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Sometimes "rare" isn't good enough--––like when we're talking about the incidence of diseases which, although seldom seen, threaten vision. Endophthalmitis is just such a disease, occurring when bacteria or toxins make their way to the inside of the eye during ocular surgery. Although endophthalmitis is rare (findings range from less than two out of every 1,000 cases, to one in 10,000 cases), it is a serious ocular problem, with about half of all stricken patients ending up with a marked loss of visual acuity.
Because most endophthalmitis is caused by organisms already on the patient ( Studies show that two strains of Staphylococcus, which are commonly found in the eyelids, are responsible for 80 to 90 percent of endophthalmitis cases), and because it is so difficult to perform well-controlled studies to investigate its cause, healthcare providers have little knowledge on how to completely prevent it. But that doesn't mean that you can't take steps to make sure it almost never happens in your facility. We employ multiple strategies to keep bacteria growth down in our operating room suites and use current protocols in aseptic technique, as recommended by the Association of periOperative Registered Nurses (AORN) and the Association for Professionals in Infection Control and Epidemiology (APIC), to develop policies and procedures that we believe keep the incidence of endophthalmitis as low as possible. We may never stamp out endophthalmitis, but we do believe it's possible to reduce its occurrence by taking the following steps.
Environmental Precautions
Keep your phaco machine infection-free. If possible, use a phaco machine that employs a closed aspiration system. If you have an older machine, run the cleaning cycles religiously, and consider culturing samples from it occasionally. Patients have contracted endophthalmitis due to contaminated phaco machines.
Clean instruments and sterilize them properly. For all of our stainless-steel instruments, we use an ultrasonic cleaner, which removes invisible soil particles. It is important to change the solution regularly, as contaminated ultrasonic cleaner baths have been reported. We put our diamond blades through an on-site steamer. Getting a steamer is expensive, but the money you save by not sending diamonds out to be steamed is worth it, in our opinion. Following the steps above, we sterilize instruments according to industry standards, in gravity-drainage autoclaves set at 270 degrees F for a specified period of time, depending on the type of instrument and whether it is wrapped or unwrapped.
Change filters frequently. We change our HVAC system filters once every month instead of following the manufacturer recommendation of once every three months. We can't prove that this has reduced the incidence of endophthalmitis. But we have found, through periodic swabbing of our ORs, that we have a more germ-free OR environment with more frequent filter changes. We recommend that you run cultures on your environment quarterly. You can send your swabs to a lab to be cultured; the lab we use sends a report with helpful recommendations (we use Pure Earth Environmental Laboratory, which is based in New Jersey).
Perform terminal cleaning every night. Although most infectious endophthalmitis is traced to the patient's own flora, a tenth to a fifth may arise from the operating environment. Have your maintenance person wipe down all flat surfaces at the end of the day––walls, ceilings, shelves, the tops of equipment, as well as exhaust vents. These are all prime areas where bacteria can grow. At our facility, we use an OSHA-approved disinfectant, which kills everything on any flat or easy-to-access surface.
Preparatory and Perioperative Precautions
Give prophylactic topical antibiotics and thorough instruction. As with so many endophthalmitis prevention measures, there is little proof that perioperative topical antibiotic administration reduces endophthalmitis, but as most infection stems from organisms on the patient, this step may be helpful. The patient applies a physician-prescribed antibiotic to the eye beginning three days pre-op, and for five days following surgery. Around the time the surgery is scheduled, the surgeon talks with the patient about good eye hygiene proper use of the antibiotic. Post-op, a nurse goes over a discharge-instruction sheet––prepared and signed by the doctor––with the patient. We make sure a family member is present during the discussion to reinforce the instructions. The nurse and patient sign the form. We also tell the patient to call the surgeon immediately if there is pain, redness, or fever, all signs of possible endophthalmitis.
If a patient presents with a red or crusty eye on the day of surgery, the surgeon evaluates it. If infection is present, we cancel surgery. If the surgeon judges the patient to be infection-free, we clear any debris with warm compresses prior to prepping the patient.
Enforce sterile technique. We employ vigilant protocols, based on AORN and APIC guidelines, for handling instruments during surgery and keeping OR work areas clean. The day our employees start with us, we give them a 75-page policy-and-procedures manual. We expect them to review it and know it, cover to cover.
Prior to surgery, a nurse covers the eyelashes, lid, brow, and parts of the cheek and forehead with a 10-percent povidone iodine (Betadine) solution; they also place a drop of 5-percent povidone iodine solution in the eye. This procedure is standard in most facilities, and for good reason; it is the only antibiotic treatment proven to reduce the incidence of endophthalmitis. When a new circulating nurse is on the floor, an experienced nurse trains her in this protocol and monitors until she is certain the new nurse has mastered it.
Encourage scrupulous hand- washing. Good scrubbing protocol is always a must, and in ophthalmic cases, with micro instruments and their sharp tips frequently causing glove punctures, no less important. Be sure to use an OSHA-approved scrub when possible, and to periodically make sure that all personnel, surgeons included, are practicing good technique.
Drape the eyelashes carefully. When this is done properly, the phaco tip never comes into direct contact with the lid margins before entering the eye during surgery. We train our scrub techs to drape per surgeon preferences. This is another task that requires close proctoring, as it can be difficult to get the drape into proper position, past the lid margin, before draping back the upper lid.
Make sure that forceps are kept dry. Scrub techs should keep forceps dry, to avoid a flying lens––not uncommon with forceps (as opposed to injectable-lens) procedures. And any lens that lands anywhere other than inside the patient's eye should be sent back to the manufacturer.
We continually review our procedures; in addition, they are examined at least four times a year by our Quality Assurance, Risk Management/Patient Care Committee, which consists of several staff members, including physicians and administrators. One of our policies is to send a surgical-complication survey to our surgeons quarterly, so we can track any incidents of postoperative infection, report cases to the Department of Health should they occur, and address any infection trends at our facility.
We may never eliminate endophthalmitis. Probably the lion's share of the disease is attributable to surgeon technique, and some cases have reportedly arisen from supplier error, such as infected or improperly formulated balanced salt solution and even contaminated viscoelastic-which would be difficult to detect until patients have been affected. Continued vigilance, however, will guarantee that your facility is as endophthalmitis-free as possible, and that it is an all-around healthy environment for your patients, to boot.
Tammy Ashley, along with her partner, Mr. Cecchetti, left Island Eye Surgicenter in Carle Place, Long Island, around the time this article was completed, and opened MedStart, LLC, a consulting company that sets up ambulatory surgery centers and physicians' offices. Ms. Ashley was director of perioperative services at Island Eye Surgicenter, having developed it from the ground up with Mr. Cecchetti, and has many years of experience in the surgery arena.
In addition to his partnering MedStart, LLC, Mr. Cecchetti is a certified ophthalmic assistant with a specialty in surgery assisting and 13 years of ophthalmology experience. He was director of operations at Island Eye Surgicenter.
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