COMMISSIONED ARTICLE

Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 107-115

Prevention of operative infection in ophthalmic surgery

Uday R Gajiwala, Rajesh U Patel, Rohan A Chariwala
Tejas Eye Hospital, Divyajyoti Trust, Surat, Gujarat, India

Correspondence Address:
Uday R Gajiwala
Superintendent Tejas Eye Hospital, Divyajyoti Trust, Suthar Falia, Opposite Hanuman Temple, Mandvi, Surat - 394 160, Gujarat
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2320-3897.183726

Prevention of infection in ocular surgery is based on the science of asepsis and antisepsis not only depends on what we do pre-, intra-, and post-operatively but also depends on how we prepare our patient and personnel. Practicing no touch technique is extremely important in preventing sporadic infections, whereas breach in sterility many times is the cause of cluster infection - whether it is the presterile product purchased from the market, or items sterilized in the operation theater (OT) protocols (such as standard operating practices) play a key role in ensuring all these. There are several guidelines available to guide us. Many activities are done in the absence of the surgeon inside the OT such as cleaning and sterilization by our staff. Their understanding of the science of asepsis and antisepsis pertaining to the tasks performed by them is very important. All these needs to be monitored and continuous medical education need to be organized for our staff also. Written protocols help in achieving this. Everybody should be aware of the protocol and this should be strictly followed. No compromise at any cost should be accepted inside the OT.

Keywords: Environment, infection, no touch technique, patient factors, prevention, sterilization

How Does an Infection Occur?

Patient Factors

• Locally: Lids, conjunctiva, lacrimal sac, etc., could be the source ^[18],[19]
• Systemically: Sepsis elsewhere in the body particularly dental infection and lowered immunity, e.g., malignancy, patients on anti-cancer drugs, human immunodeficiency virus-positive patients, etc., could be causative factor.

Sterility-related Issues

• Sterility of presterile items: Irrigating solutions, viscoelastics, intraocular lenses (IOLs), multiple use eye drops, etc., - if not ensured - could be the source
• Sterility of items sterilized inside our operation theater (OT) - surgical instruments, surgical attire, etc., - if not done properly and not monitored - could cause endophthalmitis.

Personnel Factors

• Scrubbing, gowning, and gloving techniques need to be done scientifically accurately
• All the staff working inside the OT including surgeon, anesthetist, assistant, circulating staff, cleaning staff
• Harboring infection in the upper respiratory tract or have open/infected skin wounds could transmit infection
• With poor hygiene could harbor and transmit infection to the patients.

Environmental Factors

• If OT environment is harboring foci of organisms, they can gain entry into the eye intraoperatively
• The air inside the operating room is also important.

Surgery-related Factors

• Wound leak, vitreous weak, filtering bleb, ruptured posterior capsule, clear corneal incisions, ^[28] etc., will predispose the eye to endophthalmitis
• Amount of tissue handling is also important - more handling increases the chances of infection
• Time taken for surgery is also directly related to the chances of infection - more time taken, the chances increases proportionately.

• Inadvertent touch - failure in practicing no touch technique is the most common cause in sporadic infection
• Failure of sterilization - is the most common cause in cluster infection
• Environmental factors come after all this as a causative factor
• However, many times the organisms found in the patient's flora is found to cause infection. ^[18]

Pre-operative Preparation on the Previous Day

• Complete head bath or minimum is thorough face wash - this takes care of the periocular skin flora and overall hygiene ^[24]
• Antibiotic eye drops - at least 6 times/day on the previous day in the eye to be operated - this takes care of the conjunctival flora. ^{[29],[30],[31]}
• Couple of studies showed that topical moxifloxacin administered 2 h before surgery achieved significantly higher aqueous concentrations ^[32] as well as effective in reducing conjunctival and eyelid flora than topical moxifloxacin administered 1 day before surgery with 1 drop given on the day of surgery ^[33]
• One drop of 5% povidone-iodine eye drop should be instilled in the eye to be operated - to reduce the conjunctival flora ^[34],[35]
• All the contact procedures including tonometry and biometry to be done at least 1 day before the surgery so that the organisms implanted on the surface of the eye are removed by the antibiotic and povidone iodine before surgery
• No need to trim eyelashes if we are using plastic drape and covering the lashes properly under the drape. When we trim the lashes, they fall in the conjunctival sac and huge number of organisms enter the conjunctival cul-de-sac with it ^[36],[37]
• Similarly, syringing of the lacrimal sac can be avoided. We need to check regurgitation on pressure over lacrimal sac area by pressing over the sac. By syringing, we dislodge huge number of organisms into the conjunctival cul-de-sac and in which case, surgery preferably should not be done on the next day ^[38]
• Examination of the lids and lacrimal passage area to rule out septic focus. If present, surgery should be postponed
• Discharge or stickiness of the lids should prompt postponement of the surgery
• A medical examination to rule out the presence of septic foci in the body - particularly the oral hygiene and history of tooth extraction recently are mandatory.

Pre-operative Preparation on the Day of Surgery

• Preferably, we should use separate bottle of eye drops for each patient
• Preferably, we should ask the patient to do potassium permanganate gargles to take care of oral hygiene
• The patient should change completely into OT attire - give head and foot covers
• Ensure foot wash for the patient as our patients carry lot of dust and with it organisms into the OT
• Povidone iodine (10%) painting of the periorbital area should be done carefully using copious quantity of povidone iodine
• One drop of 5% povidone-iodine eye drops should be instilled into the conjunctival sac before giving block. ^[34],[35]

Instruments and Equipment Preparation-cleaning and Sterilization

• Separate sharp instruments from blunt instruments for the purpose of cleaning
• Instruments should be cleaned as soon as possible after use, especially Simcoe cannula
• Instruments should be thoroughly cleaned by washing in distilled water/mineral water. Surfactant cleaner can be used for effective cleaning
• After removing the instruments from ultrasonic cleaner, it will be washed in four bowls [Figure 2] containing mineral water, dried [Figure 3] with towel and/or hot air oven, tipped with plastic sleeve, and packed in individual trays
• For lumened instruments, flushing with distilled water thrice and then flushing with air thrice is mandatory
• Use clean soft toothbrush for cleaning the instruments which should be changed every 15 days
• Instruments should be placed in a tray with perforated bottom. Size of instruments' pack and their placement in the tray should allow steam penetration around the instruments during autoclaving. Keep joints open. Working surface of the instruments should be exposed to steam
• Separate medium-sized drum for each set of surgery is preferable
• Place the tray in a bin after spreading the towel inside
• Must wear gloves for handling instruments to avoid contact with infective material
• All the instruments should be cleaned with ultrasonic cleaner [Figure 1] once a week. Cannulated instruments are cleaned daily. Cycle time should be 30 min. To add Enzyme solutions, use mineral water. However, use of ultrasonic cleaner is not essential
• Single use of disposable tubing and other disposable items that become wet during the operative procedure is always preferable if cost allows. (Tubing is not easy to effectively sterilize unless an ethylene oxide (ETO) gas sterilizer is available)
• Chemical sterilization should not be done
• Paste the strips from inside the drums after autoclaving into the register should be signed by the OT in charge and the ophthalmologist before the session begins.

Figure 1: An ultrasonic cleaner Click here to view

Figure 2: Four Bowl technique Click here to view

Figure 3: Instrument dried and set being prepared Click here to view

Table 1: Sterilization methods of choice for articles during eye surgery[40] Click here to view

Instruments

Figure 4: Horizontal autoclave machine Click here to view

Table 2: Bench top steam sterilizer cycles according to the types of load they are intended to process Click here to view

• Autoclaved instruments should be used within 48 h
• Servicing of machine and calibration of gauges to be done every 6 months -maintain the record.

• Autoclaved for 5 min (holding time) in high-speed autoclave at 134°C temp and 30 lb pressure or in regular autoclave with holding time of 20 min after attaining required temperature and pressure
• The instruments are cleaned in distilled water using the four bowl technique
• The cleaning water should be changed after cleaning 4-5 sets or earlier if it appears soiled.

Special Instruments

• Vitrectomy cutter and cautery wires are autoclaved only
• Alternate method which can be used is ETO
• Remove all lubricants from instruments and dry them properly
• Pack them in polythene bag with indicator tape inside the bag.

• Check clarity of solution. Look for suspended particles, color change, or turbidity
• Check for leakage and quantity of solution
• Note batch number
• For glass bottle do vacuum test (bubbles on putting drip set). Physical inspection against the light
• To be sterilized before use at our end (debatable)
• One bottle to be used for one patient
• Keep Infusion bottle for 24 h (to confirm that it is not the source of infection in case, infection occurs).

• Viscoelastics are autoclaved before surgery (debatable)
• Discard after single use.

Operation Theater Environment Preparation-cleaning and Fumigation

• No sweeping only dry dusting should be done [Figure 5] and [Figure 6]
• Daily OT floor is wet mopped with 1% sodium hypochlorite [Table 3] solution using a two/three bucket technique. One bucket contains plain water and the other hypochlorite solution. The mop is rinsed in plain water, soaked in hypochlorite solution, and then mopping is done. (Hypochlorite solution should be prepared fresh just before use)
• A record of the cleaning by charting with the name of the person, date, and time of doing the work should be maintained, verified, and signed by the OT in charge
• Starting new OT, take at least 3 times fumigations on consecutive days and get three negative cultures
• Running OT - fumigation [Figure 7], once a week is enough (If the load is very high, more frequently)
• Spray formalin 30 ml of 40% formalin dissolved in 90 ml of clean water for 1000 cft by aerosol spray - keep OT closed for 24 h. Then clean with disinfectant before use
• If fumigator is not available, use 35 ml of 40% formalin in 10 gms potassium permanganate for 1000 cft - keep OT closed for 24 h
• Use 10-15 ml liquid ammonia next morning to remove formalin fumes
• Aldekol (formaldehyde 6%, glutaraldehyde 6%, and benzalkonium chloride 5%) also can be used as an alternative. For 4000 cft, 325 ml aldekol in 350 ml of water sprayed for 30 min - close OT for 2 h - switch on air conditioner (AC) - OT will be ready in 3 h
• Alternately, glutaraldehyde + formaldehyde combination and 1% hydrogen peroxide with silver nitrate are used at regular interval. Corridors are also fumigated
• Sterile quality of air in the OT is better achieved and maintained by employing air cleaner, air curtain (on during the session), and ultraviolet lights (turned on overnight) and through improving the overall cleanliness in and around the OT [Table 4]
• Laminar air flow (LAF) system: LAF is ideal. It delivers unidirectional air flow over the operating table of 300 air changes per hour. A bacterial count of ten colony forming units or less per cubic meter at the wound site is achieved.

Figure 5: Daily cleaning Click here to view

Figure 6: Weekly cleaning Click here to view

Figure 7: Fogger machine Click here to view

Table 3: Regimen for cleaning, disinfection and sterilization of the operation theatre[40] Click here to view

Table 4: Revised guidelines in operation theatres by National Accreditation Board of Hospital and Healthcare Click here to view

• Fans, light, watches, etc., inside theatre are wiped once a week, with diluted 1% sodium hypochlorite/savlon/soap water
• Microscopes should be cleaned with 15% cetrimide and 3% chlorhexidine gluconate daily, except lens. Microscope Knobs should be autoclaved and changed after each surgery/at least cleaned with alcohol hand rub between cases
• 0.1% ethanol, 0.1% 2-propanol, and 0.06% 1-propanol mixture is used to clean the microscope head daily
• Lenses should be cleaned weekly with lens cleaning solutions.

• Tables, saline stands, and revolving chairs (surgeon seat) should be cleaned daily with 1% sodium hypochlorite or antiseptic
• The furniture on which the sterile packs are placed should be placed in the sterile area and should be clean and dry
• The top of all furniture should be approximately the same height as the operating table. This level is known as the level of sterility.

• AC filter must be cleaned once a week with detergent and sun dried
• Servicing of AC needs to be done every 3 months
• Water tank should be cleaned with bleaching powder once a month and then dried before filling up
• Block room, changing room, doctor's room must be cleaned frequently with hypochlorite solution while the surgical session is going on
• The sink area should be cleaned several times daily and kept as dry as possible. No storage is allowed below it
• The outside of autoclave machine should be cleaned daily while the inside surface is cleaned weekly. The inside cleaning needs use of trisodium phosphate to remove the chemical residue
• Before removing gloves, the scrub nurse should place all soiled linen inside the laundry bin. Do not handle soiled linen with bare hands. It should also never be left on the floor or transported on a trolley used for other purposes
• Liquid waste material (e.g. the contents of the suction bottle) should never be disposed off in a scrub/utility sink but only into a container meant for the purpose. It can be disposed off in the drain after disinfection
• Waste management as per the standard practices suggested is mandatory
• Overhead tank should be covered and all pipes should be checked for leakages.

During Surgery

• Clean the trolley with spirit using unidirectional strokes. Avoid common trolley
• Painting of peri-orbital area should be done with povidone iodine 10% for 3 min. Boundary - hairline, tip of nose, nasolabial fold, and ear on the side of the eye to be operated. Swab should be held by swab holder or artery forceps - not by hand
• Direction should be from medial canthus to lateral canthus in a semi-circular motion, inside out
• If povidone iodine is contraindicated (allergy or hyperthyroidism), aqueous solution of chlorhexidine (2%) should be used
• Big size plastic disposable drapes to isolate lashes are good. (linen is porous and can transmit organisms if wet - should be avoided)
• 5% povidone Iodine eye drop to be instilled in the eye just before the surgery - wash it after three minutes to enhance antisepsis ^[34],[35]
• Do not touch sutures/IOL, any instruments to lid margins
• Keep used and unused instruments separate.

• Apply 2.5% chlorhexidine hand rub on bare hands after removing gloves and also on the surface of the gloves after cleaning it with sterile water ^[48]
• Change the gloves after each case or when it comes in contact with unsterile surface
• Rescrubbing after each surgery is ideal
• Prepare trolley afresh every time.

• End of surgery put 5% povidone iodine drop in the conjunctival sac
• Inject subconjunctival antibiotic (Broad Spectrum) + steroid - in the inferior fornix - (reserve higher antibiotics for actual infection) ^[49]
• Topical antibiotic when surgery is performed under topical anesthesia, better to patch ^{[50],[51],[52]} for at least 6 h. (not Mandatory)
• Postoperatively, broad spectrum antibiotic with steroids should be used
• Recent studies ^{[53],[54],[55],[56],[57]} showed role and safety of intracameral injection of moxifloxacin 0.5% ophthalmic solution diluted to a 0.1% concentration or cefuroxime at the conclusion of routine cataract surgery to prevent postoperative endophthalmitis
• With a significant percentage of surgeons concerned about the risks of homemade intracameral antibiotic preparations, there is a strong desire to have a commercially available antibiotic agent for this purpose. That 77% of respondents of American Society of Cataract and Refractive Surgery ^[58] were still not injecting intracameral antibiotics as the ESCRS study did not convincingly prove a strong enough benefit-risk ratio.

Monitoring

• Periodic culture is done once in a month from nonsterile areas such as hand washing area, floors, walls, and AC and sterile areas such as surgeon's and assistant's hands, saline, cannula, distilled water once in 15 days. Interpretation is important. Swabs from nonsterile items will indicate only the level of cleanliness. Whereas the swabs from sterile areas should not have any growth at all
• The bacterial carrying particle load in theater is checked by open dish sedimentation plating technique every fortnight. Less than 30 colonies is considered normal. However, no fungal colony or Gram-negative organisms should grow.

Figure 8: Chemical indicator strips Click here to view

Figure 9: Bowie Dick test pack and vapor line indicator Click here to view

Figure 10: Biological indicator ampoule Click here to view

Common suggestions to prevent infection

• Don't use same irrigation line, irrigating solution, viscoelastic, surgical instruments set, cannula, cautery wire, etc., for several surgeries
• Preferably avoid corneal incisions ^[50],[51]
• Prefer small incision cataract surgery for mass surgeries
• When in doubt apply sutures - improper valve, wound gap to be avoided - wound must be water tight at the end of the surgery and not air tight
• Phaco - tips, sleeve, tubings, and cassette also should be changed for each case
• Maximum 25 cases/surgeon/day is allowed
• Surgical session should allow enough time for cleaning activity
• Document sequence of surgeries for future investigations if required.

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