Needle sterility during strabismus surgery

Endophthalmitis after strabismus surgery: incidence and outcome in relation to age, operated eye muscle, surgical technique, scleral perforation and immune state

PURPOSE

Identify risk factors for endophthalmitis after strabismus surgery (EASS) and relate these to incidence and outcome.

METHODS

Ophthalmologists, who had operated, diagnosed or treated EASS, completed a case record form with 71 questions in six domains: Preoperative, Surgery, Perforation, Postoperative, Outcome and Experts' opinion. To estimate the age-specific incidence per number of strabismus operations in the Netherlands during 1994-2013, the age distribution of Dutch cases was compared with the age-specific rates of strabismus surgery in the Dutch Registry of Strabismus Operations and with population data. Exploratory data analysis was performed. The immune state was evaluated in six patients. Five enucleated eyes were studied histopathologically.

RESULTS

None of the 26 patients (27 eyes with EASS) were between 9 and 65 years old, except for one patient with retinal haemorrhage followed by endophthalmitis. In the Netherlands during 1994-2013, the rate of EASS was approximately one per 11 000 strabismus operations, but one per 4300 for children aged 0-3 and one per 1000 for patients 65 and older. Endophthalmitis was diagnosed on postoperative day 1-4 in children aged 0-3. In all 15 children aged 0-5, the 16 affected eyes were phthisical, eviscerated or enucleated. The involved eye muscle had been recessed in 25 of 27 cases. It was a medial rectus in 15 of 16 children aged 0-6. It was a lateral (6), inferior (2) or medial (1) rectus in elderly. Scleral perforation went unnoticed in all children (no record in three) and in two of seven elderly (no record in two). Histopathology showed transscleral scarring compatible with scleral perforation in four patients but, in a two-year-old girl who had EASS together with a transient medial rectus palsy, the sclera underneath the former suture tract was not perforated but did contain the long posterior ciliary artery.

CONCLUSIONS

Endophthalmitis after strabismus surgery (EASS) affects children and elderly, with a grave outcome in young children. It occurs after recession of the medial rectus muscle in children, and it may occur without scleral perforation. Age and perforation are key determinants that interact with other factors that determine the occurrence and fulminance of EASS.

Strabismus Surgery Infection Prophylaxis and Timing of First Postoperative Visit

PURPOSE

To characterize the practice patterns of pediatric ophthalmologists regarding infection prophylaxis for strabismus surgery and timing of the first postoperative visit.

METHODS

A ten-question multiple-choice, close-ended questionnaire was e-mailed to members of the American Association for Pediatric Ophthalmology and Strabismus listserv. Survey responses were summarized using frequencies and percentages. Univariable tests of association between prophylactic measures and surgeons reporting a prior episode of postoperative cellulitis or endophthalmitis were performed.

RESULTS

Three hundred eighty pediatric ophthalmologists completed the survey. Most ophthalmologists instill 5% povidone-iodine solution during surgical preparation (88.4%), use topical antibiotics with or without steroids at the conclusion of surgery (90%), and prescribe oral or topical antibiotics postoperatively (85.5%). Eighty-five percent of strabismus surgeons routinely see patients for the first postoperative visit within the first week, although there is no consensus as to which day is preferred. Responders previously reporting experience with a postoperative infection were more likely to use intraoperative intravenous antibiotics (P = .002) and Tegaderm tape (3M, St. Paul, MN) or other adhesive drape to isolate the eyelids/eyelashes (P = .047).

CONCLUSIONS

A common practice pattern appears to exist regarding the use of 5% povidone-iodine solution in surgical preparation, application of topical antibiotics at the end of surgery, and a postoperative regimen of topical antibiotics/steroids. There is no prevailing practice pattern regarding the timing of the first postoperative visit. Previous experience with postoperative cellulitis or endophthalmitis may lead to the adoption of more formidable infection prophylaxis measures such as intravenous antibiotics prior to surgery. [J Pediatr Ophthalmol Strabismus. 2019;56(6):354-359.].

Extraocular and Intraocular Infections Following Strabismus Surgery: A Review

An extensive literature review of various types of infections following strabismus surgery was facilitated by using the search engines PubMed and Google Scholar. In both search engines, the phrases "infection following strabismus surgery," "infection strabismus surgery," "complications of strabismus surgery," "endophthalmitis strabismus surgery," and "strabismus scleral perforation" were used for the review. The type of infection, surface involved, and site of the infection determined the type of therapy. Infections involving deeper tissues, such as periocular infection or orbital cellulitis, required systemic therapy. Sub-Tenon's abscesses required incision and drainage, as well as systemic antibiotics. The development of endophthalmitis following strabismus surgery was rare, but was usually devastating to the visual result. Symptoms of an adverse intraocular condition began by mean postoperative day 3, but the definitive diagnosis and treatment of endophthalmitis was not made until mean postoperative day 6. Despite early detection of this latter type of infection and early surgical intervention with vitreous paracentesis and intraocular injection of antibiotics, the visual result was extremely poor in more than two-thirds of the reported cases. Although there is no known way to truly prevent all infections following strabismus surgery, several techniques may be prudent for the strabismus surgeon to adopt to decrease the bacterial load and minimize the risk of infection. The surgeon should be encouraged to consider preoperative use of povidone-iodine on the operative field and avoid scleral perforation during surgery. [J Pediatr Ophthalmol Strabismus. 2019;56(4):214-221.].

Infection following strabismus surgery

PURPOSE OF REVIEW

To provide the most up to date information on postoperative infection associated with strabismus surgery, its diagnosis, management, and prevention.

RECENT FINDINGS

Recent studies show that topical povidone-iodide is effective in reducing the bacteria colony count at the incision site and preventing contamination during strabismus surgery. Repeating povidone-iodide 5% drops after surgical preparation and presoaking the sutures in povidone-iodide reduces bacterial contamination further. There is no single postoperative day that would be best to detect the onset of a postoperative infection. Infection can follow a normal postoperative visit.

SUMMARY

Infection continues to be a concerning complication of strabismus surgery. Early detection and treatment is needed to obtain a good outcome. Patients and their families should be educated on the early signs and symptoms of postoperative infection and to contact their ophthalmologist if any occur.

Descriptive Study of Conjunctival Cysts: A Rare Complication after Strabismus Surgery

Aim

Conjunctival cyst is one of the uncommon complications of strabismus surgery. It is important for surgeons and patients to be aware of and take precautions to minimize the risk. This study aimed to explore the clinical manifestations, etiology, and prognosis of conjunctival cyst at the operative site after strabismus surgery.

Methods

The data of 1675 patients were included in our retrospective analysis, who underwent strabismus surgery at the Xiangya Hospital of Central South University between 2010 and 2016. During the postoperative follow-up, conjunctival cyst was found in 7 cases (7 eyes; 0.4% detective rate of all cases). The clinical characteristics, prognosis, and follow-up data were recorded together with the results of pathological and bacteriological tests.

Results

Seven patients between the age of 3 years 8 months and 39 years, with the mean age of 12.71 years (12.71 ± 12.59, years of age), were included in the study. Strabismus surgery affected 13 recti, 8 medial and 5 lateral recti, and 3 obliques (all inferior oblique). Conjunctival cyst was detected in seven patients between 10 days and 6 months postoperatively (42.57 ± 61.11, detected days). In six cases, the cyst was detected at the nasal (3 cases) or temporal side (other 3 cases), and at the fornix in one case. Four out of 7 patients underwent cyst excision, and methicillin-resistant Staphylococcus aureus (MRSA) was detected in one patient.

Conclusions

Conjunctival cyst is a rare postoperative complication of strabismus surgery, conjunctival epithelium implantation should be the primary cause, and infection might exaggerate the situation. A longer duration of the surgical procedure could increase the possibility of infection, which could be accompanied with a greater tendency to the occurrence of conjunctival cyst.

Complications of Strabismus Surgery

All surgeries carry risks of complications, and there is no way to avoid ever having a complication. Strabismus surgery is no different in this regard. There are methods to reduce the risk of a complication during or after surgery, and these steps should always be taken. When a complication occurs, it is important to first recognize it and then manage it appropriately to allow for the best outcome possible. This article will discuss some of the more common and/or most devastating complications that can occur during or after strabismus surgery as well as thoughts on how to avoid them and manage them should they happen.

The effect of commonly used surgical solutions on the tensile strength of sutures

PURPOSE

To investigate the new practice of soaking sutures prior to use in strabismus surgery in an effort to avoid endophthalmitis.

METHODS

Specimens of 6-0 polyglactin suture were loaded in tension until failure occurred. Tests performed were without modification and after soaking in normal saline solution, 5% povidone-iodine solution, and 0.5% chloramphenicol solution for 30 minutes.

RESULTS

There was no significant difference between the four groups with regard to mean force or type of solution used.

CONCLUSIONS

Soaking polyglactin sutures in various solutions used in strabismus surgery for 30 minutes had no effect on the tensile strength.

Pediatric infectious endophthalmitis: a review

Infectious endophthalmitis is a rare but severe complication of septecemia, intraocular surgeries, or penetrating eye trauma. The etiology, prognosis, and management of pediatric endophthalmitis resulting from exogenous and endogenous infections are reviewed. Open-globe trauma and glaucoma surgery are the most frequent causes of endophthalmitis in children, whereas endogenous infection is the least common cause. Streptococcus and Staphylococcus species are common bacterial agents in both posttraumatic and postoperative pediatric endophthalmitis, whereas Candida albicans is a commonly reported organism in endogenous endophthalmitis. Additionally, Streptococcus pneumoniae and Haemophilus influenzae appear more likely as pathogens in children than in adults. The clinical manifestations and outcome usually correlate with the virulence of the infecting organism. The visual prognosis of endophthalmitis is generally poor.

Bacterial Species and Surgical Sites Involved in Contamination During Strabismus Surgery

PURPOSE

Residual bacterial colonization of the eye after strabismus surgery is common. This study aimed to identify the bacterial pathogens and contaminated sites involved during strabismus surgery.

DESIGN

A prospective, case-control study of 44 patients aged 1-78 years who underwent strabismus surgery.

METHODS

Before participation, we received clinical research board approval, and informed consent was obtained from each of the patients or the parents. Five percent povidone-iodine was used to sterilize the surgical site in all cases. Intraoperative swabs were taken from conjunctival incision site, plain gut suture, scleral surgery site, Vicryl suture, and lid specula. Bacteria isolates were identified by culture growth and Gram staining. Positive and negative control samples were collected.

RESULTS

Samples from 13 (29.5%) of 44 cases were positive for growth of bacteria. The conjunctival incision site was involved in 9 cases (20.5%), and the lid speculum in 7 cases (15.9%). All 13 colonized plates grew the coagulase-negative Staphylococcus strain. Staphylococcus aureus was cultured in 1 case (2.3%) and was associated with the only case of postoperative infection. The S. aureus cultures came from both the conjunctival incision site and the lid speculum.

CONCLUSIONS

Despite a high contamination rate of 29.5%, incidence of clinically significant infection was low. Our study suggests involvement of the eyelids and conjunctiva in harboring bacteria even after the use of povidone-iodine. Regardless of the mechanism of contamination, we should continue to focus our efforts on reducing intraoperative conjunctival bacterial load. Irregular tear film can contribute to postoperative complications.

[Bacterial contamination of needles after intravitreal injection in Paraguay]

PURPOSE

The study was designed to prospectively evaluate the bacterial contamination of needles used for intravitreal injection during surgery.

MATERIAL AND METHODS

Between December 2007 and December 2010, 549 eyes of 413 patients were treated with intravitreal injections of 1.25 mg bevacizumab. Of the patients 322 received a single injection and 91 multiple injections. Preoperatively the periorbital skin of all patients was treated with 10% povidone iodine (PVI) and the conjunctival sac was irrigated with 1% PVI. No pre-injection antibiotics were administered. Immediately after the injection the needles were rinsed 3 times in thioglycolate broth which was then cultured at 37°C for 5 days. As a negative control 73 sterile unused needles were treated in the same way.

RESULTS

Out of the 549 needle points tested 8 (1,45%) were found to be contaminated after intravitreal injections. The isolated bacteria were coagulase negative Staphylococcus (n = 7), Propionibacterium acnes (n = 1) and Klebsiella pneumoniae (n = 1) (co-contamination in one case).

CONCLUSION

Contamination of needles is minimal after prophylactic povidone iodine irrigation before intravitreal injections. Therefore, this prophylaxis technique is recommended before intravitreal injections in order to prevent postoperative infections.

Application of 10% povidone iodine reduces conjunctival bacterial contamination rate in patients undergoing cataract surgery

PURPOSE

To determine the efficacy of 10% povidone iodine (PVI) drops given before cataract extraction in addition to routine irrigation of the conjunctival sac with 1% PVI.

METHODS

This prospective, randomized, single-center study at the Department of Ophthalmology, Ludwig-Maximilians-University, Munich, includes 263 eyes of 242 patients undergoing cataract surgery. Patients were randomized to receive 3 drops of 10% PVI into the conjunctival sac (study group) or no PVI drops (control group). All patients underwent periorbital disinfection with 10% PVI followed by irrigation of the conjunctiva with 10 mL of 1% PVI. Specimens were obtained prior to the application of PVI, after antibiotic administration (T1), after irrigation with PVI but before surgery (T2), and at the conclusion of surgery (T3).

RESULTS

After PVI disinfection, the number of positive cultures was significantly reduced in all groups (p<0.0001) from 69%-93% at T1 to 1%-16% at T3. In outpatients, the study group showed significantly fewer positive cultures at the conclusion of surgery compared to the control group (4% vs 16%; p=0.03). Also in inpatients significant fewer positive cultures were found in the study group compared to the control group at T2 (12% vs 28%; p=0.03) and at T3 (1% vs 10%; p=0.03).

CONCLUSIONS

Three additional drops of 10% PVI prior to surgery provided additional benefit by reducing the conjunctival bacterial contamination rate even in the setting of preoperative irrigation of the conjunctiva with 1% PVI.

Suture contamination in strabismus surgery

PURPOSE

To document the contamination rate of sutures used in strabismus surgery and evaluate the reduction of contamination using antibiotic-coated and antiseptic/antibiotic-coated sutures.

METHODS

This was a prospective randomized analysis of suture contamination and potential prophylaxis measures after strabismus surgery. Muscle sutures (6-0 polyglactin) used in 302 consecutive cases of strabismus from October 2008 to May 2009 were collected and randomly assigned to three groups: (1) a control without pretreatment sutures (61); (2) antibiotic/steroid-coated sutures (200); and (3) antiseptic-soaked and antibiotic/steroid-coated sutures (141). The sutures were used under sterile conditions and then cut into pieces and transferred to blood agar plates, which were incubated for 48 hours and then checked for growth.

RESULTS

Group 1 had bacterial growth in 17 of 61 (28%) sutures; group 2 had growth in 44 of 200 (22%) sutures; and group 3 had growth in 12 of 141 (9%) sutures. The reduction in bacterial growth using the antibiotic/antiseptic coating was significant (P = .006). One patient developed coagulase-negative Staphylococcus epidermidis endophthalmitis 1 week after surgery, which was promptly diagnosed and successfully treated. No complications from the antibiotic-coated or antiseptic-soaked sutures were noted.

CONCLUSIONS

Although endophthalmitis after strabismus surgery is rare, estimated at 1 in 35,000 to 1 in 185,000, visual outcome is uniformly poor. The authors hypothesize that strabismus sutures can be contaminated via contact with the eyelashes and skin, providing a possible conduit for endophthalmitis. Bacterial contamination of strabismus sutures is high (28%) and can be reduced significantly if sutures are soaked in antiseptic before use.

The effect of surgical preparation technique on the bacterial load of surgical needles and suture material used during strabismus surgery

PURPOSE

To investigate the effectiveness of 3 surgical preparation techniques in decreasing bacterial contamination of needles and suture material during strabismus surgery.

METHODS

Consecutive patients requiring 2-muscle strabismus surgery were randomized into 1 of 3 groups. In Group A, patients' periocular skin and bulbar conjunctivae underwent preparation with 5% povidone-iodine; the drape was placed without regard to eyebrows; and an open wire-loop lid speculum was used. Group B patients underwent the same preparation as Group A patients; however, the eyelashes and eyebrows were scrubbed with 5% povidone-iodine on cotton tip applicators, and the drape was placed to exclude the eyebrows from the surgical field. Group C patients underwent the same preparation as Group B patients; however, a bladed lid speculum was used during surgery to exclude some of the eyelashes from the surgical field. After the procedure, all needles and suture materials were sent separately for aerobic culture. The data were analyzed for differences in contamination rates between the groups.

RESULTS

Of 77 patients, 24 (31.4%) had either a needle and/or suture contaminant. Groups A, B, and C had mean contamination rates of 29.6%, 34.6%, and 29.2%, respectively. There was no significant statistical variation in contamination among the 3 groups. The most common organism identified was a coagulase-negative staphylococcus strain.

CONCLUSIONS

More meticulous sterile preparation of the surgical field did not result in a meaningful reduction in suture or needle contamination rates during strabismus surgery.

Subretinal abscess after strabismus surgery: case report and literature review

PURPOSE

The purpose of this study is to describe the first reported case of a subretinal abscess after strabismus surgery and the successful treatment with vitrectomy, intravitreal antibiotics, and cryotherapy.

METHODS

This is a retrospective case report and literature review.

RESULTS

A 4-year-old boy underwent uncomplicated bilateral medial rectus muscle recession. Within 9 days after surgery, he developed unilateral endophthalmitis with a subretinal abscess at the approximate location of the medial rectus muscle insertion. The rectus muscle-scleral suture was removed, and transscleral cryotherapy was applied to the abscess site. Vitrectomy with injection of intravitreal antibiotics was performed. A bacterial culture of the removed suture was positive for Staphylococcus aureus and sensitive to his antibiotics. By 1 month, the abscess and vitritis had resolved completely.

CONCLUSION

This is the first reported case of endophthalmitis with a subretinal abscess occurring after strabismus surgery. In general, endophthalmitis after strabismus surgery has a poor visual prognosis. Early diagnosis and intervention with intravitreal antibiotics and possible vitrectomy may be advantageous for patients with a subretinal abscess.

Bacterial contamination of needles used for intravitreal injections: a prospective, multicenter study

PURPOSE

To determine the incidence of bacterial contamination of needles used for intravitreal injections.

METHODS

Patients undergoing intravitreal injections were enrolled prospectively. No pre-injection antibiotics were administered. Following povidone-iodine irrigation, conjunctival cultures were taken and the injection was performed. The needle was cultured. A dry control needle was exposed to the surgical field and cultured.

RESULTS

No patients developed endophthalmitis. Eighteen injection needles (18%) yielded positive bacterial growth. The most commonly encountered organisms were Propionibacterium acnes (n = 8) and Staphylococcus epidermidis (n = 6). Four control needles showed positive growth, in 2 cases with the same organism as a matching positive used needle. The difference between contamination rates of used and control needles was significant (p = .002, McNemar's test).

CONCLUSIONS

Bacterial contaminants are present on a substantial proportion of needles. Since the needle contacts both the ocular surface and the vitreous, it is possible that inoculation of the vitreous cavity occurs in such cases.

Bacterial contamination of needle points after intravitreal injection

PURPOSE

Evaluation of the magnitude and pattern of bacterial contamination of needle points with conjunctival bacteria during the intravitreal injection. Analysis of the efficacy of preinjection prophylaxis.

METHODS

A total of 550 intravitreal injections were done in 414 patients (n=425 eyes). A total of 289 patients were injected once, while 125 patients received several injections. Before the intravitreal injection in the operation room, the following standard preoperative preparation of the eye-10% povidone iodine scrub on the eyelids, eyelashes, and forehead and irrigation of the conjunctival sac with 1% povidone iodine-was carried out. Immediately after the injection, the needle points were rinsed three times in thioglycolate broth, which was cultured at 35 degrees C for 5 days afterwards. As a negative control, 200 sterile unused needle points were treated the same way.

RESULTS

Only 2 out of 550 (0.36%) needle points were contaminated after intravitreal injection. In sensitivity testing, the isolated Staphylococcus epidermidis and Corynebacterium sp did not show multidrug resistance. All 200 unused needle points proved to be sterile after 5 days of cultivation.

CONCLUSIONS

Contamination of needle points is minimal after iodine irrigation prophylaxis before intravitreal injection. Therefore, we recommend this prophylaxis technique before intravitreal injections. The low incidence of contaminated needle points, however, shows that there still is a risk of bacteria entering into the eye during injection.

Bacterial contamination of ocular surface and needles in patients undergoing intravitreal injections

PURPOSE

To evaluate potential sources of bacterial contamination during intravitreal (IVT) injection procedures.

METHODS

Patients scheduled for IVT injection were asked to enroll in the study at the California Vitreoretinal Center (Menlo Park, CA) and the Vantage Eye Center (Salinas, CA) between October 2004 and April 2005. A total of 104 patients participated in the study, with a total of 118 IVT injection procedures performed on 107 eyes. Standard microbiological techniques were used to culture, identify, and quantify bacterial contamination of injection needles and the bulbar conjunctiva at the injection site in patients undergoing IVT injections. The main outcomes measured were type and quantity of bacterial isolates.

RESULTS

Two (2%) of 114 needles collected were contaminated with bacteria. The prevalence of bacterial contamination of the injection site on the bulbar conjunctiva was 43% before prophylaxis on the day of the injection with topical antibiotics and povidone-iodine, with a statistically significant reduction to 13% after prophylaxis (P < 0.0001). Coagulase-negative Staphylococcus, the most common bacterium isolated from the ocular surface, was isolated from both culture-positive needles.

CONCLUSIONS

IVT injection needles became contaminated with bacteria during the injection procedure. Although the contamination rate was low, this supports a mechanism of postinjection endophthalmitis in which there is direct inoculation of ocular surface flora into the vitreous cavity by the injection needle.

Orbital cellulitis after strabismus surgery

Serious infection is uncommon after eye muscle surgery. Orbital cellulitis is a rarely reported but is potentially vision- and life-threatening complication after strabismus surgery. In this report, we describe a case of unilateral orbital cellulitis after strabismus surgery for sensory exotropia in a healthy adolescent boy.

Suprachoroidal septic effusion leading to panophthalmitis following strabismus surgery

We describe a case of endophthalmitis following strabismus surgery. Drainage of the suprachoroidal effusion with injection of antibiotics was unsuccessful in salvaging vision. Endophthalmitis following strabismus surgery may present with findings simulating a choroidal effusion or hemorrhage. Treating physicians should be alert to signs and symptoms of this severe complication of strabismus surgery in preverbal children.

Three-day application of topical ofloxacin reduces the contamination rate of microsurgical knives in cataract surgery

PURPOSE

To determine the rate of contamination of microsurgical knives during cataract surgery and the benefit of a 3-day versus a 1-hour preoperative application of topical ofloxacin in reducing the contamination rate.

DESIGN

Prospective, randomized controlled trial.

PARTICIPANTS

Seventy-eight eyes of 75 patients were randomly assigned to control (39 eyes) or study groups (39 eyes).

METHODS

All patients from both groups received 0.3% topical ofloxacin 1 hour before surgery, 5% povidone-iodine (PVI) scrub of the periorbital area, and 2 drops of PVI onto the ocular surface preoperatively. The patients in the study group also received ofloxacin 4 times a day for 3 days before surgery.

MAIN OUTCOME MEASURES

Microsurgical knives were placed in blood culture broth media immediately after the incision had been made. The number of positive cultures and types of bacteria isolated were determined.

RESULTS

Ten of 39 knives (26%) in the control group were found to be positive for bacterial growth compared with only 2 of 39 (5%) in the study group (P = 0.028).

CONCLUSIONS

The initial paracentesis incision frequently results in contamination of the microsurgical knife and may serve as a mechanism for introducing bacteria from the ocular surface into the anterior chamber. The application of topical ofloxacin for 3 days before surgery significantly reduces the contamination rate of the microsurgical knives, compared with a preoperative application of ofloxacin given 1 hour before surgery.

Eye muscles surgery

In the past year, experimental studies have analyzed instrument-induced measurement errors during strabismus surgery, investigated intraoperative variables pertinent to adjustable sutures, and investigated ways to prevent and create adhesions in animal models. Newer surgical techniques include coincident resection and recession of a rectus muscle, recession and resection without placement of scleral sutures, and modification of graded anterior transposition of the inferior obliques. Ocular motility problems related to thyroid ophthalmopathy, or lost muscles, as well as those occurring after surgery for retinal detachment remain a challenge. Patients may avoid the risks associated with the use of topical corticosteroids after strabismus surgery by using nonsteroidal anti-inflammatory drugs in their place. Recent contributions to the literature on these issues are reviewed here.