The effect of currently available contact lens disinfection systems on Acanthamoeba castellanii and Acanthamoeba polyphaga

Common Ophthalmic Preservatives in Soft Contact Lens Care Products: Benefits, Complications, and a Comparison to Non-Preserved Solutions

PURPOSE

Preservatives are essential for preventing contact lens (CL)-related microbial keratitis (MK). The purpose of this review is to summarize the current knowledge related to the use of common ophthalmic preservatives in CL care products with respect to both safety and efficacy.

METHODS

Manuscripts written in English were obtained by searching PubMed.gov with the term contact lens plus antimicrobial, benzalkonium chloride, biguanide, Aldox, polyquaternium, preservative, thimerosal, EDTA (ethylenediaminetetraacetic acid), chlorhexidine, or blister pack.

RESULTS

This review found that first-generation preservatives are no longer used in CL multipurpose solutions (MPS) due to their high levels of ocular toxicity. Modern, high-molecular-weight preservatives, including polyquaternium-1 (PQ-1) and biguanides (PHMB), are generally effective against bacteria, minimally effective against fungi, and not effective against Acanthamoeba. PQ-1 and PHMB are likely safe when used with CLs, but they may cause ocular adverse events, with roughly equal risk between the two preservatives. Some CL MPS contain both PQ-1 and PHMB, but no increased risk of adverse events has been reported when combining the two. Hydrogen-peroxide (H₂O₂) solutions are effective against all common ocular microbes, including Acanthamoeba, and they have been proven safe with proper compliance. Povidone-iodine (P-I) solutions are not currently commercially available in North America, but they have been shown in other countries to be safe and effective.

CONCLUSION

Patients should be monitored when using PQ-1 or PHMB-containing solutions since they have been associated with ocular adverse events. If events are detected, patients should be switched to an alternative solution. H₂O₂ or P-I solutions are preferred for any patient who may expose their CLs to water because they are the only solution categories effective against Acanthamoeba.

Acanthamoeba keratitis and contact lens wear

Acanthamoeba keratitis is a rare but serious complication of contact lens wear that may cause severe visual loss. The clinical picture is usually characterised by severe pain, sometimes disproportionate to the signs, with an early superficial keratitis that is often misdiagnosed as herpes simplex virus (HSV) keratitis. Advanced stages of the infection are usually characterised by central corneal epithelial loss and marked stromal opacification with subsequent loss of vision. In this paper, six cases of contact lens-related Acanthamoeba keratitis that occurred in Australia and New Zealand over a three-year period are described. Three of the patients were disposable soft lens wearers, two were hybrid lens wearers and one was a rigid gas permeable lens wearer. For all six cases, the risk factors for Acanthamoeba keratitis were contact lens wear with inappropriate or ineffective lens maintenance and exposure of the contact lenses to tap or other sources of water. All six patients responded well to medical therapy that involved topical use of appropriate therapeutic agents, most commonly polyhexamethylene biguanide and propamidine isethionate, although two of the patients also subsequently underwent deep lamellar keratoplasty due to residual corneal surface irregularity and stromal scarring. Despite the significant advances that have been made in the medical therapy of Acanthamoeba keratitis over the past 10 years, prevention remains the best treatment and patients who wear contact lenses must be thoroughly educated about the proper use and care of the lenses. In particular, exposure of the contact lenses to tap water or other sources of water should be avoided.

Chemical disinfectants in ophthalmic practice

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

Variables Affecting the Recovery of Acanthamoeba Trophozoites

While the results of Acanthamoeba testing have been extensively published, laboratories conducting such testing are left to develop their own methods in the absence of a standardized methodology. The wide disparity of methods has resulted in equally inconsistent reported results for contact lens care (CLC) products. This study's objective was to determine the source of these discrepancies by evaluating basic Acanthamoeba biology and their impact on antimicrobial efficacy testing, including the ability of a recovery method to stimulate a single trophozoite to proliferate. Antimicrobial efficacy testing was conducted using well-published Acanthamoeba strains, storage conditions, and growth-based recovery methods. To identify variables that influence results, test solutions with low Acanthamoeba disinfection rates were utilized to prevent differences from being masked by high log reductions. In addition, single-cell proliferation assays were executed to understand the growth requirements to stimulate trophozoite propagation in two recovery methods. These studies indicated that both nutrient density (>106 CFU) and the length of plate incubation (at least 14 days) could significantly influence the accurate recovery of trophozoites. Together, this study emphasizes the need to understand how Acanthamoeba trophozoites biology can impact test methods to create divergent results.

Effectiveness of a polyhexanide irrigation solution on methicillin-resistant Staphylococcus aureus biofilms in a porcine wound model

Irrigation and removal of necrotic debris can be beneficial for proper healing. It is becoming increasingly evident that wounds colonized with biofilm forming bacteria, such as Staphylococcus aureus (SA), can be more difficult to eradicate. Here we report our findings of the effects of an irrigation solution containing propyl-betaine and polyhexanide (PHMB) on methicillin-resistant Staphylococcus aureus (MRSA) biofilms in a porcine wound model. Thirty-nine deep partial thickness wounds were created with six wounds assigned to one of six treatment groups: (i) PHMB, (ii) Ringer's solution, (iii) hypochlorous acid/sodium hypochlorite, (iv) sterile water, (v) octenidine dihydrochloride, and (vi) octenilin. Wounds were inoculated with MRSA and covered with a polyurethane dressing for 24 hours to allow biofilm formation. The dressings were then removed and the wounds were irrigated twice daily for 3 days with the appropriate solution. MRSA from four wounds were recovered from each treatment group at 3 days and 6 days hours after initial treatment. Irrigation of wounds with the PHMB solution resulted in 97·85% and 99·64% reductions of MRSA at the respective 3 days and 6 days assessment times when compared to the untreated group. Both of these reductions were statistically significant compared to all other treatment groups (P values <0·05).

The comparison of antimicrobial effectiveness of contact lens solutions

PURPOSE

The aim of this study was to compare the effects of widely used multipurpose contact lens solutions against Staphylococcus aureus and Pseudomonas aeruginosa, in addition to cystic and trophozoite forms of Acanthamoeba castellanii and A. polyphaga, that cause microbial keratitis.

METHODS

Three multipurpose solutions were tested: SOLO-care, ReNu, and Opti-Free Express. The test solutions were challenged with P. aeruginosa (ATCC 27853) and S. aureus (ATCC 2913) based on the ISO stand-alone and regiment test procedure for disinfecting products, A. polyphaga (ATCC 30871) and A. castellanii (1501/1A) cystic and trophozoite forms. Multipurpose solutions were sampled for surviving microorganisms at manufacturer's minimum recommended disinfection time. The number of viable organisms was determined, and log reductions were calculated.

RESULTS

ReNu and SOLO-care resulted in a reduction greater than the required mean 3.0 logarithmic reduction against S. aureus, and SOLO-care and Opti-Free Express resulted in a reduction more than the required mean 3.0 logarithmic reduction against P. aeruginosa. Against the cystic and trophozoite forms of A. castellanii, the log reduction provided by SOLO-care was 1.01 and 1.31 log, respectively. ReNu provided a 0.83 log reduction of the cystic form and a 1.21 log reduction of the trophozoite form. Using Opti-Free Express, the log reduction for both forms was 1.31. SOLO-care led to a 0.61 log reduction of the cystic form of A. polyphaga and a 1.01 log reduction of the trophozoite form. ReNu provided a 0.41 log reduction of the cystic form and a 4.99 log reduction of the trophozoite form. Opti-free Express resulted in a 0.89 log reduction of the cystic form and a 3.11 log reduction of the trophozoite form.

CONCLUSIONS

Multipurpose contact lens solutions using similar regimens can show different disinfection abilities.

The use of dimethyl sulfoxide in contact lens disinfectants is a potential preventative strategy against contracting Acanthamoeba keratitis

Acanthamoeba castellanii is the causative agent of blinding keratitis. Though reported in non-contact lens wearers, it is most frequently associated with improper use of contact lens. For contact lens wearers, amoebae attachment to the lens is a critical first step, followed by amoebae binding to the corneal epithelial cells during extended lens wear. Acanthamoeba attachment to surfaces (biological or inert) and migration is an active process and occurs during the trophozoite stage. Thus retaining amoebae in the cyst stage (dormant form) offers an added preventative measure in impeding parasite traversal from the contact lens onto the cornea. Here, we showed that as low as 3% DMSO, abolished A. castellanii excystation. Based on the findings, it is proposed that DMSO should be included in the contact lens disinfectants as an added preventative strategy against contracting Acanthamoeba keratitis.

Miraflow, Soft Contact Lens Cleaner: Activity Against Acanthamoeba Spp

OBJECTIVE

Miraflow is a cleaner for soft contact lens which contains 20% isopropyl alcohol. The purpose of this study was to determine the activity against Acanthamoeba trophozoites and cysts for Miraflow. In addition, to determine the activity of combined Miraflow and multipurpose solutions (MPSs) against Acanthamoeba cysts.

METHODS

Two simulated-use studies were conducted. The significance in the log reduction in the number of trophozoites and cysts of A. castellanii strains ATCC 50514 and ATCC 50370 or A. polyphaga ATCC 30461 after exposure to Miraflow alone was determined by the Spearman-Karber method. To examine the activity against Acanthamoeba of combined Miraflow and an MPS, the log reduction in the number of cysts after a 1-min exposure to Miraflow followed by a 4-hr exposure to MPS (ReNu fresh) was also determined.

RESULTS

Short-time exposure of 30 sec to Miraflow demonstrated activity against the Acanthamoeba trophozoites. However, a 1-min treatment was only relatively effective (1.1 log reduction) against the cysts of A. castellanii ATCC 50514, but no statistically significant reduction was observed for the cysts of the other 2 strains. The combined use with Miraflow and MPS demonstrated activity against the cysts, and a 3.0, 1.0, or 1.5 log reduction in the numbers was obtained for A. castellanii ATCC 50514, A. castellanii ATCC 50370, and A. polyphaga ATCC 30461, respectively.

CONCLUSIONS

Exposure to combined Miraflow and MPS resulted in reductions in the number of Acanthamoeba cysts.

Effect of low concentrations of benzalkonium chloride on acanthamoebal survival and its potential impact on empirical therapy of infectious keratitis

IMPORTANCE

The significant antiacanthamoebal effect of benzalkonium chloride, at or below concentrations used for preservation of common ophthalmic preparations, should be understood both when choosing empiric antibiotic therapy for infectious keratitis and when assessing the persistent rise in Acanthamoeba cases in the United States since 2003.

OBJECTIVE

To characterize the antiacanthamoebal efficacy of low concentrations of benzalkonium chloride (BAK) for drug preservation and therapeutic effect against Acanthamoeba.

DESIGN

Experimental study with a review of the literature.

SETTING

Laboratory.

EXPOSURES

A concentration of 10(4) trophozoites of 3 well-characterized clinical strains of Acanthamoeba were exposed at 0.5, 2.0, 3.5, 5.0, and 6.5 hours to BAK (0.001%, 0.002%, and 0.003%), moxifloxacin hydrochloride (0.5%), and moxifloxacin (0.5%) + BAK (0.001% and 0.003%) with hydrogen peroxide (3%) and amoeba saline controls.

MAIN OUTCOMES AND MEASURES

Amoeba survival was calculated using the most probable number method recorded as log kill values. The relationship of BAK concentration and exposure time as well as the relative effect of BAK and moxifloxacin on acanthamoebal survival were analyzed.

RESULTS

Amoebicidal activity of BAK is both time dependent and concentration dependent in pooled and strain-stratified analyses (P < .001). Moxifloxacin demonstrated no significant independent inhibitory effect or additive effect to BAK efficacy on acanthamoebal survival. The profound antiacanthamoebal effect of BAK, 0.003%, was similar to that of hydrogen peroxide for certain strains.

CONCLUSIONS AND RELEVANCE

Low concentrations of BAK, previously demonstrated to concentrate and persist in ocular surface epithelium, exhibit significant antiacanthamoebal activity in vitro at or below concentrations found in commercially available ophthalmic anti-infectives. The unexplained persistence of the Acanthamoeba keratitis outbreak in the United States, clusters abroad, and clinical studies reporting resolution or modification of Acanthamoeba keratitis without specific antiacanthamoebal therapy suggests that other contributing factors should be considered, including changes in the formulations used for empirical therapy of presumed infectious keratitis occurring in the same period.

Hygiene compliance in contact lens wearers presenting to an ophthalmic casualty department

Poor compliance with contact lens care regimens is a factor considered important in the development of potentially sight-threatening microbial keratitis. The purpose of this study was to highlight particular areas of non-compliance in contact lens care. One hundred and sixty contact lens wearers, who presented to an ophthalmic casualty department over a period of six months, were surveyed using a self-administered questionnaire. Of the 142 patients who used daily wear lenses, 29 (20 per cent) did not clean/disinfect their contact lenses after every use. Soft contact lens wearers used a wide variety of care regimens, some of which would be ineffective in disinfecting the lenses. The care of the lens case was a particular problem, with only 10 patients (7 per cent) using a regular and effective method of case cleaning. Seventy-three patients (50 per cent) either rarely or never discarded their contact lens solutions 28 days after opening. Of the 128 patients wearing non-disposable lenses, 43 (34 per cent) either rarely or never used enzymatic cleaning tablets to remove protein from their lenses. Tap water, a potential source of microbial contamination, was used for rinsing contact lenses before or after cleaning by 36 patients (25 per cent). The results highlight specific areas where there was deviation from recognised standards of practice for contact lens care. There is a need for contact lens wearers to be re-educated in the care of their lenses. Since pharmacies are a major source of contact lens care products, pharmacy staff could have an important role to play in the counselling of contact lens wearers to help prevent serious ocular pathologies.

In vitro amoebicidal activity of a ceragenin, cationic steroid antibiotic-13, against Acanthamoeba castellanii and its cytotoxic potential

Acanthamoeba is a free-living amoeba causing a potentially blinding infection of the cornea. Acanthamoeba keratitis is difficult to treat, without total efficacy in some patients because of cysts that are less susceptible than trophozoites to the usual treatments. Contact lens wearers are most at risk and account for some 95% of cases. Cationic steroid antibiotic (CSA)-13 is a small molecule aminosterol that has been shown to mimic the activity of endogenous antimicrobial peptides and has bactericidal activity based on membrane disruption. We investigated here the in vitro effectiveness of CSA-13 with a concentration of 100, 75, 50, and 25  mg/mL on proliferation of Acanthamoeba castellanii trophozoites and cysts and cytotoxic potential. CSA-13 was evaluated for its amoebicidal activity using an inverted light microscope at 1, 2, 4, 8, 12, and 24  h. For the determination of cytotoxicity of the CSA-13 on L929 cells, agar diffusion tests were performed. CSA-13 inhibited trophozoite growth in dose- and time-dependent ways. At 1  h, no viable trophozoites were observed in the presence of CSA-13 solution in a concentration 100  mg/mL in phosphate-buffered saline. Results of cytotoxicity experiments demonstrated that CSA-13 solution had mild toxicity at 100  mg/mL concentration on cells, whereas it had no toxicity at 75  mg/mL concentration. The findings of this experiment as in vitro ameboebicidal activity for Acanthamoeba suggest that CSA-13 has a potential to be used as a new agent in lens solutions to prevent Acanthamoeba growth and infections.

Prevalence of Acanthamoeba spp. and other free-living amoebae in household water, Ohio, USA--1990-1992

Knowledge of the prevalence of free-living amoebae (FLA) in US household water can provide a focus for prevention of amoeba-associated illnesses. Household water samples from two Ohio counties, collected and examined for amoebae during 1990-1992, were used to describe the prevalence of Acanthamoeba and other FLA in a household setting. Amoebae were isolated and identified by morphologic features. A total of 2,454 samples from 467 households were examined. Amoebae were found in water samples of 371 (79%) households. Sites most likely to contain amoeba were shower heads (52%) and kitchen sprayers (50%). Species of Hartmannella, Acanthamoeba, or Vahlkampfia were most common. Detection was higher in biofilm swab samples than in water samples. Detection of FLA and Acanthamoeba, at 79% and 51%, respectively, exceed estimates that have been published in previous surveys of household sources. We believe FLA are commonplace inhabitants of household water in this sample as they are in the environment.

18S ribosomal DNA genotypes of Acanthamoeba species isolated from contact lens cases in the Philippines

This study was carried out to document the genotypes of Acanthamoeba present in contact lens cases from 50 randomly selected contact lens wearers living in Quezon City, Metro Manila, Philippines. Acanthamoeba species were isolated from eight (16%) in 50 contact lens cases examined. We analyzed partial 18S ribosomal DNA (Rns) sequences of the eight isolates and found that the sequence differences were sufficient to distinguish the genotypes. After the isolates were genotyped, using the Basic Local Alignment Search Tool program, their phylogenetic positions relative to known Acanthamoeba isolates were determined. The model-based (GTR+Gamma+Iota) neighbor-joining, maximum likelihood, and Bayesian inference analyses, as well as the non-model-based maximum parsimony analysis were used. Results showed that of the eight isolates, six were Rns genotype T5 while two were Rns genotype T4. This present study indicates that genotype T5 is also a common contaminant in contact lens storage cases.

Bilateral acanthamoeba keratitis after orthokeratology

PURPOSE

To report bilateral Acanthamoeba keratitis after wearing an overnight reverse geometric contact lens for 5 days.

METHODS

Case report and review of the medical literature

RESULTS

A 22-year-old woman developed bilateral corneal ulcers during orthokeratology. A slit-lamp examination showed round epithelial abrasion, radial infiltration, and disciform keratitis in both corneas. Visual acuity OD was hand motion and OS was counting fingers. Bilateral Acanthamoeba keratitis was diagnosed by culture by using non-nutrient agar overlaid with viable Escherichia coli. Small, round, and double-walled cysts were observed in non-nutrient agar under an inverted phase contrast microscope. Topical 0.02% polyhexamethylene biguanide, Cravit (0.5% levofloxacin), and Tobra (0.5% tobramycin) were administered. After 1 month of treatment, the corneal ulcer had healed, and the patient's best-corrected visual acuity was 20/100 OD and 20/25 OS.

CONCLUSIONS

Acanthamoeba keratitis can simultaneously affect both eyes during overnight orthokeratology.

Amoebicidal activities of alexidine against 3 pathogenic strains of acanthamoeba

OBJECTIVES

Effective pharmacotherapy for Acanthamoeba keratitis has been hampered because of the marked resistance of various stains to a variety of antimicrobial agents. In view of the fact that topical Brolene (propamidine isethionate) and neosporin are currently considered to be the first-line medical treatment of choice in Europe, we sought to determine whether Alexidine is equally effective, because the latter drug is more readily available in the United States.

METHODS

Trophozoites and cysts from 3 pathogenic corneal isolates (A. castellanii, A. polyphaga, and A. rhysodes) were incubated in peptone-yeast extract-glucose medium containing different concentrations of Alexidine for 24 hr. The number of trophozoites was counted by hemocytometer. The cysts were plated in to nonnutrient agar plates precoated with Escherichia coli and observed for viability or excystment over a period of 2 weeks. The capacity of different concentrations of Alexidine to induce cytolysis of corneal epithelial cells was tested in vitro. Chinese hamster corneas were treated with 5 microL of Alexidine topically, every hour; 6 times a day and the corneas were stained with fluorescein to asses the epithelial defects in vivo.

RESULTS

Alexidine was effective in killing the trophozoites at a concentration of 10 microg/mL. However, a higher concentration of Alexidine (100 microg/mL) is required to kill Acanthamoeba cysts and the cytotoxic activities of Alexidine are comparable with chlorhexidine. We have also demonstrated that both Alexidine and chlorhexidine at 100 microg/mL induced significant cytopathic effect on the corneal epithelial cells in vitro. In vivo results indicate that Alexidine at a concentration of 100 microg/mL is less toxic than chlorhexidine when applied topically to the Chinese hamster cornea.

CONCLUSIONS

Our study has identified Alexidine as a novel anti-Acanthamoeba drug and suggests that Alexidine may be an effective therapeutic option because of its potency and low toxicity to the corneal tissues when applied topically in vivo.

In vitro evaluation of the amoebicidal activity of garlic (Allium sativum) extract on Acanthamoeba castellanii and its cytotoxic potential on corneal cells

Free-living protozoa of the genus Acanthamoeba can cause one of the most severe, potentially sight-threatening infections of the eye, the so-called A. keratitis. A. keratitis is difficult to treat because, under adverse conditions, the amoeba encyst and medical therapy is often less effective against cysts than against trophozoites. The aim of this study was to investigate evaluate the in vitro effect of the nonpolar subfraction of the methanol extract of garlic (Allium sativum) on the growth of A. castellanii trophozoites and cysts and also its cytotoxicity on corneal cells in vitro. Extract was evaluated for its amoebicidal activity, using an inverted light microscope. The effect of the nonpolar extract with the concentrations, ranging from 0.78 to 62.5 mg/mL on the proliferation of A. castellanii trophozoites and cysts, were examined in vitro. For the determination of cytotoxicity of the extract on corneal cells, agar diffusion tests were performed. The present study demonstrates the in vitro effectiveness of the garlic against the A. castellanii growth curve. Evaluations revealed that garlic inhibits trophozoite growth in dose- and time-dependent ways. In the case of the cyctotoxic acitivities, it showed no cytotoxicity for the cornea cells in the concentration of 3.90 mg/mL. These findings indicate that nonpolar subfraction of the methanol extracts of garlic has amoebicidal, as well as its cysticidal, properties on Acanthamoeba trophozoites and cysts. Garlic alone, and in combination with other amoebicidal agents, may be used in clinical practices after further investigations.

Efficacy of contact lens storage solutions against different acanthamoeba strains

PURPOSE

This study was undertaken in order to determine the susceptibility of acanthamoebae to various contact lens disinfecting systems, with respect to type of disinfectant and exposure time.

METHODS

Ten contact lens solutions, including one new system, were tested for their effectivities against cysts of three Acanthamoeba strains. Of main interest was an incubation time of 8 hours (overnight disinfection) and cyst quantities of 10 and 10, respectively.

RESULTS

Boston Advance (polyaminopropyl biguanide 0.0005%, chlorhexidine 0.003%) for the storage of rigid gas permeable contact lenses destroyed the cysts of all strains at either concentration within one hour of exposure. Meni Care Plus (polyhexamethylene biguanide 0.0005%) also destroyed 10 cysts of all strains, however, 10 cysts only of two strains within one hour; after an exposure time of 8 hours all cysts were killed. The disinfecting solutions for soft contact lenses did not kill 10 cysts of either strain after 8 hours of incubation time.

CONCLUSION

Two of the tested contact lens solutions (the ones for rigid gas permeable lenses) destroyed the cysts of all strains. One of these, containing a combination of two amoebicidal ingredients even after only one hour of exposure time.

Tonometers and infectious risk: myth or reality? Efficacy of different disinfection regimens on tonometer tips

PURPOSE

To evaluate the adequacy of common disinfection regimens for disposable tonometer tips and assess if disinfection of reusable prisms or the use of disposable tips is preferable.

METHODS

We used disposable tonometer tips, using the same material and tip diameter of standard Goldmann tonometer prism. Strains of Pseudomonas aeruginosa, Staphylococcus aureus, Bacillus subtilisand Candida albicanswere tested according to the European standard guidelines for disinfectants test. Antimicrobial effectiveness of the following disinfection practices has been assessed: dry wipe, Minuten wipes (Alpro), soaking in 3% hydrogen peroxide, 0.5% benzalkonium chloride, and 0.5% Pantasept for 1, 5, and 15 min. All tests have been performed three times and all conditions tested in duplicate.

RESULTS

Dry wiping and 1 min soak in 3% hydrogen peroxide were ineffective on all microrganisms. Minuten wipes, 1 min soak in 0.5% benzalkonium chloride or 3% hydrogen peroxide were ineffective on B. subtilis. 0.5% Pantasept soak was effective in 1 min for all microrganisms tested, whereas 3% hydrogen peroxide and 0.5% benzalkonium chloride soaks were effective when performed for at least 5 min. B. subtiliswas the most resistant organism to disinfectant regimes at 1 min time.

CONCLUSIONS

Results of our study demonstrate a relative disinfection efficacy for the different evaluated regimens, provided that correct exposure times are adopted for the chosen disinfectants, a condition difficult to ensure in a busy clinic setting. We conclude that disposable prism tonometry provides a safe alternative to Goldmann tonometry.

One- and two-step hydrogen peroxide contact lens disinfection solutions against Acanthamoeba: How effective are they?

PURPOSE

Effective contact lens disinfection solutions are important to keep the storage case free of acanthamoebae and thus prevent an infection of the eye. The aim of our study was to evaluate the effectivity of two new one-step hydrogen peroxide disinfecting solutions against Acanthamoeba spp. and compare it to the effectivity of other commercially available systems.

METHODS

Nine one-step 3% hydrogen peroxide systems including the new systems Silver Sept (platinum and silver disk for intensifying disinfection) and Blue Vision (newly composed catalytic tablet) and 2 two-step systems (0.6 and 3.0% H(2)O(2)) were tested for their effectivity against cysts of two Acanthamoeba keratitis isolates at different concentrations.

RESULTS

After a soaking time of 8 h (overnight soaking of contact lenses) the 2 two-step systems completely destroyed the cysts of both Acanthamoeba strains, even at the highest concentration of cysts tested. The nine tested one-step systems showed weaker effects. The new Blue Vision system was able to eradicate the cysts of one strain at the low concentration of cysts.

CONCLUSIONS

One-step hydrogen peroxide systems do not have sufficient effects on Acanthamoeba cysts and therefore may not protect the contact lens user from a possible infection of the eye. Further development of tablets like the ones used in the Blue Vision system may result in better cysticidal effects for one-step systems.

Biocides currently used for bronchoscope decontamination are poorly effective against free-living amoebae

Free-living amoebae may be pathogenic and harbor several agents of pneumonia. We tested the susceptibility of amoebal cysts and trophozoites to currently used biocides for bronchoscope decontamination. We showed that two particular biocides are inadequate for disinfecting bronchoscopes, as Acanthamoeba polyphaga survived 3 hours of exposure to these undiluted agents.

Disinfection Capacity of PuriLens Contact Lens Cleaning Unit Against Acanthamoeba

PURPOSE

The PuriLens contact lens system is indicated for cleaning and disinfection of soft (hydrophilic) contact lenses by means of subsonic agitation to remove lens deposits and microorganisms, and ultraviolet irradiation of the storage solution for disinfection. The capacity of the PuriLens system to disinfect storage solutions contaminated with known concentrations of Staphylococcus aureus, Pseudomonas aeruginosa, and Acanthamoeba species was evaluated.

METHODS

An in vitro assessment of the antibacterial and antiparasitic efficacy of the PuriLens system was performed. Separated batches of the storage solution for the cleansing system were contaminated with stock strains of S. aureus and P. aeruginosa. A comparison of the microbiologic content was made between the solution before and after the cycle.

RESULTS

The PuriLens system effectively eradicated S. aureus and P. aeruginosa organisms after a 15-minute cycle. However, viable cysts of acanthamoeba were recovered in the solution after the 15-minute cycle.

CONCLUSIONS

The PuriLens system is highly efficient in protecting against contamination with common bacterial ocular pathogens. Acanthamoeba cysts, however, can survive in the solution or contact lens bath undergoing integrated subsonic debridement and indirect ultraviolet light disinfection. Use of chemical disinfecting solutions that contain agents such as chlorhexidine or other cationic antiseptics may be advisable in conjunction with use of the PuriLens device, especially in high-risk settings.

Determination of amoebicidal activities of multipurpose contact lens solutions by using a most probable number enumeration technique

Six multipurpose contact lens solutions [All-in-One, All-in-One (Light), ReNu MultiPlus, Optifree Express, Complete, and Solo-care soft] were tested for their efficacies against Acanthamoeba castellanii trophozoites and cysts by using a most probable number (MPN) technique for amoebic enumeration. Against trophozoites, All-in-One, ReNu Multiplus, and Optifree Express achieved total kill (log reduction of >3) after the manufacturer's minimum recommended disinfection time (MMRDT), with the remaining solutions failing to reach a log reduction of 1. After 24 h of exposure, all solutions proved trophozoiticidal, achieving, with the exception of Complete (log reduction of 3.13), total kill. Against cysts, All-in-One gave a log reduction of >3 within the MMRDT, with all other solutions failing to achieve a log reduction of 1. After 24 h of exposure, All-in-One achieved total kill of cysts (log reduction of 3.74), ReNu MultiPlus gave a log reduction of 3.15, and the remaining solutions reached log reductions of between 1.09 and 2.27. The MPN technique provides a simple, reliable, and reproducible method of amoebic enumeration that depends on simply establishing the presence or absence of growth on culture plates inoculated with a series of dilutions and determining the MPN of amoebae present from statistical tables. By use of this technique, two of the multipurpose solutions tested, ReNu MultiPlus and Optifree Express, demonstrated effective trophozoiticidal activities within the recommended disinfection times; however, only All-in-One proved effective against both trophozoites and cysts over the same time period. This MPN technique, which uses axenically produced trophozoites and mature, double-walled cysts, has the potential to form the basis of a national standard for amoebicidal efficacy testing of multipurpose contact lens disinfecting solutions.

SA. Phagocytosis affects biguanide sensitivity of Acanthamoeba spp

The incidence of Acanthamoeba keratitis, a disease associated with contact lens wear, has been in apparent decline with the advent of multipurpose contact lens solutions. The concentrations of the biguanides chlorhexidine digluconate (CHX) and particularly polyhexamethylene biguanide (PHMB) included in multipurpose solutions (MPSs) are sublethal for amoebae. We evaluated by flow cytometry the effects of these two biguanides on phagocytosis of particles and the survival of trophozoites of Acanthamoeba castellanii and A. polyphaga. Trophozoites of A. castellanii and A. polyphaga (10(6)/ml) were exposed to solutions of 5 and 50 microg of PHMB and CHX per ml in the presence and absence of particles (i.e., heat-killed yeasts and bacteria and latex beads). In addition, trophozoites were exposed to particles treated with these concentrations of the two biguanides. In the absence of particles, trophozoites of A. polyphaga appeared to be more resistant to the biguanides than those of A. castellanii. In the presence of particles, the rates of survival of both species were decreased. In most instances, particles treated with sublethal concentrations of both biguanides that were adsorbed onto the particles reduced the incidence of phagocytosis. Particles present in MPSs in contact lens cases may be involved in the decreased incidence of Acanthamoeba keratitis.

Resistance of Acanthamoeba castellanii cysts to physical, chemical, and radiological conditions

Resistance of Acanthamoeba castellanii cysts to disinfection agents, antimicrobial agents, heat, freeze-thawing, ultraviolet radiation (UV), gamma irradiation, and cellulase were evaluated in vitro. Following exposure to different agents, the cysts were removed and cultured for A. castellanii trophozoites for 3-14 days. Solutions containing 20% isopropyl alcohol or 10% formalin effectively killed A. castellanii cysts. Hydrogen peroxide (3%, AOSept Disinfectant) effectively killed A. castellanii cysts after 4 hr of exposure. Polyhexamethylene biguanide (0.02%), clotrimazole (0.1%), or propamidine isethionate (Brolene) were effective in killing A. castellanii cysts in vitro. Acanthamoeba castellanii cysts were resistant to both 250 K rads of gamma irradiation and 800 mJ/cm2 of UV irradiation. Excystment of trophozoites was accelerated after exposure to 10, 100, and, 1,000 units of cellulase. These results suggest that A. castellanii cysts benefit by enhanced survival because of their resistance to very harsh environmental conditions.

Degradation of immunoglobulins, protease inhibitors and interleukin-1 by a secretory proteinase of Acanthamoeba castellanii

The effect of a secretory proteinase from the pathogenic amoebae Acanthamoeba castellanii on host's defense-oriented or regulatory proteins such as immunoglobulins, interleukin-1, and protease inhibitors was investigated. The enzyme was found to degrade secretory immunoglobulin A (sIgA), IgG, and IgM. It also degraded interleukin-1 alpha (IL-1 alpha) and IL-1 beta. Its activity was not inhibited by endogenous protease inhibitors, such as alpha 2-macroglobulin, alpha 1-trypsin inhibitor, and alpha 2-antiplasmin. Furthermore, the enzyme rapidly degraded those endogenous protease inhibitors as well. The degradation of host's defense-oriented or regulatory proteins by the Acanthamoeba proteinase suggested that the enzyme might be an important virulence factor in the pathogenesis of Acanthamoeba infection.

Contact lens induced keratitis associated with contact lens wear

PURPOSE

To evaluate clinical characteristics, risk factors, management and outcome of contact lens induced keratitis (CLIK) associated with contact lens wear.

METHODS

The study comprised all consecutive patients presenting with contact lens related presumed microbial keratitis during a 12-month period at our department. Detailed demographic data, type of contact lens, duration of lens wear, wearing schedule and lens hygiene were derived from a self-administered questionnaire. Severity of ulcer, corneal scrapings, treatment and final outcome were evaluated.

RESULTS

27 patients with CLIK, some of which may have been sterile peripheral infiltrates, due to contact lens wear were detected. In the majority of the cases patients had used disposable soft contact lenses (89%) and most of them had a daily wearing schedule (78%). 51.8% patients cleaned their lenses regularly. 6 (22%) applied no disinfection since their lenses were disposable on removal. In 3 of our cases with CLIK, penetrating keratoplasty had to be performed.

CONCLUSION

Disposable contact lenses seem to have been a predisposing factor for contact lens induced keratitis also when used on a daily wear schedule. Insufficient contact lens care products and/or manufacturing characteristics may be responsible for CLIK, which is also observed in otherwise compliant contact lens users. In 3 of our patients with CLIK keratoplasty became necessary, indicating that contact lens induced keratitis may result in severe corneal complications.

Tear IgA and serum IgG antibodies against Acanthamoeba in patients with Acanthamoeba keratitis

PURPOSE

Exposure to Acanthamoebaspecies appears to be ubiquitous, as 50% to 100% of healthy human subjects display anti-Acanthamoebaantibodies. However, the presence of specific anti-Acanthamoebaantibodies in the serum and tears of patients has not been investigated. The prevalence of serum immunoglobulin G (IgG) and tear IgA against three species of Acanthamoebawas assessed in healthy subjects and patients with Acanthamoebakeratitis.

METHODS

The level of specific serum IgG and tear IgA against A. castellanii, A. astronyxis, and A. culbertsoniin the sera of 23 patients and 25 healthy subjects was tested by enzyme-linked immunosorbent assays. Total serum IgM, IgG, and IgA concentrations were measured by nephelometry. Acanthamoebakeratitis was diagnosed clinically and confirmed by in vivo confocal microscopy. In some patients, corneal biopsies were also performed and trophozoites were cultured on lawns of Escherichia colion non-nutrient agar.

RESULTS

All healthy subjects and patients with Acanthamoebakeratitis had detectable serum IgG antibodies against all Acanthamoebaantigens. However, patients with Acanthamoebakeratitis had significantly higher anti-AcanthamoebaIgG antibody titers than healthy subjects. In contrast, Acanthamoeba-specific tear IgA was significantly lower in patients with Acanthamoebakeratitis in comparison with healthy subjects. Total serum immunoglobulins did not differ significantly between healthy subjects and patients with Acanthamoebakeratitis.

CONCLUSIONS

The results suggest that a low level of anti-AcanthamoebaIgA antibody in the tears appears to be associated with Acanthamoebakeratitis.

Microwave treatment of contact lens cases contaminated with acanthamoeba

PURPOSE

Microbially contaminated contact lens cases are a predisposing risk factor for Acanthamoeba keratitis. Several findings have shown that microwave irradiation kills the six Food and Drug Administration test challenge microorganisms. We aimed to determine what effect microwave irradiation has on Acanthamoeba trophozoites and cysts.

METHODS

Different types of contact lens cases were contaminated with trophozoites and cysts of three different Acanthamoeba species (A. comandoni, A. castellanii, A. hatchetti) and were exposed to microwave irradiation for 3, 5, and 8 minutes, respectively.

RESULTS

Trophozoites, as well as cysts of the different Acanthamoeba strains, were effectively killed, even by only 3 minutes of microwave irradiation, and there were no negative effects of irradiation on the contact lens cases themselves.

CONCLUSION

We demonstrate that microwave treatment is a very effective, easy, and cheap method to keep contact lens cases free of Acanthamoeba, thus considerably reducing the risk of an Acanthamoeba keratitis.

A comparison of cyst age and assay method of the efficacy of contact lens disinfectants against Acanthamoeba

AIMS

(i) To determine effect of Acanthamoeba cyst age, method of production, and (ii) to assay technique on the efficacy of multipurpose solutions (MPS) and hydrogen peroxide based contact lens disinfectants. (iii) To establish if MPS can remove mature cysts from contact lenses according to the ISO/DIS 14729 regimen test for microbe removal.

METHODS

Immature and mature cysts of A polyphaga were tested against the MPS Opti-Free express and the hydrogen peroxide based solutions Oxysept 1Step and Oxysept 1 using two assay methods. Simulated patient regimen testing was performed with the Opti-Free express and Complete using mature cysts inoculated on to group I or group IV lenses.

RESULTS

Immature cysts were sensitive to disinfection by all solutions. No killing was observed with mature cysts with Opti-Free express, while immature cysts yielded a 1-2 log reduction in viability. Oxysept 1Step gave a 1.1 (SD 0.3) log reduction in mature cysts after 6 hours. Oxysept 1 gave a 2.4 (0.3) log reduction in mature cysts after 4 hours and a 3.8 (0.5) log reduction after 6 hours. Patient regimen testing using Opti-Free express and Complete resulted in no recovery of viable mature cysts from the contact lenses or from the soaking solutions.

CONCLUSION

Cyst age but not method of production used in this study influences the efficacy of contact lens disinfectants against Acanthamoeba. MPS are effective in removing cysts from contact lens surfaces and may have a role in the prevention of acanthamoeba keratitis.

Characterization and pathogenetic role of proteinase from Acanthamoeba castellanii

A secreted proteinase was purified from the culture supernatant of Acanthamoeba castellanii with several chromatographic steps. The purified proteinase was a chymotrypsin-like serine proteinase. Its molecular weight was approximately 12 kDa on SDS-PAGE, and its native molecular weight was 12 kDa when determined by molecular sieve chromatography. It showed a broad temperature optimum ranging 30-55 degrees C with an optimal at 55 degrees C and an optimal pH of 8.5. It could degrade various protein substrates, such as collagen, fibronectin, laminin, secretory immunoglobulin A, immunoglobulin G, plasminogen, fibrinogen, haemoglobin and rabbit corneal proteins. It showed strong cytopathic effects in cultured cells, including HEp2 and HEK cells. The corneal lesions, induced by both the purified proteinase and A. castellanii, displayed similar clinical results for both cases, in which the stromal infiltration and opacity with the epithelial defect were revealed. These results suggest that the enzyme was highly associated with the pathogenesis of Acanthamoeba. The fact that cytopathic effects and development of corneal lesions caused by the proteinase of Acanthamoeba were inhibited by the proteinase inhibitor suggest that the proteinase inhibitor might be useful as a therapeutic agent.

Purification and characterization of iron superoxide dismutase and copper-zinc superoxide dismutase from Acanthamoeba castellanii

Two superoxide dismutases (SOD I and SOD II) were purified from Acanthamoeba castellanii and characterized for several biochemical properties. Analysis of the primary structure and inhibition studies revealed that SOD I is iron SOD (Fe-SOD), with a molecular mass of 50 kDa, and SOD II is copper-zinc SOD (Cu,Zn-SOD), with a molecular mass of 38 kDa. Both enzymes have a homodimeric structure consisting of 2 identical subunits, each with a molecular mass of 26 and 19 kDa for SOD I and SOD II, respectively. The isoelectric points of SOD I and SOD II were 6.4 and 3.5, respectively, and there were no isoenzyme forms detected. Both enzymes show a broad optimal pH of 7.0-11.0. Because no differences were observed in the apparent molecular weight of SOD I after addition of the reducing agent 2-mercaptoethanol, the subunits do not appear to be linked covalently by disulfide bonds. However, the subunits of SOD II were covalently linked by intra- and interdisulfide bonds. Western blot analyses showed that the 2 enzymes have different antigenicity. Both enzymes occur as cytoplasmic and detergent-extractable fractions. These enzymes may be potential virulence factors of A. castellanii by acting both as antioxidants and antiinflammatory agents. These enzymes may be attractive targets for chemotherapy and immunodiagnosis of acanthamoebiasis.

Results of a trial of combined propamidine isethionate and neomycin therapy for Acanthamoeba keratitis. Brolene Study Group

PURPOSE

To characterize patients with Acanthamoeba keratitis and to evaluate the safety and efficacy of propamidine isethionate 0.1% ophthalmic solution (Brolene) when administered concomitantly with neomycin-polymyxin B-gramicidin ophthalmic solution (Neotricin) in the treatment of Acanthamoeba keratitis.

DESIGN

Prospective, noncomparative case series.

METHODS

The authors report the clinical characteristics and outcomes of patients who entered this multicentered, open-label, clinical trial. Eighty-three patients with Acanthamoeba keratitis representing 87 infected eyes entered the trial.

RESULTS

Sixty (69%) of the 87 eyes enrolled had data analyzed for treatment efficacy and safety. Of these 60 eyes, 50 (83%) experienced treatment success. Thirty (60%) patients successfully treated adhered to treatment protocol guidelines. Patients who broke protocol had disease exacerbation during the maintenance therapy phase. The only eyes lost/enucleated were 7 of 17 in which penetrating keratoplasty was performed before eradication of the infectious agent.

CONCLUSION

Propamidine isethionate and neomycin are an effective treatment for Acanthamoeba keratitis. Penetrating keratoplasty should be performed only for visual rehabilitation and not to "debulk" an active infection. The authors advocate treating patients with topical medications, mainly Brolene, until all organisms are eradicated. There should be no signs of infection for at least 3 months in the patients not receiving antiamebic medications before penetrating keratoplasty is performed.

Anti-Acanthamoeba activity of contact lens solutions

AIMS

This study was undertaken to investigate the effects of contact lens disinfecting solutions on strains of Acanthamoeba from the United Kingdom and southern Africa and to compare the results with those of other researchers. No information was previously available for southern African isolates.

METHODS

11 contact lens solutions were tested on cysts of 10 strains of Acanthamoeba.

RESULTS

Not all solutions used in the study were effective, with some for hard and gas permeable contact lenses being more satisfactory than those for soft contact lenses. The most effective of the gas permeable and hard contact lens solutions tested was Transoak (0.01% (wt/vol) benzalkonium chloride), which killed cysts of all strains within 4 hours of exposure. Oxysept 1 (31 mg hydrogen peroxide/ml) was the best soft contact lens solution tested. It eliminated cysts of certain strains within 4 hours, whereas cysts of other strains were only inactivated within either 8 or 72 hours.

CONCLUSIONS

Manufacturers should be aware of the killing time for Acanthamoeba by contact lens solutions and should provide appropriate guidelines for the use thereof. The killing time for cysts of the African and UK isolates studied is, in general, similar. Therefore, it must in the present state of knowledge be assumed that usage guidelines suggested in the UK are also appropriate for travellers to South Africa and for local residents in South Africa.

Acanthamoeba keratitis

Acanthamoeba species are an important cause of microbial keratitis that may cause severe ocular inflammation and visual loss. The first cases were recognized in 1973, but the disease remained very rare until the 1980s, when an increase in incidence mainly associated with contact lens wear was reported. There is an increased risk when contact lens rinsing and soaking solutions are prepared with nonsterile water and salt tablets. The clinical picture is often characterized by severe pain with an early superficial keratitis that is often treated as herpes simplex infection. Subsequently a characteristic radial perineural infiltration may be seen, and ring infiltration is common. Limbitis and scleritis are frequent. Laboratory diagnosis is primarily by culture of epithelial samples inoculated onto agar plates spread with bacteria. Direct microscopy of samples using stains for the cyst wall or immunostaining may also be employed. A variety of topically applied therapeutic agents are thought to be effective, including propamidine isethionate, clotrimazole, polyhexamethylene biguanide, and chlorhexidine. Various combinations of these and other agents have been employed, often resulting in medical cure, especially if treatment is commenced early in the course of the disease. Penetrating keratoplasty is preferably avoided in inflamed eyes, but may be necessary in severe cases to preserve the globe or, when the infection has resolved, to restore corneal clarity for optical reasons.

Systemic immune response to Acanthamoeba keratitis in the Chinese hamster

Recrudescence is a common and troubling feature of Acanthamoeba keratitis and suggests that corneal infection with this organism fails to stimulate the systemic immune apparatus. The present study examined the cell-mediated and humoral immune responses to Acanthamoeba keratitis in the Chinese hamster. Corneal infection with A. castellanii failed to induce either delayed-type hypersensitivity (DTH) or serum IgG antibody against parasite antigens. The failure to induce cell-mediated and humoral immunity did not result in anergy or tolerance since subsequent intramuscular (i.m.) immunization with parasite antigens elicited robust DTH and IgG antibody responses. The inability of corneal infections to induce primary cell-mediated immune responses was due to the absence of resident antigen-presenting cells in the central cornea because induction of Langerhans cell (LC) migration into the central cornea prior to infection with Acanthamoeba promoted the development of parasite-specific DTH. Although the presence of resident LC did not promote the development of a primary humoral immune response, subsequent i.m. immunization elicited heightened parasite-specific IgG antibody production which was indicative of an anamnestic response. Collectively, the results indicate that in the absence of resident antigen-presenting cells, corneal infection with Acanthamoeba fails to stimulate primary cell-mediated or humoral immunity. Induction of peripheral LC into the central corneal epithelium promotes the development of parasite-specific DTH, but does not exacerbate corneal disease.

Acanthamoeba corneal infection in a contact lens wearer

Corneal infections cause by micro-organisms are the most serious complications of wearing contact lenses. The paper presents the first case of contact lens-associated keratitis caused by the protozoon Acanthamoeba sp. identified in Slovenia so far. The identification of Acanthamoeba as a cause of keratitis in a soft contact lens wearer alerted us to the fact that this health issue should be given more attention in the future.

Aspects of the mechanisms of action of biguanides on trophozoites and cysts of Acanthamoeba castellanii

A non-radioactive method was used to investigate the uptake by Acanthamoeba castellanii of chlorhexidine diacetate (CHA) and polyhexamethylene biguanide (PHMD). Based on the Giles et al. (1974) hypothesis, the uptake of CHA by trophozoites appeared to be of the L3 pattern whereas that of cysts was C2. Unlike CHA, trophozoites took up PHMB with an L2 pattern at low concentrations followed by a C-type pattern at higher concentrations, the uptake by cysts was found to be of the C2 pattern with a plateau effect at high concentrations. A diphasic leakage effect was found in trophozoites whereas a relatively low peak of maximal leakage occurred from cysts treated with high biocide concentrations. The amount of pentose release depended on the formulation ingredients. No correlation between pentose leakage and trophozoicidal or cysticidal activity was found.

Methods of disinfecting contact lenses to avoid corneal disorders

The contact lens industry has grown rapidly over the past four decades due to the wide-spread demands of the American population for a convenient alternative to spectacle wear for the correction of myopia. Unfortunately, many people who wear contact lenses are not aware of the potential risks associated with them, and consumer education about lens care has not been adequate. This article reviews the role of disinfection in contact lens wear, summarizes the current available contact lens disinfection systems, and provides recommendations for safe contact lens use.

The lethal effects of biguanides on cysts and trophozoites of Acanthamoeba castellanii

The effects of a range of biocides on trophozoite and encysted forms of Acanthamoeba castellanii were investigated. Viable acanthamoebae were enumerated by a plaque assay technique. The cyst form of Acanthamoeba castellanii was more resistant to all biocides tested than the trophozoite form. Of the biocides tested, chlorhexidine diacetate (CHA) and polyhexamethylene biguanide (PHMB) were the most effective. Their lethal effects were time- and concentration-dependent. CHA was very effective when formulated in 0.1% EDTA combined with Tris buffer pH 7.8 whereas PHMB activity was reduced by 0.1% EDTA. Three per cent dimethylsulphoxide (DMSO) enhanced the activity of CHA but not of PHMB.