H202…What’s behind the bubbles?

Patients have a lot of options when it comes to contact lens care. In fact, the choices can be quite overwhelming if patients have been given no direction before heading to the aisle. Many offices hand out and recommend peroxide-based solutions, though the basis for patient selection may differ from office to office. Some doctors use peroxide-based cleaning systems as their first choice for every patient, while others reserve these systems for “problem patients.” Because peroxide is so effective at removing lens deposition and debris, peroxide systems can add wear time and tolerability for patients who suffer from allergies, build up, or even dryness.

Several things are evident about peroxide users. First and foremost, this population is extremely loyal. Once patients consistently use peroxide-based lens care, they rarely return to a multi-purpose solution. Years ago, during a manufacturing shortage, people successfully sold Clear Care (Alcon) on eBay for more than $200 per bottle. Peroxide users are also more compliant. They understand how the system is used and typically don’t top off or reuse solution, as patients often do with a multi-purpose solution. This pattern is evidenced by market research showing that a peroxide user buys nearly 50% more solution compared with a patient using a multipurpose solution.¹ They buy more ounces per year, which translates to better compliance.

But the question is why? Perhaps the patient sees the bubbles when using fresh solution and understands there is a particular cleaning action that no longer occurs when they reuse or top off. Or perhaps we, as doctors and staff, spend more deliberate and focused time educating patients on how to use the peroxide system correctly, rather than shrinking in fear that misuse will lead to an unpleasant and potentially scary experience for the patient.

How does it differ from brown-bottle peroxide?

Hydrogen peroxide is a strong oxidizing solution known for its disinfecting qualities. Some patients may assume that a peroxide-based system is simply brown-bottle peroxide repackaged. Not only is there a difference in the quality of peroxide used, but it also must be neutralized to a gentle saline. This can be done using a tablet or a disc. The value and success of a peroxide system boils down to a few key components that vary from brand to brand: the quality of the starting peroxide, it’s ability to clean the lens, and the effectiveness of the neutralization to obtain a comfortable end point.

Currently, there are three brands of peroxide systems and several generics available to the consumer. Clear Care occupies the overwhelming majority of the market share, but the generic segment has grown quickly.

• Clear Care (Alcon) is a one-step system representing more than 80% of the peroxide systems purchased in the U.S.² The difference between Clear Care and the other two brands is that Clear Care contains a surfactant. The high-grade peroxide cleans, the surfactant loosens debris and deposits, and the bubbles lift them away. The addition of the surfactant not only keeps soil from adhering to the lens, but also helps provide an environment that repels proteins from the surface. It also aids in making the lens more wettable and comfortable for the patient. Its platinum disc is effective for up to 100 uses; however, a single bottle has enough ounces for approximately 30 uses. This ensures that the disc continues to perform consistently for the entire month, leaving only a very small amount of residual peroxide after the soak, typically undetectable to the patient.
• Oxysept (AMO) utilizes tablet neutralization, resulting in a slower neutralization process. Therefore, the lens has a longer exposure time to the more concentrated peroxide, which may be beneficial. AMO recommends the patient use a daily cleaner and saline rinse in addition to the Oxysept peroxide system. The company also recommends adding a weekly enzymatic cleaner. This multi-step, multi-product process may be expensive for the patient and may affect compliance.
• AOSept (Alcon) is a disc-neutralized, peroxide-based system. It also requires a separate daily cleaner and saline rinse. Historically, the case and disc were purchased separately, but now they are packaged together with the AOSept solution. The ability of a disc to neutralize peroxide decreases with usage. Therefore, patients had to remember to replace the disc in a timely manner or suffer irritation from the un-neutralized peroxide. AOSept is scheduled to be completely phased out by the end of this year.

What about generic peroxide systems?

Generic peroxide systems have recently been introduced to the market. Doctors and staff are often well equipped with information to steer patients away from private-label multi-purpose solutions, but is there a difference in peroxide-based generics? It comes down to the same three elements: the quality of peroxide used, the presence or absence of an effective cleaning surfactant, and the system’s ability to fully neutralize the peroxide. The first two are straightforward, but the third is a little more complicated.

When a disc is used for neutralization (AOSept, Clear Care, and generics), the design of the case plays an important role. Clear Care and AOSept use the same design, incorporating a high-quality platinum disc attached to the lid/lens holder. This is important because as soon as the peroxide comes into contact with the disc, neutralization begins. In fact, a majority of this process is completed within the first several minutes after contact. If the disc is stationary in the bottom of the case, as in generics, the solution may be in contact with the disc for several minutes before the patient gets their lenses out and secured into the basket. So by the time the lenses are in position, the strength of the disinfectant may already be somewhat diminished. Also, if the disc is stationary in the bottom of the case, dirt may accumulate on the disc and increase the disinfection burden on the peroxide. Finally, the quality of the disc affects the comfort of the patient. Studies dating back to the 1980s show that any residual (un-neutralized) peroxide exceeding 100 parts per million (ppm) can potentially cause irritation to the patient.^3,4 Normal saline contains about 60 ppm. The Clear Care/AOSept disc is very effective at neutralizing to less than 60 ppm, but we do not know the amount of residual peroxide left with private-label systems, nor the longevity of the disc. As with any private-label product, companies continually compete for the job, so the manufacturer (solution formulation and case) may change, despite identical labeling to the patient.

Is it safe?

There is no reason to steer patients away from peroxide-based solutions out of fear of misuse. Many of us have been eyewitness to patients who rinsed their lenses with a peroxide cleaner. Upon application, the lens delivers a significant burn-the longer it is in the eye, the greater the toxic keratitis that develops. The outer layer of corneal cells in the epithelium is extremely fragile and can be damaged and sloughed off with very little effort. When un-neutralized peroxide ends up in the tear film, it is harmful to these cells. Even after the lens is removed and the eye is rinsed, there is lingering patient discomfort (such as light sensitivity, tearing) because the cells are damaged. Fortunately, once the natural tear film is restored, these cells heal very quickly. Meanwhile, supportive treatments, such as artificial tears and gels, can provide symptomatic relief. It is important to understand and to educate patients that no permanent damage is done, even if the product is used incorrectly by accident.

Peroxide-based cleaners provide patients with exceptional disinfection against microbes and excellent lipid and protein removal when a surfactant is present. Patients are extremely loyal and compliant with its use. When recommending a peroxide-based system, understand what differentiates the products and what cleaning steps are involved. Then make a recommendation for a specific product accompanied by patient education on use and compliance.

Likewise, we should consider the difference in our delivery and try to translate that same degree of urgency to our multi-purpose system users in an attempt to improve compliance and reduce complications among all our patients.ODT

References

1.   Nielsen Home scan, April 2013

2.   Nielsen EQ Share xAOC 52 Weeks 3/23/2013

3.   Paugh JR, Brennan NA, Efron N. Ocular response to hydrogen peroxide. Am J Optom Physiol Opt 1988;65(2):91-98.

4.   Epstein, A and Freedman, J. Keratitis associated with hydrogen peroxide disinfection in soft contact lenses. International Contact Lens Clinic (ICLC) 1990;17(3,4):74-82.

Author Info

Dr. Brimer is a graduate of UNC-Chapel Hill and Southern College of Optometry. She has a private practice in Wilmington, NC, and has special interests in contact lenses and dry eye management. Dr. Brimer enjoys writing and speaking nationally on both practice management and disease management topics. E-mail her at drbrimer@crystalvisionservices.com.

SIDEBAR A

All the same?

Is there a difference in peroxide-based generics? It comes down to three factors:

• Quality of peroxide used

• Presence or absence of an effective cleaning surfactant

• The system’s ability to fully neutralize the peroxide.

SIDEBAR B

Patient resource

Consider sending your contact lens patients to PourThatOut.com, an online consumer resource created by Alcon. The site offers dos and don’ts, myths and facts, and eyecare professional discussion guide. It guides patients who want to learn more about how to incorporate proper lens care hygiene into their daily lens care routine.

Take-Home Message

Peroxide-based contact lens cleaning systems provide patients with disinfection against microbes and excellent lipid and protein removal when a surfactant is present. Patients are extremely loyal to a brand and remain compliant with its use. When you recommend a peroxide-based system, understand what differentiates the products and what cleaning steps are involved. Then, make a recommendation for a specific product accompanied by patient education on use and compliance.

Pull-quote 1

Market research shows that a peroxide user buys nearly 50% more solution compared with a patient using a multipurpose solution.

Pull-quote 2

Many of us have been eyewitness to patients who rinsed their lenses with a peroxide cleaner.