This Guidance does not change what you must do under the law.

Infection control is concerned with two main areas. Firstly, transmission from person to person, and secondly, transmission via a contaminated object, such as an ophthalmic device or piece of equipment, or via contaminated contact lens solution bottles or multi-dose eye drops that have been used on another patient. In addition, there are environmental hazards that arise from your disposal of waste. 

There are four main routes for transmission, these are: 

1. physical contact, which can spread directly or indirectly: 
   • direct transmission may occur from contact with non-intact skin or mucous membranes
   • indirect transmission may occur from contact with infected surfaces or objects (fomite transmission)
     
     Examples of infections that spread via physical contact include: 
   • ophthalmic infections, such as bacterial and adenoviral conjunctivitis  
   • skin infections, for example staphylococcus, herpes simplex or fungi
   • enteric infections, for example viral gastroenteritis
2. airborne particles, including respiratory infections, for example tuberculosis: 
   • airborne particles include respiratory droplets (>5-10 microns in diameter) and aerosols (<5 microns in diameter)
   • you are at a higher special risk of the transmission of  infection from airborne particles because of your close proximity to the patient’s nose and mouth when undertaking eye care procedures  for an extended period of time 
   • potentially infectious respiratory droplets and aerosols are generated when an individual sneezes, coughs or talks. Particles over five microns in diameter do not normally travel more than one metre, but smaller particles can travel longer distances and remain airborne for longer
3. contact with blood and other bodily fluids:
   • Bodily fluids also include secretions and excretions (excluding sweat)
   • There is extremely low risk of transmitting blood borne viruses, such as human immunodeficiency virus (HIV) and hepatitis B and C, in optometric practice 
   • tears can contain infectious agents (including these viruses, and others that are much more contagious, such as adenovirus) which may be transmitted to you or to other patients, if your hands are not properly decontaminated after the clinical examination 
   • all surfaces soiled with spillages of blood and/or body fluids should be decontaminated immediately using a product that contains a detergent and disinfectant. Do not use mops for this. Use disposable paper towels and dispose of them as clinical waste.¹⁸⁶
4. use of sharps: the main risk of transmission is associated with invasive procedures in which injury, for example needlestick, could result in blood from the infected individual entering open tissues of another person. If you suffer an injury from a sharp which may be contaminated, you should: 
   • gently encourage the wound to bleed, if possible whilst holding it under running water
   • wash the wound using running water and plenty of soap
   • dry the wound and cover it with a waterproof plaster or dressing
   • seek urgent medical advice
   • report the injury to your employer.^{187, 188} 

You should not suck the wound or scrub it while you are washing it.

You must use adequate infection control measures to avoid transmitting infections.¹⁸⁹ 

You must decontaminate your hands regularly and thoroughly to prevent the spread of infection.¹⁹⁰  You can reduce the risk of transmitting infections such as methicillin-resistant Staphylococcus aureus (MRSA) or Clostridium difficile (C.diff) if you use fastidious hand hygiene.  

There are a number of organisms present in healthy skin: some are resident organisms (skin commensals) and are mostly harmless, although some are known to cause mild eye infections. You can reduce the number of skin commensals left on your skin by washing with an antiseptic detergent preparation, instead of soap and water. 

Other transient organisms can be deposited on the skin, including certain gram-negative bacteria which could lead to more serious corneal infections. You can remove most of these transient organisms by thoroughly washing with liquid soap and water (use warm water where available).

You must decontaminate your hands, as appropriate: 

1. before every episode of direct patient contact or care
2. after every episode of direct patient contact or care
3. after any exposure to body fluids (including tears)
4. after any other activity or contact with a patient’s surroundings that could potentially result in hands becoming contaminated
5. before putting on and after removing gloves.

You can use an antibacterial handrub between seeing patients during a clinic session. Alcohol is not a cleaning agent, so you should perform a proper handwash with soap and water at the beginning and completion of the clinic session, as well as after exposure to body fluids or if your hands are visibly soiled or dirty. Alternatively, you can wash your hands between patients.

You should also decontaminate your hands:  

1. before (and after) contact lens insertion or removal
2. after going to the toilet
3. when hands are visibly dirty
4. before (and after) contact with ocular surfaces and adnexae
5. before (and after, if necessary) administering medication, for example eye drops
6. after any possible microbial contamination, e.g. contact with body fluids, wounds, or clinical waste.

You must ensure you follow the correct procedure for hand washing as set out in each nation's infection prevention control manual (NIPCM). You should ensure you and your team receive regular handwashing training.  

• NHS England » National infection prevention and control manual (NIPCM) for England 
• National Infection Prevention and Control Manual: Home (scot.nhs.uk) 
• About the Manual - Public Health Wales (nhs.wales) 
• PHA Infection Control | (niinfectioncontrolmanual.net) 

Hand hygiene agents include: 

1. liquid soap
2. antiseptic
3. antibacterial (alcohol-based) handrubs.¹⁹¹

Handwashing with soap and water is effective in removing most transient microorganisms and is usually all you need to prevent infection. In clinical areas, you should: 

1. use liquid soap in disposable containers or containers that are washed and dried before refilling
2. never top up the containers.

Antiseptic agents are effective in reducing both transient and resident microorganisms. Chlorhexidine (4%) preparations have a residual effect against transient organisms influencing the survival time on hand surfaces.¹⁹² You should use an antiseptic agent: 

1. before and after direct contact with patients in clinical settings, where there is an outbreak of antimicrobial resistant organisms (e.g. residential or nursing homes)
2. where there is heavy microbial contamination
3. before performing invasive procedures or minor operations.

Antibacterial (alcohol-based) handrubs rapidly destroy microorganisms on the skin's surface. However, they are not a cleaning agent and you should not use them if hands are visibly dirty or contaminated with blood, bodily fluids or other potentially infectious agents. They are especially useful in situations where handwashing and drying facilities are inadequate e.g. domiciliary visits, or between patient contacts.

You should not use alcohol handrubs as a substitute for handwashing with soap and water, when these are available. You are strongly advised to wash your hands at the start and finish of a session. Alcohol handrubs are not effective against Clostridium difficile spores or norovirus (a cause of viral gastroenteritis), so you should use liquid soap and water in situations where there is potential for the spread of these organisms.

The standard for efficacy of hygienic handrubs uses a reference of 60% isopropyl alcohol. However, to be effective against staphylococci, including MRSA, handrubs must contain 70% of either ethyl or isopropyl alcohol.

Using an unperfumed alcohol-based handrub prior to contact lens insertion has been shown to have a negligible effect on ocular comfort, redness and lens wettability. You should ensure that the handrub has been allowed to dry on the hands as instructed by manufacturers (often 15 seconds). 

To maintain the integrity of your skin, you should:

1. cover cuts and abrasions to skin with waterproof dressings (preferably coloured)
2. dry your skin properly with paper hand towels after washing
3. use hand cream as appropriate; you should not share jars of hand cream with others.

You should keep up to date with immunisation, including: 

1. tetanus
2. polio
3. tuberculosis
4. hepatitis B. 

You should minimise the risk of airborne infection by:¹⁹³

1. covering your nose and mouth and using a tissue whilst coughing or sneezing
2. disposing of used tissues in the nearest appropriate receptacle as soon as possible¹⁹⁴ 
3. performing hand hygiene after coughing or sneezing
4. not working in clinical practice if you have an acute upper respiratory tract infection, such as the common cold
5. avoiding touching your mouth, eyes and nose unless you have performed hand hygiene
6. attach a breath guard or shield where appropriate, such as to the slit lamp or keratometer 
7. you must comply with appropriate health and safety measures for adequate ventilation throughout the practice.

You should risk assess whether to wear personal protective equipment (PPE) 

1. where you anticipate exposure to protect against direct contact with blood, body fluids or non-intact skin

2. while handling and cleaning decontaminated equipment 

All PPE should be: 

3. located close to the point of use 

4. single-use only items, unless specified by the manufacturer or public health body. Reusable PPE items, must be decontaminated according to the manufacturer’s recommendations

5. stored appropriately 

6. disposed of after use into the correct waste stream.

You should wear a fluid resistant surgical face mask (FRSM Type IIR) when 

1. Performing procedures when in close proximity to the patient  

2. You consider there is a risk of respiratory infection  

3. There is a public health requirement to wear one, such as during a pandemic, Unless the relevant national or local public health guidance recommends an alternative specification and level of protection.¹⁹⁵

You should wear gloves, and apron as appropriate, where you consider there is a risk from: 

1. invasive procedures
2. contact with:
   • non-intact skin
   • mucous membranes
3. exposure to:
   • blood
   • bodily fluids, including tears
   • secretions
   • excretions
   • sharp or contaminated instruments
   • other contaminated material, for example dressings.

You should consider the following factors when deciding to wear gloves and aprons: 

1. whether the patient has an overt infection, such as ulcerative blepharitis or acute viral or bacterial conjunctivitis
2. the degree of contact with bodily fluids or infected tissue
3. the consequences of infection.

You do not have to wear gloves or aprons to:

1. carry out a normal eye examination
2. perform minor procedures where there is no likelihood of cross-inoculation with bodily fluids
3. fit contact lenses.

You should practise thorough hand hygiene before wearing, and after removing, gloves, as they may not provide complete protection.

You must dispose appropriately of gloves and aprons that you believe are contaminated.

You can use non-sterile disposable examination gloves. However, if you undertake a procedure which requires a sterile environment, you must use sterile surgical gloves. You must not use polythene gloves for clinical interventions. If you choose to use latex gloves you should be aware that these might cause allergic reactions such as asthma in sensitised individuals^196, 197.

You must only use sharps where necessary.¹⁹⁸

If you need to use sharps, you should use and dispose of them safely by: ¹⁹⁹

1. using equipment with safety devices
2. using safe handling and disposal procedures.

You should follow the NICE guidance on sharps containers.²⁰⁰ 

High-risk groups include patients with MRSA, C.difficile, tuberculosis (within the first two weeks of treatment), or pandemic influenza (where there is no vaccine available),Staphylococcus aureus and SARS-CoV-2 (responsible for COVID-19 infection), which have caused particular concern in recent times.

Staphylococcus aureus is a bacterium that can reside on the skin, or can be found in the nose. About one third of healthy individuals carry S. aureus. MRSA is a less common variant of S. aureus which may be resistant to many antibiotics making it more difficult to treat than normal strains of the bacterium. MRSA is a problem in many hospitals. Although the risk of serious infection with MRSA is lower in the community, it is increasingly seen in community health care units, such as nursing homes. MRSA does not cross intact skin.

There is little risk of infection for healthy clinical staff; however, infection control is important to avoid transmission to vulnerable people.

MRSA detected in the community may be the result of:

1. patients discharged from hospital with MRSA
2. nursing home residents who have acquired MRSA
3. MRSA transmitted to non-hospitalised patients, or other individuals, from MRSA patients
4. MRSA arising naturally in the community.

If you examine a patient with a known or suspected transmissible infection, you should: 

1. follow guidance on examining patients with symptoms of respiratory infection,and  implement appropriate transmission-based infection control precautions to protect yourself and other people from contracting infection. 
2. ensure good hand hygiene by following your nations IPC manual and local public health guidance if issued. 

Transmission via an inert agent can be from a contaminated object, such as an ophthalmic device or piece of equipment, or via contaminated contact lens solution bottles or multi-dose eye drops that have been used on another patient.

The agents that may harbour infection are:

1. contact lenses, contact lens cases and other paraphernalia
2. ophthalmic devices such as:
   • tonometer heads
   • pachymeters
   • diagnostic lenses that come into contact with the ocular surface, such as: gonioscopes, fundus lenses, three-mirror lenses and lenses used in conjunction with laser therapy
3. the environment: bacteria may contaminate flat surfaces if they become airborne. Bacteria that are shed into the environment may survive for long periods in dust. Flat surfaces act as reservoirs for S. aureus, including MRSA, and contamination will transfer easily to hands that touch them. Contamination on hands and/or gloves may then be transferred by contact with equipment, switches, phones, computer keyboards, door handles, light switches etc.

You should use the following routine infection control precautions: 

1. maintain good hand hygiene,²⁰¹  
2. maintain good respiratory and cough etiquette,  
3. wear suitable personal protective equipment where appropriate, 
4. decontaminate equipment after use,  
5. decontaminate used linen 
6. decontaminate the environment by: 
   • keeping it visibly clean and free from clutter and dust 
   • undertaking regular routine cleaning (and disinfection where appropriate) in line with national cleaning standards. The frequency and level of decontamination may increase when there is a public health requirement to do so, such as during a local outbreak or pandemic 
   • Appropriately decontaminating spills of blood and other bodily fluid. 

You should appropriately decontaminate equipment that comes into contact with patients, including:

1. trial frames
2. chin and forehead rests
3. refractor heads
4. handheld occluders
5. rulers
6. tonometer heads
7. medical devices such as contact lenses and sample frames
8. gonioscopes and other diagnostic lenses.

You should decontaminate equipment in all situations where you or your patients are at risk of any known transmissible infection, including nursing homes, schools and workplaces.

There are three levels of decontamination. You should use the one that is most appropriate for the item being decontaminated. The three levels are:

1. cleaning to remove organic or inorganic debris. This may be done with detergents or ultrasonic cleaning
2. disinfecting to reduce viable microorganisms with heat or chemicals
3. sterilising to kill or remove all microorganisms, including spores. This is not normally required in optometric practice.

You must clean the items first.

Not all equipment needs to be sterile before being used and you should:

1. clean equipment which does not come into close contact with mucous membranes or sterile body areas, e.g. trial frames and refractor heads
2. clean surfaces in the consulting room, unless contaminated with body fluids, see d below
3. disinfect equipment which comes into contact with intact mucous membranes, or becomes contaminated with blood and other bodily fluids, using a chlorine-releasing disinfectant such as sodium hypochlorite 1% (10,000 ppm of available chlorine) 
4. disinfect surfaces in the consulting room if contaminated with body fluids, using a chlorine-releasing disinfectant such as sodium hypochlorite 1% (10,000 ppm of available chlorine)
5. sterilise equipment introduced into a sterile body area or in contact with a break in the skin or mucous membrane
6. follow the manufacturer’s instructions for a suitable alternative agent if the item or surface cannot withstand chlorine-releasing agents for disinfection.

You should have access to a hand basin in the consulting room.

Agents recommended for cleaning and disinfection procedures:
 

Agent	Preparation	Examples of use
Liquid soap	as supplied	handwash
Chlorhexidine gluconate 4% skin cleanser	500 ml bottles with pump dispenser eg Hibiscrub	antiseptic handwash
Chlorhexidine 5% in 70% isopropyl alcohol 202	500 ml bottles with pump dispenser eg Hibisol	antiseptic hand disinfectant for use before aseptic procedures or after handling contaminated materials
Alcohol-based hand sanitizer	as supplied, usually in bottles with pump dispenser eg Purell (contains 63% ethyl alcohol)	routine handrub
Detergent	general purpose detergent or detergent impregnated wipes eg Cutan multisurface wipes	cleaning of hard surfaces
Isopropyl alcohol 70%	Isopropyl alcohol of a concentration of 70% has been shown to be effective against SARS-CoV-2, MRSA and staphylococcus infection. Alternative wipes may be used if they carry the CE or UKCA mark, and are used according to the manufacturer’s instructions. For example, impregnated swabs eg mediswabs or wipes eg mediwipes	disinfection of hard surfaces, chin rests etc. (not suitable for use with medical devices that come into contact with the surface of the eye)
Hypochlorite solution 0.1% (1,000 ppm available chlorine)	available from pharmacies eg Milton or own brand sterilising solution (dilute to concentration required) under normal usage, these agents are disinfectants, and not sterilants	general disinfection (ensure that items are thoroughly rinsed in sterile saline or distilled water after using hypochlorite)
Hypochlorite solution 1% (10,000 ppm available chlorine)		disinfection of body fluid spills and decontamination of trial contact lenses, diagnostic contact lenses, tonometer heads and other devices that come into contact with the surface of the eye (ensure that items are thoroughly rinsed in sterile saline or distilled water after using hypochlorite)

Items must be clean before progressing to disinfection or sterilisation.

There is a remote theoretical risk, identified by the Department of Health (DH), of transmitting prion proteins, which are associated with transmissible spongiform encephalopathies (TSEs) and are implicated in Creutzfeldt-Jakob Disease (CJD) and variant CJD (vCJD), through re-useable ophthalmic devices and trial contact lenses. However, there is no evidence that this has occurred,²⁰³ and this risk has been questioned.²⁰⁴ The anterior eye has been designated as low risk.

You should follow the advice of your local infection control team if available. If this is not available:

1. You should use single patient use lenses and devices that contact the surface of the eye where practicable.
2. You should not re-use a lens or device that is intended by the manufacturer for single use.
3. When single use lenses and devices are not practicable, you should:
   • balance the benefits that patients receive from contact lenses and ophthalmic devices against the transmission of disease
   • apply appropriate disinfection procedures. These should include the use of sodium hypochlorite solution where possible, see section on Levels of decontamination.

You should note these definitions of contact lenses:

1. trial contact lens: a lens that is used to assess fitting following which it is either disposed of by the clinician or dispensed to the patient. The majority of contact lens patients are currently fitted with single patient use lenses of various types
2. special complex lens: a lens used by the clinician to assess performance of the design on the eye. This may be necessary where there is disease or abnormality of the lid, cornea or ocular surface. These lenses may be re-used.

The above definitions can apply to the following categories of lenses:

1. hydrogel lenses
2. silicone hydrogel lenses
3. hybrid lenses
4. rigid lenses, including:
   • corneal
   • sclera
   • scleral shells
   • ocular prostheses.

Special complex lenses may be of any type. If you use these lenses you must carry out appropriate disinfection.

An ophthalmic device is any instrument which comes into contact with the ocular surface, including:

1. tonometer
2. contact pachymeter
3. gonioscope
4. other lens to aid diagnosis of disease.

Where it is practicable, you should use single use devices, such as disposable tonometer heads or tips.

Some devices are not able to withstand certain forms of disinfection. In these cases, you should use your professional judgement, bearing in mind that undetected disease may have sight- or life-threatening consequences.

You must explain to the patient the risks and benefits of re-using a device.

The following advice reduces the potential risk of iatrogenic transmission of CJD/vCJD via contact devices.

You should not use alcohol wipes alone to disinfect contact devices as they are ineffective against many organisms, and may fix prion proteins to the surface of the instrument.

Prion proteins adhere strongly to materials including smooth surfaces. You should ensure that the device is thoroughly cleaned to remove adhered debris as the potential for the transmission of cellular and proteinaceous debris via tonometer prisms has been demonstrated.^205, 206

You should not use agents or procedures capable of binding proteins to surfaces e.g. isopropyl alcohol, glutaraldehyde or autoclaving, unless you decontaminate devices first, following the process outlined in paragraphs below. 

You should use 1% sodium hypochlorite solution to disinfect equipment. This concentration is:

1. appropriate for inactivating infectious agents such as bacteria and viruses
2. less harmful to the eye than stronger concentrations, should it accidentally come into contact with it.

You need the following equipment for disinfecting of contact lenses or ophthalmic devices:

1. water for irrigation BP, or sterile normal saline
2. cleaning solution, such as liquid soap or detergent
3. sodium hypochlorite solution 1% (10,000 ppm of available chlorine).

You should follow this process to disinfect contact lenses or an ophthalmic device:
 

Step	ACDP TSE WG, 2011 recommendation203	Notes
Timing	immediately after use	immediately disinfect the item, and if this is not possible, keep it in a container of water for irrigation BP or sterile normal saline, until it can be disinfected.
Do not dry	do not allow to dry
Rinse	in water for irrigation BP/sterile normal saline for at least 30 sec
Clean	rubbing with liquid soap or detergent	thoroughly clean the item (including by rubbing) to remove cellular debris and adherent protein
Disinfect	using sodium hypochlorite 1% (10,000 ppm of available chlorine) for 10 min	disinfect it by using sodium hypochlorite
Rinse	in water for irrigation BP/sterile normal saline for at least 10 min with 3 changes of water/saline	thoroughly rinse off the sodium hypochlorite, which is toxic to the eye, before re-use
Dry	shake off excess, dry with tissue, re-use immediately or store dry	return the item to its dedicated case, if it has one
Further steps	if necessary, since hypochlorite is not effective against all spores or cysts	follow with conventional disinfection

Chlorine can be toxic to the eye, but if you follow the disinfection guidelines correctly, sodium hypochlorite solution will not come into contact with a patient’s eye. However, if this does occur, you should follow this process: 

1. irrigate the affected eye immediately with copious quantities of sterile normal saline solution or water
2. check the ocular surface for epithelial damage using fluorescein
3. examine the anterior segment for inflammation
4. check intraocular pressure
5. if there are no clinically significant signs, advise the patient to return to the practice if they experience any problems with their eyes. Otherwise you should re-examine them at the normal interval
6. if there are clinically significant signs, you should re-examine the patient the following day or refer them to the Hospital Eye Service, as appropriate
7. record any adverse incident centrally, in your practice’s system or in the practice Accident Book
8. if you feel it is appropriate, report the incident to the National Reporting and Learning System (or equivalent relevant body for your nation). This is anonymous and helps us to learn lessons from adverse incidents.²⁰⁷

You are not required to label sodium hypochlorite 1% solution as harmful or irritant under the COSHH regulations.²⁰⁸ You should follow appropriate measures for safe storage, access and handling.

You should carefully maintain all contact lens care products and medicines used during examination and discard them when they reach their expiry date.

You should:

1. be aware that multi-dose containers can be a source of infection
2. be aware that varying levels of contamination exist in plastic bottles containing contact lens solutions
3. note on the bottle when it was  opened and when it should be discarded according to manufacturer’s guidelines.

You should:

1. keep the dropper tip free from contamination
2. replace the lid on the container immediately after use, as all solutions are susceptible to contamination while the lid is off
3. dispose of solutions immediately if you suspect contamination.

Use single use drug delivery systems, where possible.

Patient groups that have been identified as being at greater than normal risk of developing transmissible spongiform encephalopathies (TSE) include:

1. patients with a family history of CJD or other prion disease
2. recipients of pituitary derived hormones such as human growth hormone or gonadotrophins
3. patients who have had surgery on the brain or spinal cord
4. patients who have received more than 50 units of blood or have received blood or blood components on more than 20 occasions, since 1980.

Before carrying out any procedure that might involve the re-use of a contact lens or ophthalmic device you should, as far as possible, question the patient to establish if they fall into any of the above high-risk groups. If the patient is in a high-risk group, you must only use items intended for single patient use. If this is not possible you should consider referring the patient to the Hospital Eye Service.

If you use a re-usable item in an emergency with a patient in one of the above high-risk groups, you should discard it immediately after use.

If you examine a patient with a known transmissible infection, you should:

1. cover cuts and abrasions to skin with waterproof dressings (preferably coloured) 
2. carry out hand hygiene before and after each patient contact and before and after leaving their home or care home, see section; Methods of preventing infection transmission from person to person, and
3. follow the guidance in section; Situations of increased concern – transmission from person to person.

You must take all reasonable steps to deal appropriately with controlled, clinical and offensive waste, including both non-hazardous and hazardous waste^{209, 210, 211, 212}

Controlled waste is defined as waste from households, industry or commerce.

Clinical waste means waste from a healthcare activity¸ and waste of a similar nature from a non-healthcare activity, that:²¹³

1. contains viable microorganisms or their toxins which are known or reliably believed to cause disease in humans or other living organisms
2. contains, or is contaminated with, a medicine that contains a biologically active pharmaceutical agent
3. is a sharp, or a body fluid or other biological material (including human and animal tissue) containing, or contaminated with, a dangerous substance within the meaning of Council Directive 67/548/EEC on the approximation of laws, regulations and administrative provisions relating to the classification, packaging and labelling of dangerous substances.

Offensive waste means waste that:²¹⁴

1. is not clinical waste
2. contains body fluids, secretions or excretions

3. falls within code 18-01-04, 18-02-03 or 20-01-99 in Schedule 1 to the List of Wastes (England) Regulations 2005, in relation to England,²¹⁵ or the List of Wastes (Wales) Regulations 2005, in relation to Wales.²¹⁶

   Is covered within the Scottish Environmental Protection Agency’s Guidance on the classification and assessment of waste.²¹⁷

   Is covered within the waste management section of the Northern Ireland Regional Infection Prevention and Control Manual.²¹⁸