On Infection Prevention & Control

Experiences, case studies and news about infection prevention and control.

Failure to High Level Disinfect Ophthalmology Devices Leading to Transmission of Infectious Agents


By Sylvia Garcia-Houchins, MSN, RN, CIC, director, Infection Prevention and Control
The American Academy of Ophthalmology has reported that transmission of infectious agents could occur from failure to adequately disinfect ophthalmology devices, such as tonometers, which is resulting in multiple declarations of an immediate threat to health and safety of patients.
Infectious agents that could be transmitted include:
  • adenovirus 
  • herpes simplex virus HIV
  • hepatitis C virus (HCV)
  • enterovirus 70
  • Pseudomonas aeruginosa
  • methicillin-resistant Staphylococcus aureus
  • Acanthamoeba
  • prions (transmissible spongiform encephalopathies, such as Creutzfeldt-Jakob disease) 
In reviewing Joint Commission survey data, we have identified either a lack of awareness of the requirements or misinterpretation of manufacturer’s instructions — combined with lack of staff training and leadership oversight — related to the disinfection of ophthalmology devices. The Joint Commission issued QuickSafety 49: Disinfection of tonometers and other opthamology devices earlier this month.
Reprocessing Issues with Eye Equipment
Lack of compliance with reprocessing has been observed with tonometers, YAG laser lens, and eye specula. Tonometer tips are particularly problematic because disinfectants can dissolve the glue that holds the hollow tip together, causing the tip to swell and crack. It’s important to note that tonometer tips have been identified as sources of ophthalmic nosocomial outbreaks commonly linked to adenovirus types 8 and 19. Desiccated virus remains viable and can be recovered after 49 days on dried plastic or metal surfaces.
Areas where these items are used include: 
  • emergency departments 
  • urgent care centers 
  • ophthalmology clinics
  • optometrist offices and procedure rooms 
  • neonatal intensive care units (NICUs) 
Safe Sterilization Practices
Items that touch mucous membranes — such as the eye — must be, at minimum, high-level disinfected. Items that come into contact or enter sterile tissues — such as instruments that are used for surgical procedures or touch an ulcerated cornea — must be sterilized. 
Health care organizations can use the following safety actions to protect patients from the risk of infection associated with tonometers and other ophthalmology devices: 
  • Review cleaning and disinfection instructions for use of eye instruments to ensure they are being reprocessed appropriately. Items that touch intact surfaces of the eye must be high-level disinfected. Those that touch non-intact surfaces of the eye or are used for eye surgery must be sterilized. 
  • Ensure that disinfectants listed as compatible, other than bleach, are U.S. Food and Drug Administration (FDA)-approved high-level disinfectants. Manufacturers often list products as compatible that may be used for pre-cleaning. Some of these products may be commonly available surface disinfectants but are not effective as high-level disinfectants.
  • Keep and follow manufacturer instructions for use for both the devices used for ophthalmology examinations and procedures, as well as cleaning and disinfection products.
  • Ask a well-informed individual who has knowledge about different types of disinfectants to review the product label and instructions for use. If instructions are unclear, technical services for the manufacturer of the item and any products used in conjunction with reprocessing should be contacted.
These seemingly simple steps can help avoid an “immediate threat to health and safety” survey finding and, more importantly, keep your patients safe from serious infections.
Sylvia Garcia is the director, Infection Prevention and Control in the Division of Healthcare Improvement. Garcia has over 30 years of experience in infection control in both hospital and long term care settings, as well as eight years of clinical microbiology experience. Most recently, she served as the director, Infection Control at University of Chicago Medicine and was also an intermittent consultant for Joint Commission Resources for 10 years. Ms. Garcia has provided infection prevention and control consultation, assessment and education in a variety of health care settings including hospitals, health clinics, ambulatory surgery, and dialysis centers both domestically and internationally.