All About Contact Lens Care Products
by John W Elman OD
There used to be very good contact lens care products available a few years ago that are no longer available now. It has been very frustrating for me, a contact lens practioner, because products that I have recommended to patients for years, products that worked and which patients had no problems with, have either been discontinued or are difficult to get.
Since the advent of disposable contact lenses, which require less care when used as directed, the five manufactuers of contact lens solutions: Abbott- Advanced Medical Optics (AMO)(which took over the Allergan line of contact lens solutions), Alcon, Bausch and Lomb, and Ciba/Novartis (now Alcon), have tended to market only their multipurpose disinfecting solutions (MPDS): Abbot's RevitaLens OcuTec® AMO's COMPLETE® MPS EasyRub™, Alcon's OPTI-FREE® Express™, OPTI-FREE® RepleniSH™, OPTI-FREE® PureMoist® MPDS, or Opti-One® Multi-Purpose Solution, B&L's ReNu® Multiplus Multi-Purpose Solution and its newer Biotrue™, and CIBA's AQuify® 5 Minute Multi-Purpose Solution, respectively. (Bausch and Lomb's ReNu® with MoistureLoc® Multi-Purpose Solution was taken off the market in April, 2006 when it was implicated by the CDC in cases of fungal keratitis, and AMO's COMPLETE® Moisture PLUS™ was recalled May 25th, 2007, when it was implicated by the CDC in cases of Acanthamoeba keratitis). The function of these multipurpose contact lens solutions is to clean, disinfect, and keep moist (both in and out of the eye) any of the traditional hydrogel soft contact lenses, as well as the newer silicone hydrogel materials. With one day (single use) type of disposable contact lenses you don't have to use any solutions, other than the saline solution the sealed contact lens comes in. That is the primary advantage of one day disposable contact lenses. Theoretically, the wearer of a continuous wear disposable contact lens, if it didn't get dirty in the eye, could avoid using solutions, too. Exposure to infective agents in the environment (such as swimming, hot tubs, et al) while the lenses are worn could could cause these microorganisms to adhere to and multiply on a contact lens that is worn for an extended period of time, especially if one has a compromised immune system. A wearers lens handling is the source of most contamination and if your disposable contact lenses are to be taken out of the eye and reused then you must store them in some type of solution. A pure sterile saline solution could be used to store a sterile contact lens for a short time, but soft contact lenses, once they have been taken out of the sterile package in which they were shipped, are good media for growing bacteria, fungus, virus or other microbes. Solutions without disinfecting properties might be alright for a while, but if they have become contaminated from bacteria or other microbes on skin, tears, lens case, or anywhere else, these microbes can multiply in the pure saline in which the contact lens has been placed and infect the eye when the contact lens is later worn. From early on, methods of disinfecting contact lenses were developed that effectively killed pathogens. These methods included either heat, or some type of chemical for disinfection. Heat sometimes shortened the life of contact lenses and couldn't be used at all on some contact lens materials. Hydrogen peroxide was and still is a very effective disinfection method. In addition to disinfection, one or more methods of cleaning were developed to preserve contact lenses, surfactant cleaners that were rubbed on contact lens surfaces and enzyme cleaners which removed protein which had built up on contact lenses that had been worn for a period of time. So traditional contact lens care systems had separate steps and solutions, to disinfect, clean, and store contact lenses and these systems worked well.
"No Rub" Multipurpose Solutions
I always have to chuckle when I ask patients what contact lens solution they are using and their reply is, "No Rub." There never was a solution named "No Rub." But the four primary manufacturers of multipurpose solutions all prominently printed on the outside of the boxes and bottles of their products the words "No Rub." The illusion they wanted to portray is that one can be lazy about contact lens care without risk, when in reality this is not the case. Multipurpose contact lens solutions made by the four major contact lens solution manufacturers probably work alright for most people wearing disposable contact lenses. The only contact storage products given to America's contact lens fitters as samples are the multipurpose solutions by the four manufacturers. In turn, they are usually the only contact lens storage products given to new contact lens patients. Although the manufacturer of each of these products used to tout its product as being better than the others because of its ability to keep contact lenses moist while in the eye, it turned out that the moisturizing agents in B & L's ReNu® with MoistureLoc® and AMO's COMPLETE® Moisture PLUS™ is what apparently attracted microorganisms (fungus and amoeba, respectively) causing corneal infections that led to the recall of these products. I believe Alcon was the first of the multipurpose solution makers to print "No Rub" on its boxes of OPTI-FREE® multipurpose solution, and the other three manufacturers soon started printing that on their boxes too. Personally, I have long felt that rubbing a cleaner on the contact lens surface, and then rinsing the debris off before before storing, cleans the lens better than just taking the lens out of the eye and storing in the solution without rubbing it. I am sure laboratory tests will confirm that. Rubbing is a good thing, not a bad thing, even if it takes a few seconds to do it. Lately contact lens solution makers are starting to realize the error in their ways in playing into the "No Rub" myth by admitting that rubbing helps clean contact lenses and AMO even has put rub into the brand name of its 2007 replacement product by calling it AMO COMPLETE® MPS EasyRub™. I guess rubbing is not so difficult after all. But the "No Rub" designation is not my main gripe. Besides the "No Rub" idea, there are two other things I don't like about multipurpose solutions: First, even though multipurpose solutions have cleaning and disinfecting agents in them I believe that multipurpose solutions neither clean nor disinfect as well as solutions dedicated to that purpose. Second, people can be, and many are, allergic to the agents in the multipurpose solutions that are used for disinfection and cleaning. Dr. Gary Andrasko studied the toxicity affects of various multipurpose solutions by soaking contact lenses made of the newest contact lens materials in these solutions and then placing the contact lenses on the eyes of volunteer subjects. The toxicity effect was measured by the amount of corneal staining produced by various lens/solution combinations. The results are were tabulated on a grid and published on the web at www.staininggrid.com.
The Good Ol' Days of AOSEPT®
To me, the gold standard of contact lens care systems, the one I traditionally used for people using non-disposable premium soft contact lenses, is the Ciba AOSEPT® system. A contact lens system is not just a single solution but several products and steps, used together to achieve the goal of cleaning and disinfecting contact lenses, without bothering the eye in any way. The original AOSEPT® system consists of: 1) Removing contact lenses from eyes and rubbing lens surfaces with a daily cleaner (Miraflow®), 2)rinsing cleaner off lenses with sterile non-preserved saline solution (generally Softwear® Saline), 3)placing contact lenses in a special case that has a disc (AOdisc®) at the bottom 4) filling the case up to the line with AOSEPT® solution (a 3 % hydrogen peroxide premixed with saline). The disc acts as a catalyst to neutralize the peroxide into water and oxygen. Peroxide is an effective disinfecting agent and it is passively neutralized into pure non-preserved saline solution overnight (minimum 6 hours) by the disc. In the morning the clean and disinfected contact lenses can be removed from the case and put directly in the eyes or rinsed with the non-preserved saline solution before placing in eyes. 4)Once per week a tablet of Allergan (now AMO) Ultrazyme is placed in the AOsept® case along with the AOsept® solution to remove protein. This system works, or shall we say worked, 100% of the time without causing allergy problems.
BUT... Miraflow® Cleaner was discontinued by Ciba (Walgreen's Extra-Strength Daily Cleaner seems to have same ingredients, if one can find it). The excellent Softwear® Saline was also discontinued. For AOsept users Ciba(now Alcon) has been promoting Ciba Clear Care® (also known as AOSEPT® Plus), which eliminates the dedicated cleaner, and which has a "No Rub" designation. It is AOSEPT® without dedicated cleaner and saline solution. There are good reasons for all the components of the original AOSEPT® system. Although hydrogen peroxide is primarily a disinfecting agent, it has cleaning properties as well. It does not, however, clean as well as the original dedicated cleaners. Packaging Clear Care® without a rinsing saline solution, there is the danger of mistakenly getting the peroxide in the eye before it is neutralized in the lens case (Getting Clear Care® solution in the eyes may burn for hours, but it does no permanent damage). Besides warning my patient's about the need for neutralization of Clear Care®, I try to always dispense it with an additional solution for rinsing, either a non-preserved saline solution or MPS. Since I posted the original version of this article in 2006, I have had comments from contact lens patients from across the country, who agreed with my frustration with the contact lens solution manufacturers. As I have suspected, those who were using dedicated cleaners (such as Miraflow®) have said Clear Care® does not clean as well as their previous cleaners. Based on the Androsko Staining Grid Clear Care may be the best multipurpose solution when used as directed, and Alcon's solutions (OPTI-FREE® PureMoist, OPTI-FREE® Replenish and OPTI-FREE® Express) may come in a close second. Allergy and toxicity do not seem to be a problem with these products. But for cleaning of contact lenses, a dedicated cleaning solution still does the best job, even though the contact lens solution manufacturers seem to deny or ignore this fact.
A system that is very similar to AOSEPT®, using hydrogen peroxide as a disinfecting agent, and utilizing a dedicated cleaner, is AMO's Oxysept® (originally Allergan UltraCare®) System. AMO changed the name to Oxysept® in 2008.
The original Oxysept®/UltraCare® disinfecting system consisted of:
- Oxysept® Disinfecting Solution - a sterile 3% hydrogen peroxide solution for lens disinfection.
- Oxysept® Neutralizing Tablets - a delayed-release neutralizing tablet that is added at the beginning of the disinfection cycle, and colors the solution pink to show that the tablet has been added. This tablet allows disinfection to occur before neutralizing the solution all in one easy step (and serves the function of not only neutralizing the hydrogen peroxide, but adds the salt to produce a preservative-free sterile saline solution--it does what the combination of AOsept and the neutralizing disc did in the original CIBA AOSEPT® system).
- Lens Plus® Daily Cleaner is the preservative-free daily cleaner to be rubbed on the contact lens surface before rinsing with saline.
- Lens Plus® Sterile Saline Solution is for preservative free rinsing of any soft contact lens. It is in a spray can, which gives it bacteria controlling action of a preservative without having a chemical preservative in it.
- Oxysept® Cup - a specially designed lens cup that must be used with this system.
- Ultrazyme® enzyme cleaner - an enzyme tablet that is placed in the UltraCare™ Cup with UltraCare® Disinfecting Solution once a week to remove protein deposits on the contact lenses.
When Allergan first started selling the UltraCare™ system at least a decade ago all the components of the system were bundled in a starter kit made available to eyecare professionals, similar to Ciba's AOSept® kits available at that time. AMO, which was spun off from Allergan, does not make a bundled kit (just as Ciba stopped making an AOSept® kit). If you want to use the UltraCare™ system, you have to buy each component separately (the commerically available Oxysept® box found in stores has bundled a 12 ounce Oxysept® Disinfecting Solution with Oxysept® Neutralizing Tablets), but I recommend the Oxysept® system for people previously using the traditional AOSEPT® system, and been unable to find it. In September, 2006 AMO sold rights to Lens Plus® Sterile Saline Solution and Lens Plus® Daily Cleaner to another company, Exaeris. Exaeris is a pharamaceutical company that previously had no had eye care products. Distribution of these two former AMO components of the UltraCare™system is therefore limited. In fact neither are currently available. In speaking to representatives of Exaeris they will make the LENSPLUS® saline available first, then the LENSPLUS® cleaner. I have received numerous e-mails from people all over the world who have found the website and this article, and have expressed their frustration in finding a dedicated contact lens cleaner. If one looks hard there are still some contact lens cleaners available (see Soft Contact Lens Cleaners below). When used as directed the peroxide systems (AOSept®, ClearCare or Oxysept®) are the best systems for cleaning and disinfecting but patient's need to remember that the peroxide in these solutions must be neutralized before contact lenses containing these solutions can be put into the eye. Lenses cannot be rinsed with these solutions and then placed in the eye. Neutralization can be accomplished either by soaking the lenses for 6 hours in the special container with the Neutralizing disc in the case of AOSept® or ClearCare or with the Oxysept® Neutralizing Tablets in the case of Oxysept®. Failing to do this will cause a non-permanent burning of the eyes which may last hours.
Saline and cleaning solution of the Oxysept® system can be substituted for available Ciba AOSEPT® components (or with other manufacturer"s products):
Non-Preserved Saline Products: Non-preserved sterile saline solution should cause no problem on the eye when used with soft contact lenses, as long as it hasn't been contaminated. Unfortunately non-preserved saline solution is a good media for growing microorganisms, and to keep this from happening various preservatives have been added to saline solutions to inhibit the growth of bacteria and other microorganisms. Unfortunately, many of the preservatives bother the eyes of contact wearers, causing allergic reactions and discomfort. Even Bausch and Lomb's Sensitive Eyes® Saline and Alcon Saline Solution use edetate disodium as a preservative. This preservative can bother some people. Prior to the peroxide systems, heat was used for contact lens disinfection, and at least one of the original non-preserved saline solutions initially intended for heat disinfection is still available, Alcon Unisol 4. We have also seen a store brand equivalent made by CVS pharmacy. These are 4 ounce bottles of non-preserved saline solution. Not having a preservative in sterile saline solution can cause the solution to become contaminated and become non-sterile after opening, so once it is opened it should be used immediately and the unused portion discarded within 30 days (or sooner if it has become contaminated--refrigeration can help preserve sterility). Another method of preserving saline solution without potentially harmful chemical preservatives is manufacturing the saline in a can in which it can be expelled using a gas propellent. This is what Allergan did in the production of Lens Plus® Saline. Later AMO, and then Exaeris, Inc, was been given the rights to this product. On July 2, 2007, Exaeris, Inc. filed petition for bankruptcy. Blairex Preservative Free Saline is another spray saline in a can. It can be ordered from online drugstores.
- Soft Contact Lens Cleaners: Besides the problem of getting non-preserved saline solutions, it has also been difffult lately getting dedicated soft contact lens cleaners. Ciba MiraFlow® Cleaner was discontinued by Ciba in 2010. In 2014 optometrist William R Martin brought back MiraFlow Extra Strength Cleaner and is selling it on line at http://www.MiraFlow.com. Two alternatives use the same forumla: Walgreen's Extra Strength Daily Cleaner uses the Miraflow formula, as does Lobob Laboratories Sof/Pro® 2. Both of these products are available online. Since AMO has sold the rights to LensPlus® Cleaner to Exaeris and since Exaeris has had no previous distribution of ophthalmic products we have yet to see any of this cleaner in stores. AMO's excellent non-preserved cleaner LC-65 is no longer made, nor are are Alcon OPTI-CLEAN® II Daily Cleaner, OPTI-FREE® Daily Cleaner, PLIAGEL, or Bausch and Lomb Sensitive Eyes® Cleaner. Most of these companies also make 1 day disposable contact lenses. Perhaps it is because they make 1 day disposables, which are discarded daily and not cleaned, they do not feel the need to make cleaners. This of course is not good news for the people who wear reuseable contact lenses.
- Derelection of responsibility by all contact lens solution manufacturers forces contact lens fitters and wearers to create their own systems. I still consider peroxide systems with separate dedicated cleaners the gold standard when contact lens wearers have allergies to preserved products and/or need better cleaning than multipurpose solutions provide. Unisol 4, Blairex Simply Saline could be used with one of the hard to find contact lens cleaners, with ClearCare Peroxide sytem or the Oxysept system. If one uses ClareCare you must use the case that comes with it. If you use Oxysept Disinfecting Solution, it is pure 3% hydrogen peroxide and must be used with theOxysept Neutralizing Tablets to work. Now it is hard to find any non-preserved saline to use with the peroxide system except Unisol 4 and its equivalents. Good luck in finding ANY dedicated soft lens cleaning agent. In gerneral you are not going to find any of these products at you local drugstore, where the shelves are lined with less effective multipurpose solutions, that neither clean nor disinfect as well as peroxide systms used with separate effective dedicated cleaners.