title: A systematic review and cost-effectiveness analysis of tonometer disinfection methods.
abstract: OBJECTIVE
  The Goldmann applanation tonometer presents the problem of being one of the most widely used pieces of equipment in the ophthalmic clinic and a known risk factor for the transmission of epidemic keratoconjunctivitis (EKC). The purpose of this review is to assess the effectiveness of 3 methods of disinfection: alcohol swabs, immersion in peroxide, and the use of disposable prisms. An economic evaluation is undertaken to assess the cost-effectiveness of the 3 alternatives. In doing so, we contribute an evidence-based overview of the issue at an opportune time, because several jurisdictions are developing protocols regarding tonometer tip disinfection.
  
  
  METHODS
  Systematic review and cost-effectiveness analysis.
  
  
  METHODS
  A comprehensive literature review was undertaken with a librarian, comprising searches of 6 electronic databases and hand searches of the grey literature. A 3-level screening process was undertaken by 2 reviewers according to prespecified inclusion and exclusion criteria. Values from included papers were used to inform a cost-effectiveness analysis undertaken using a decision tree model implemented in TreeAge. The analysis was undertaken from the hospital perspective and included all equipment and labour costs.
  
  
  RESULTS
  Synthesis of in vitro data indicates that all 3 methods are plausible methods of disinfection with a 64% reduction in log growth of EKC when peroxide is used compared with alcohol swabs. The incremental cost-effective ratios from the cost-effectiveness analysis were $12,000/case averted using peroxide and $61,000/case averted with Tonosafe as compared with alcohol.
  
  
  CONCLUSIONS
  Assuming clinical infection rates match in vitro disinfection data, the cost of bleach is high and the cost of Tonosafe is unacceptably high to reduce 1 potential case of adenoviral keratoconjunctivitis.
authors.affiliation: Departments of Epidemiology and Biostatistics.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Omar Akhtar
authors.affiliation: Departments of Epidemiology and Biostatistics.
authors.forename: Hargurinder
authors.initials: H
authors.lastname: Singh
authors.affiliation: Ophthalmology, Western University, London, Ont.
authors.forename: Francie
authors.initials: F
authors.lastname: Si
authors.affiliation: Departments of Epidemiology and Biostatistics; Ophthalmology, Western University, London, Ont.. Electronic address: William.Hodge@sjhc.london.on.ca.
authors.forename: William G
authors.initials: WG
authors.lastname: Hodge
mesh_terms: D003362:Cost-Benefit Analysis / Q000191:economics*; D003663:Decision Trees; D004203:Disinfection / Q000191:economics* / Q000379:methods*; D015817:Eye Infections / Q000191:economics / Q000517:prevention & control; D006801:Humans; D007429:Intraocular Pressure / Q000502:physiology*; D007637:Keratoconjunctivitis / Q000191:economics / Q000517:prevention & control; D012307:Risk Factors; D014065:Tonometry, Ocular / Q000191:economics*