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Eyewash Mistaken for Contact Lens Soaking Solution
850
AMERICAN JOURNAL OF OPHTHALMOLOGY
EYEWASH MISTAKEN FOR CONTACT L E N S SOAKING SOLUTION A L L A N J. F L A C H , M . D . , AND J O H N A. S O R E N S O N , M.D.
Department ofOphthalmohgy, Veterans Administration Hospital, 4150 Clement St., San Francisco, CA 94121 (Dr. Flach)
Recently the potential hazards of simi larly packaged drugs have been brought to your readers' attention.1"5 We would like to describe a drug substitute error that oc curred in our community. During a routine ophthalmologic exam ination, an aphakic soft contact lens was accidentally soaked in eyewash (BlinxBarnes Hind) instead of contact lens stor age solution. At the completion of the examination, about 30 minutes later, the soft contact lens was placed in the pa tient's eye. The patient tolerated the con tact lens for approximately one hour but the pain and photophobia then became intolerable. The patient removed the contact lens and called his ophthalmolo gist. The next day the patient's best correct ed visual acuity was 20/200. Pseudoptosis was associated with eyelid edema, conjunctival chemosis, and corneal edema that included folds in Descemet's mem brane. The intraocular pressure was nor mal. Trace cells and flare were present in the anterior chamber of the involved eye. Chemical keratoconjunctivitis secondary to eyewash was diagnosed and the patient was treated with corticosteroid eyedrops. Approximately three days after the epi sode the patient's visual acuity had im proved to 20/25 and external eye had returned to normal. The similar sizes and shapes of the containers may have contributed to this iatrogenic chemical keratoconjunctivitis. The Figure shows the involved eyewash and examples of a commonly used contact lens cleansing solution and a commonly
JUNE, 1983
used contact lens rinsing solution. In this particular incident the eyewash was sub stituted for the rinsing and storage solu tion (Boil n Soak). More damage might have occurred had the cleansing solution (Pre-flex) been substituted for the storage and rinsing solution. Most rinsing and storage solutions consist of sterile pre served saline solution. The involved eye wash contained boric acid and sodium borate with phenylmercuric acetate 0.004% added as a preservative. This irrigating solution is designed for use with fluorescein ophthalmic strips. Al though the label cautions, "Do not use while lenses are in the eye," it is used as an eyewash or irrigating solution. The cleansing solution is a buffered, isotonic, aqueous solution containing sodium phos phates, sodium chloride, tyloxapol hydroxyethylcellulose, and polyvinyl alco hol, preserved with thimerosal 0.004% and edetate disodium 0.2%. This solution is not intended for use directly in the eye and is so labeled. In this specific case, the contact lens rinsing and storage solution could have been used to irrigate the eye and for soft contact lens storage, but the eyewash solution was clearly contraindicated for even temporary contact lens storage. The contact lens industry produces
Figure (Flach and Sorenson). Eyewash mistaken for storage solution.
VOL. 95, NO. 6
LETTERS TO THE JOURNAL
many solutions packaged in many differ ent containers by many different manu facturers. Therefore, it is probably a good idea to keep contact lens solutions sepa rate from solutions designed specifically for periocular and, certainly, intraocular instillation. REFERENCES 1. Duane, T. D.: Fluorescite-fluorouracil. A near ly tragic coniusion in identity, correspondence. Am. J. Ophthalmol. 7^277, 1974. 2. Rumelt, Μ.τί,: Dangers of similar packaging, correspondence. Am, J. Ophthalmol. 91:804, 1981. 3. Partamian, L., and Kass, M.: Similar packaging of ophthalmic drugs, correspondence. Am. J. Oph thalmol. 92:586, 1981. 4. Berger, R.: Super Glue mistaken for pilocar pine, correspondence. Am. J. Ophthalmol. 94:267, 1982. 5. Flach, A. J., and Murphy, A.: Cortisporin dis pensing error, correspondence. Am. J. Ophthalmol. 94:565, 1982. E D I T O R ' S N O T E : The editors believe that ophthalmologists and the industry are by now sufficiently alerted to the dangers of look-alike packaging. This will conclude the series.
SOFT CONTACT L E N S E S A N D CLINICAL DISEASE J O S E P H A. B A L D O N E , M . D . , AND H E R B E R T E. K A U F M A N , M.D.
Louisiana State University Eye Center, 136 S. Roman St., New Orleans, LA 70112 (Dr. Kaufman)
Extended-wear therapeutic soft contact lenses can be used with greater success in patients with corneal disease if lens selec tion is based on a knowledge of the hydrophilic or hydrophobic nature of the lens material. There is considerable evapora tion from the anterior surface of lenses made from high water content plastics. This evaporation draws water from the precorneal tear film and the eye, which produces a dehydrating effect. Lenses with low water content or lenses with
851
out water tend to conserve the precorneaj fluid film and reduce evapora tion. Patients with early endothelial decom pensation find that their vision is worse on arising, probably as a result of having the eyes closed all night, and the conse quent reduction in evaporation from the anterior cornea. This edema can be treat ed with topically applied 5% saline (os motic agents) and warm air from a hair dryer. The use of these two dehydrating mechanisms can produce good early morning vision—without these proce dures, such vision is often not achieved until late in the afternoon. We have found that the use of soft contact lenses with a high water content also provides a mech anism for dehydration in these patients. It appears that, as water evaporates from the anterior surface of the high water content lenses, a sort of "wicking" action draws water from the cornea into the lens, thereby reducing edema and im proving vision. Conversely, patients with dry eyes benefit from wearing soft contact lenses with lower water content. These lenses provide a barrier to evaporation from the corneal surface, and do not seem to have the same water requirements as the high er water content lenses. An extended-wear therapeutic soft lens with a very low water content (0 to 1%, for example, the Reviens*) actually traps tears behind the lens and can improve epithelial healing. We saw a patient with a large area of disruption of corneal epithelium over the inferior one third of the cornea, consistent with the diagno sis of lagophthalmos. At the time, she was using two artificial tear inserts (Lacriserts) per day and nonpreserved The Reviens is a soft acrylic rubber lens that has been used successfully in Japan and Canada for several years. It is currently being tested for approval in the United States by the Food and Drug Adminis tration. Further information about the lens is avail able from BioContacts, Incr, 111 Sutter St., Suite 600, San Francisco, CA 94104.
AMERICAN JOURNAL OF OPHTHALMOLOGY
EYEWASH MISTAKEN FOR CONTACT L E N S SOAKING SOLUTION A L L A N J. F L A C H , M . D . , AND J O H N A. S O R E N S O N , M.D.
Department ofOphthalmohgy, Veterans Administration Hospital, 4150 Clement St., San Francisco, CA 94121 (Dr. Flach)
Recently the potential hazards of simi larly packaged drugs have been brought to your readers' attention.1"5 We would like to describe a drug substitute error that oc curred in our community. During a routine ophthalmologic exam ination, an aphakic soft contact lens was accidentally soaked in eyewash (BlinxBarnes Hind) instead of contact lens stor age solution. At the completion of the examination, about 30 minutes later, the soft contact lens was placed in the pa tient's eye. The patient tolerated the con tact lens for approximately one hour but the pain and photophobia then became intolerable. The patient removed the contact lens and called his ophthalmolo gist. The next day the patient's best correct ed visual acuity was 20/200. Pseudoptosis was associated with eyelid edema, conjunctival chemosis, and corneal edema that included folds in Descemet's mem brane. The intraocular pressure was nor mal. Trace cells and flare were present in the anterior chamber of the involved eye. Chemical keratoconjunctivitis secondary to eyewash was diagnosed and the patient was treated with corticosteroid eyedrops. Approximately three days after the epi sode the patient's visual acuity had im proved to 20/25 and external eye had returned to normal. The similar sizes and shapes of the containers may have contributed to this iatrogenic chemical keratoconjunctivitis. The Figure shows the involved eyewash and examples of a commonly used contact lens cleansing solution and a commonly
JUNE, 1983
used contact lens rinsing solution. In this particular incident the eyewash was sub stituted for the rinsing and storage solu tion (Boil n Soak). More damage might have occurred had the cleansing solution (Pre-flex) been substituted for the storage and rinsing solution. Most rinsing and storage solutions consist of sterile pre served saline solution. The involved eye wash contained boric acid and sodium borate with phenylmercuric acetate 0.004% added as a preservative. This irrigating solution is designed for use with fluorescein ophthalmic strips. Al though the label cautions, "Do not use while lenses are in the eye," it is used as an eyewash or irrigating solution. The cleansing solution is a buffered, isotonic, aqueous solution containing sodium phos phates, sodium chloride, tyloxapol hydroxyethylcellulose, and polyvinyl alco hol, preserved with thimerosal 0.004% and edetate disodium 0.2%. This solution is not intended for use directly in the eye and is so labeled. In this specific case, the contact lens rinsing and storage solution could have been used to irrigate the eye and for soft contact lens storage, but the eyewash solution was clearly contraindicated for even temporary contact lens storage. The contact lens industry produces
Figure (Flach and Sorenson). Eyewash mistaken for storage solution.
VOL. 95, NO. 6
LETTERS TO THE JOURNAL
many solutions packaged in many differ ent containers by many different manu facturers. Therefore, it is probably a good idea to keep contact lens solutions sepa rate from solutions designed specifically for periocular and, certainly, intraocular instillation. REFERENCES 1. Duane, T. D.: Fluorescite-fluorouracil. A near ly tragic coniusion in identity, correspondence. Am. J. Ophthalmol. 7^277, 1974. 2. Rumelt, Μ.τί,: Dangers of similar packaging, correspondence. Am, J. Ophthalmol. 91:804, 1981. 3. Partamian, L., and Kass, M.: Similar packaging of ophthalmic drugs, correspondence. Am. J. Oph thalmol. 92:586, 1981. 4. Berger, R.: Super Glue mistaken for pilocar pine, correspondence. Am. J. Ophthalmol. 94:267, 1982. 5. Flach, A. J., and Murphy, A.: Cortisporin dis pensing error, correspondence. Am. J. Ophthalmol. 94:565, 1982. E D I T O R ' S N O T E : The editors believe that ophthalmologists and the industry are by now sufficiently alerted to the dangers of look-alike packaging. This will conclude the series.
SOFT CONTACT L E N S E S A N D CLINICAL DISEASE J O S E P H A. B A L D O N E , M . D . , AND H E R B E R T E. K A U F M A N , M.D.
Louisiana State University Eye Center, 136 S. Roman St., New Orleans, LA 70112 (Dr. Kaufman)
Extended-wear therapeutic soft contact lenses can be used with greater success in patients with corneal disease if lens selec tion is based on a knowledge of the hydrophilic or hydrophobic nature of the lens material. There is considerable evapora tion from the anterior surface of lenses made from high water content plastics. This evaporation draws water from the precorneal tear film and the eye, which produces a dehydrating effect. Lenses with low water content or lenses with
851
out water tend to conserve the precorneaj fluid film and reduce evapora tion. Patients with early endothelial decom pensation find that their vision is worse on arising, probably as a result of having the eyes closed all night, and the conse quent reduction in evaporation from the anterior cornea. This edema can be treat ed with topically applied 5% saline (os motic agents) and warm air from a hair dryer. The use of these two dehydrating mechanisms can produce good early morning vision—without these proce dures, such vision is often not achieved until late in the afternoon. We have found that the use of soft contact lenses with a high water content also provides a mech anism for dehydration in these patients. It appears that, as water evaporates from the anterior surface of the high water content lenses, a sort of "wicking" action draws water from the cornea into the lens, thereby reducing edema and im proving vision. Conversely, patients with dry eyes benefit from wearing soft contact lenses with lower water content. These lenses provide a barrier to evaporation from the corneal surface, and do not seem to have the same water requirements as the high er water content lenses. An extended-wear therapeutic soft lens with a very low water content (0 to 1%, for example, the Reviens*) actually traps tears behind the lens and can improve epithelial healing. We saw a patient with a large area of disruption of corneal epithelium over the inferior one third of the cornea, consistent with the diagno sis of lagophthalmos. At the time, she was using two artificial tear inserts (Lacriserts) per day and nonpreserved The Reviens is a soft acrylic rubber lens that has been used successfully in Japan and Canada for several years. It is currently being tested for approval in the United States by the Food and Drug Adminis tration. Further information about the lens is avail able from BioContacts, Incr, 111 Sutter St., Suite 600, San Francisco, CA 94104.