Contamination of multi dose eyedrops in the intra and perioperative context

Evaluating and Managing the Microbial Contamination of Eye Drops: A Two-Phase Hospital-Based Study

The microbial contamination of eye drop tips and caps varies between 7.7% and 100%. In seeking patient protection and continuous improvement, the Pharmacy Department in the Sterile Ophthalmological and Oncological Preparations Unit at Cochin Hospital AP-HP, Paris, France, conducted a two-phase study to compare the antimicrobial efficiency and practical use of standard packaging and a marketed eye drop container incorporating a self-decontaminating antimicrobial green technology by Pylote SAS at the tip and cap sites. The first phase was conducted in situ to identify the microbial contaminants of eye drops used in the hospital and community settings. A total of 110 eye drops were included for testing. Staphylococcus species were the most prevalent bacteria. Candida parapsilosis was detected in only one residual content sample and, at the same time, on the cap and tip. The second phase was performed in vitro, according to JIS Z2801. Reductions above one log in Staphylococcus aureus and Pseudomonas aeruginosa counts were noted in Pylote SAS eye drop packaging after 24 h of contact. The practical tests showed satisfactory results. Pylote SAS antimicrobial mineral oxide technology exhibited promising effects that combined effectiveness, safety, and sustainability to protect the patient by preventing infections due to the contamination of eye drop containers.

Achieving net-zero in the dry eye disease care pathway

Climate change is a threat to human health and wellbeing across the world. In recent years, there has been a surge in awareness of this crisis, leading to many countries and organisations setting "net-zero" targets. This entails minimising carbon emissions and neutralising remaining emissions by removing carbon from the atmosphere. At the 2022 United Nations Climate Change Conference (COP27), commitments to transition away from fossil fuels and augment climate targets were underwhelming. It is therefore imperative for public and private sector organisations to demonstrate successful implementation of net-zero and set a precedent for the global political consensus. As a top 10 world employer, the United Kingdom National Health Service (NHS) has pledged to reach net-zero by 2045. The NHS has already taken positive steps forward, but its scale and complexity as a health system means stakeholders in each of its services must highlight the specifications for further progress. Dry eye disease is a chronic illness with an estimated global prevalence of 29.5% and an environmentally damaging care pathway. Moreover, environmental damage is a known aggravator of dry eye disease. Worldwide management of this illness generates copious amounts of non-recyclable waste, utilises inefficient supply chains and involves recurrent follow-up appointments and prescriptions. By mapping the dry eye disease care pathway to environmental impact, in this review we will highlight seven key areas in which reduced emissions and pollution could be targeted. Examining these approaches for improved environmental sustainability is critical in driving the transformation needed to preserve our health and wellbeing.

Preservative-Free Topical Anesthetic Unit-Dose Eye Drops for the Management of Postoperative Pain Following Photorefractive Keratectomy

INTRODUCTION

Ocular pain is a common complication following photorefractive keratectomy (PRK). The level of patient satisfaction with current pain control strategies is not high. This study aims to assess the efficacy and safety of a novel regimen of preservative-free oxybuprocaine hydrochloride 0.4% unit-dose eye drops for post-PRK pain control.

METHODS

In a contralateral eye study, 144 eyes of 72 patients who underwent bilateral transepithelial PRK (TransPRK) were stratified into experimental and control groups. The experimental group received preservative-free oxybuprocaine hydrochloride 0.4% unit-dose eye drops five times daily postoperatively until complete epithelial healing, while the control group received sodium hyaluronate 0.2% instead. The main outcome measures were pain scores assessed by the verbal rating scale and visual analogue scale (VRS, VAS), the corneal epithelial defect (CED) area, epithelial healing duration evaluated by slit-lamp biomicroscopy and anterior segment optical coherence tomography (AS-OCT), and endothelial cell density (ECD) measured before and 1 month after surgery.

RESULTS

Pain scores assessed by VRS and VAS were significantly lower in the experimental group 8 h after surgery, and 1, 2, and 3 days postoperatively (P < 0.001). The mean CED area showed no significant differences between the two groups at different follow-ups (P value > 0.05). The corneal epithelial healing had a mean duration of 3.32 ± 0.47 days in both studied groups and was parallel in both eyes of each patient. In each group, 49 eyes (68%) and 72 eyes (100%) had a fully epithelialized surface on the third and fourth postoperative days, respectively. No significant changes were observed in the mean ECD 1 month following surgery in both groups (P value > 0.05).

CONCLUSION

Preservative-free oxybuprocaine hydrochloride 0.4% unit-dose eye drops are effective and safe in controlling early postoperative pain following TransPRK. The availability of the single-dose unit preparation can overcome the problem of topical anesthetic abuse.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05733741.

How Ophthalmologists Can Decarbonize Eye Care: A Review of Existing Sustainability Strategies and Steps Ophthalmologists Can Take

TOPIC

Understanding approaches to sustainability in cataract surgery and their risks and benefits.

CLINICAL RELEVANCE

In the United States, health care is responsible for approximately 8.5% of greenhouse gas (GHG), and cataract surgery is one of the most commonly performed surgical procedures. Ophthalmologists can contribute to reducing GHG emissions, which lead to a steadily increasing list of health concerns ranging from trauma to food instability.

METHODS

We conducted a literature review to identify the benefits and risks of sustainability interventions. We then organized these interventions into a decision tree for use by individual surgeons.

RESULTS

Identified sustainability interventions fall into the domains of advocacy and education, pharmaceuticals, process, and supplies and waste. Existing literature shows certain interventions may be safe, cost-effective, and environmentally friendly. These include dispensing medications at home to patients after surgery, multi-dosing appropriate medications, training staff to properly sort medical waste, reducing the number of supplies used during surgery, and implementing immediate sequential bilateral cataract surgery where clinically appropriate. The literature was lacking on the benefits or risks for some interventions, such as switching specific single-use supplies to reusables or implementing a hub-and-spoke-style operating room setup. Many of the advocacy and education interventions have inadequate literature specific to ophthalmology but are likely to have minimal risks.

CONCLUSIONS

Ophthalmologists can engage in a variety of safe and effective approaches to reduce or eliminate dangerous GHG emissions associated with cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Non-aqueous formulations in topical ocular drug delivery - a paradigm shift?

Topical eyedrop application is the preferred route for drug delivery to anterior segment tissues; however, the challenge of overcoming the eye's anatomical and physiological barriers while minimising tissue toxicity has restricted developments in this field. Aqueous vehicles have traditionally been used, which typically require several additives and preservatives to achieve physiologically compatible and sterile eyedrops, elevating their toxicity potential. Non-aqueous vehicles have been suggested as efficient alternatives for topical drug delivery as they can address many of the limitations associated with conventional aqueous eyedrops. However, despite their obvious advantages, non-aqueous eyedrops remain poorly researched and few non-aqueous formulations are currently available in the market. This review challenges the conventional hypothesis that aqueous solubility is a prerequisite to ocular drug absorption and establishes a rationale for using non-aqueous vehicles for ocular drug delivery. Recent advances in the field have been detailed and future research prospects have been explored, pointing towards a paradigm shift in eyedrop formulation in the near future.

Pupil dilation evaluation of two mydriatic dosing profiles delivered by the Optejet®

Aim: To compare pupil dilation achieved by a single microdose versus two microdoses of tropicamide-phenylephrine fixed combination (TR-PH FC) delivered by the Optejet^®. Patients & methods: In this assessor-masked, crossover, noninferiority study, 60 volunteers underwent two treatment visits and received either one (∼8 μl) or two sprays (∼16 μl) of TR-PH FC to both eyes in randomly assigned order. Results: At 35 min postdose, mean change in pupil diameter was 4.6 mm and 4.9 mm following one or two sprays, respectively. The estimated treatment group difference was -0.249 mm (standard error: 0.036; 95% CI: -0.320, -0.177). No adverse events were reported. Conclusion: A single microdose was noninferior to two microdoses of TR-PH FC and achieved clinically significant mydriasis in a timely manner. Clinical Trial Registration: NCT04907474 (ClinicalTrials.gov).

Bacterial contamination of multi-use antibiotic steroid eye ointments and drops

PURPOSE

This comprehensive prospective study aimed to investigate the bacterial contamination of antibiotic steroid eye ointments and drops frequently used by eye patients.

METHOD

In this comprehensive prospective study, a total of 410 multi-use topical eye medications containing 15 different ingredients from 22 pharmaceutical companies used by 185 patients were analyzed. Four groups were formed as follows: group 1: antibiotic ointments (n: 109); group 2: antibiotic drops (n: 103); group 3: steroid ointments (n: 67); and group 4: steroid drops (n: 131). Topical multi-use eye drops and ointments used by patients at home for at least 1 week were randomly collected. The caps and contents were separately bacteriologically examined in a chocolate agar medium.

RESULTS

Our study detected bacterial contamination in 23 containers (5.6%) of the total 410 topical drugs. According to the groups, bacterial contamination was detected in 10 of 67 (14.9%) steroid ointments, 6 of 109 (5.5%) antibiotic ointments, 4 of 131(3.1%) steroid drops, and 3 of 103 (2.9%) antibiotic drops. While the bacterial contamination rate in ointments was 9.1%, this rate was 3% in drops. The difference between them was statistically significant (p = 0.015). According to the post-hoc pairwise comparisons, the difference between steroid drops and steroid ointment (p = 0.0023) was statistically significant. Among all drugs, contamination was detected in 12 of the 93 (12.9%) containers used after keratitis, conjunctivitis, and inflammatory conditions. It was determined that preservatives statistically reduced bacterial growth on the cap. The preservatives did not have a statistically significant effect on the bacterial contamination of the contents compared to the caps. While all contaminations were detected in illiterate and primary school graduates, no contamination was seen in the drugs used by any secondary school or university graduate.

CONCLUSION

Our study detected contamination in all topical ophthalmic drug groups. Contamination rates were found to be higher in ointments and steroids. Bacterial contamination was also seen in drugs containing preservatives. We should be careful in the use of topical medications. We do not recommend the bilateral use of ointments and drops in infected eyes, such as those with keratitis, or after intraocular surgeries, such as those for cataracts.

Highlighting the Microbial Contamination of the Dropper Tip and Cap of In-Use Eye Drops, the Associated Contributory Factors, and the Risk of Infection: A Past-30-Years Literature Review

The sterility of eye drop content is a primary concern from manufacturing until opening, as well as during handling by end users, while microbial contamination of the dropper tip and cap are often disregarded. The contamination of these sites during drug administration represents a risk of microbial transmission and ocular infection. In this review, we aim to assess microbial contamination of the dropper tip and cap of in-use eye drops, the associated contributory factors, and the risk of infection. We conducted a literature search of the MEDLINE, PubMed, and Cochrane Central databases. A total of 31 out of 1503 studies were selected. All the studies conducted in different settings that documented microbiologically contaminated in-use eye drops were included. Our review showed that microbial contamination of the dropper tip and cap of in-use eye drops ranged from 7.7 to 100% of the total contaminated tested samples. Documented contributory factors were conflicting across the literature. Studies investigating the association between eye infection and microbial contamination of the dropper tip and cap were scarce. New technologies offer a promising potential for securing the long-term sterility of eye drop content, tips, and caps, which could benefit from more research and well-defined study protocols under real-life scenarios.

Potential Cost Savings Associated with a Multiuse Preoperative and Preinjection Eyedrop Protocol

OBJECTIVE

Calculate the cost savings associated with a multiuse preoperative and preinjection eyedrop protocol.

DESIGN

Economic analysis PARTICIPANTS: Adults undergoing ophthalmic surgical procedures requiring preoperative dilation and intravitreal injections.

METHODS

Economic modeling with scenario analysis was used to derive the value for cost-savings attributable to a protocol where perioperative mydriatic eyedrop bottles are used across multiple patients versus the current protocol where drop bottles are wasted after single patient use. Similar analyses were performed for a multiuse povidone-iodine protocol for intravitreal injections. Sensitivity analyses were used to test baseline model assumptions with varying degrees of waste and patient volume.

RESULTS

The multi-use mydriatic protocol allowed for a 97.1% reduction in the number of eyedrop bottles required for the single-use protocol (1037 bottles vs. 35850 bottles). This led to an estimated five year cost savings of approximately $240,000 (nominal) per institution (performing an average of 1434 cases/year) in the base case. This savings varied minimally in sensitivity analyses accounting for practical limitations (loss, expiration, or contamination) of multi-use containers, with savings of 97.54-95.00% for excess supply ranges from 0%-100% in the multiuse protocol. Likewise, the cost savings varied minimally in sensitivity analyses for eye drop sizes, with savings of 99.23-96.69% for mydriatic eye drop sizes of 15 microliter per drop to 65 microliter per drop, respectively, in the multi-use protocol. Over a five-year period, for povidone-iodine drops prior to performing intravitreal injection, the multi-use protocol required 153 bottles compared to 41,954 bottles (99.6% reduction) for the current single-use protocol, resulting in a nominal cost savings of $41,801, which varied minimally in sensitivity analyses.

CONCLUSIONS

Multiuse perioperative mydriatic eyedrops are a viable option for cost and environmental waste reduction for ophthalmologic procedures and surgeries requiring dilation. Likewise, multiuse povidone-iodine may allow for large relative cost reduction for in office procedures. The total potential savings over five years was estimated greater than $280,000 before adjusting for inflation.

Microbial contamination of multiple-dose preservative-free hospital ophthalmic preparations in a tertiary care hospital

Background

It is possible that preservative-free eye drops can be contaminated. The aim of this study was to assess the incidence of microbial contamination of preservative-free hospital-prepared anti-infective eye drops and investigate factors that contribute to contamination. This finding may help to raise awareness of this problem to medical healthcare staff and patients in order to prevent the transmission of microorganisms from eye drops to the patients through treatment of pre-existing eye diseases.

Methods

Two hundred and ninety-five eye drop bottles were collected from patients attending Rajavithi Hospital Ophthalmologic outpatient and inpatient department, including both those used by patients at home and those administered in the hospital by medical staff. Samples were taken from the tips of droppers and bottles, and the residual fluid inside the bottles was then cultivated onto different culture plates. The culture results were identified and analyzed according to various factors related to both individual users and the bottles.

Results

Seven different types of eye drops were collected and 71 (24.06%) of the 295 bottles were contaminated. Vancomycin eye drops were the most contaminated. Twenty-six different types of pathogens were identified, most frequently mold (42.98%), and the amount of contamination was higher in tips than in residual fluid inside the bottle. There was no statistically significant difference in contamination between patients used eye drops collected in outpatient units (32.14%) and medical staff used eye drops collected in inpatient settings (23.22%). The only factor that was statistically significant was the number of eye drops used per person. We found that samples from patients who used only up to 2 eye drops suffered contamination (42.8%) more than those from their counterparts who used at least 3 (22.18%), P ​= ​0.02.

Conclusions

Of these preservative-free hospital preparations anti-infective eye drops, 24.06% were contaminated. The number of eye drops used per person was statistically significant in triggering contamination. There is a possibility of number of eyedrops use person may trigger contamination.