac/08/
minutes/2008-4363m1.pdf.
48. Carnt N, Keay L, Naduvilath T, Holden BA,
Willcox MDP. Risk factors associated with
corneal inflammation in soft contact lens
daily wear. Invest Ophthalmol Vis Sci 2007; 48:
E-abstract 4326.
49. Shoff ME, Joslin CE, Tu EY, Kubatko L,
Fuerst PA. Efficacy of contact lens systems
against recent clinical and tap water Acan-
thamoeba issues. Cornea 2008; 27: 713–
719.
© 2009 Institute for Eye Research
Journal compilation © 2009 Optometrists Association Australia
CL Care Summit Sweeney, Holden, Evans, Ng and Cho
50. Hughes R, Kilvington S. Comparison of university population. J Br Contact Lens Assoc
hydrogen peroxide contact lens disinfec- 1993; 16: 105–111.
tion systems and solutions against Acan- 64. Claydon BE, Efron N, Woods C. A prospec-
thamoeba polyphaga. Antimicrob Agents tive study of the effect of education on non-
Chemother 2001; 45: 2038–2043. compliance behaviour in contact lens wear.
51. Carnt NA, Willcox MDP, Evans VE, Naduvi- Ophthalmic Physiol Optics 1997; 17: 137–
lath TJ, Tilia D, Papas EB, Sweeney DF et al. 146.
Corneal staining with various contact lens 65. Yung AM, Boost MV, Cho P, Yap M. The
solutions—Silicone hydrogel lens combina- effect of a compliance strategy (self-review)
tions and significance: The IER Matrix on the level of lens care compliance and
Study. Contact Lens Spectrum September, contamination of contact lenses and lens
2007. care accessories. Clin Exp Optom 2007; 90:
52. Carnt NA, Evans VE, Holden BA, Naduvi- 190–202.
lath TJ, Tilia D, Papas EB, Willcox MDP.
The IER Matrix Study update with Night Corresponding author:
and Day. Contact Lens Spectrum March, 2008. Professor D Sweeney
53. Nichols KK, Mitchell GLM, Stonebraker S, Vision CRC
Karen M, Chivers DA, Edrington TB.
Corneal staining in hydrogel lens wearers.
Rupert Myers Building
Optom Vis Sci 2002; 79: 20–30. University of New South Wales
54. Carnt N, Jalbert I, Stretton S, Naduvilath T, Sydney NSW 2052
Papas E. Solution toxicity in soft contact AUSTRALIA
lens daily wear is associated with corneal E-mail: d.sweeney@ier.org.au
inflammation. Optom Vis Sci 2007; 84: 309–
315.
55. Tilia D, Jalbert I, Carnt N, Keay L, Naduvi-
lath T, Willcox MDP, Papas E et al. Evalua-
tion of solution toxicity associated with lens
care products during silicone hydrogel lens
wear. American Academy of Optometry
Meeting, 2006.
56. Jones L. Understanding incompatibilities.
Contact Lens Spectrum July 2004.
57. Andrasko G, Ryen K. Corneal staining and
comfort observed with traditional and sili-
cone hydrogel lenses and multipurpose
solution combinations. Optometry 2008; 79:
444–454.
58. Donshik PC, Ehlers WH, Anderson LD,
Sucheki JK. Strategies to better engage,
educate and empower patient compliance
and safe lens wear: compliance: what we
know, what we do not know, and what we
need to know. Eye Contact Lens 2007; 33:
430–433.
59. Claydon BE, Efron N. Non-compliance in
contact lens wear. Ophthalmic Physiol Opt
1994; 14: 356–364.
60. Kame RT. Clinical management of
hydrogel-induced edema. Am J Optom
Physiol Opt 1976; 15: 61–63.
61. Sankaridurg PR, Willcox MDP, Sharma S,
Gopinathan U, Janakiraman D, Hickson S,
Vuppala N et al. Haemophilus influenzae
adherent to contact lenses associated with
production of acute ocular inflammation. J
Clin Microbiol 1996; 34: 2426–2431.
62. Keay L, Edwards K, Stapleton F. Putting
research into practice: Contact lens ass-
ociated MK. Editorial http://www.
siliconehydrogels.com./editorials/nov_05.
asp.
63. Radford CF, Woodward EG, Stapleton F.
Contact lens hygiene compliance in a
Clinical and Experimental Optometry 92.2 March 2009
89