EVERY MINUTE DETAIL ON DIFFERENT METHODS , TECHNIQUE AND PROTOCOLS TO BE FOLLOWED TO PREVENT INTRAOCULAR INFECTIONS DURING EVERY PHASE OF SURGERIES. COVERING PROTOCOLS DESIGNED BY AIOS AND WHO.

1. PREVENTION OF
INTRAOCULAR INFECTION
DR. ARVIND KUMAR MORYA
MBBS, MS OPHTHALMOLOGY(Gold Medalist),
MNAMS,
CATARACT(MICS), GLAUCOMA, PAEDIATRIC
OPHTHALMOLOGY,
STRABISMUS,REFRACTIVE AND MEDICAL RETINA
SERVICES,
ASSOCIATE PROFESSOR ,
DEPARTMENT OF OPHTHALMOLOGY,
AIIMS, JODHPUR

2. Pre operative measures

3. Blood sugar
(Recent – within last 1 week)
• Fasting blood sugar should be </= 140
mg/dl
• Random blood sugar/ post prandial
should be </= 200 mg/dl

4. Ocular examination
• Pre-operative: ROPLAS / syringing done;
(but, no syringing/ ROPLAS on day of
surgery)
• If infection of lids, adnexa & surroundings
– postpone surgery; manage infection/
block- then operate.
• No contact procedures like biometry/
tonometry on day of surgery

5. Pre-operative topical
antibiotics
• Pre-operative topical antibiotics: not
mandatory(when used: broad spectrum
antibiotics)
• Povidone iodine (betadine) 5% avoiding the
cornea- mandatory: just before surgery – allow
contact time of 3 minutes.
• No need of clipping lashes
(plastic drape to cover lid margins & lashes properly)

6. Physician clearance
• Fitness from qualified physician or
anesthetist where required especially in
patients with diagnosed systemic illness
such as hypertension, diabetes, cardiac
disorders etc.
• Cardiac monitoring is also advised in co-
morbid cases.

7. In mass surgeries
(Not more than 25 eyes/surgeon/session of 4
hours)
• Patients with multiple systemic problems-
surgery NOT to be done
• Combined surgery- NOT to be done
• High risk cases & topical surgeries to be done
only by experienced surgeons with all due
precautions.

8. • One-eyed patients: avoid in mass
surgeries (unless patient’s condition
compels-then consider with special care)
• Emergency services to be available for 1
week after mass surgery to cater for any
untoward consequences.
• Dedicated eye OT in a hospital set-up –
no make shift OT’s
In mass surgeries

9. Operative measures

10. General
• Written informed consent in patient’s
language explaining the risks involved and
benefits expected –to be signed by the
patient, his/her relative and/or interpreter
(wherever required)
• Anaesthesist is not a must, basic life support
(BLS) trained technician staff sufficient
• Pulse oximeter mandatory for all cases
under topical/local anaesthesia.
• All patients should have a secured i.v. line.

11. General
• High risk cases (3 or more co-
morbidities): Anaesthesiologist or a
doctor (other than surgeon) should be
there; I/V line should be maintained.
• Emergency drugs- mandatory (annexure)
• Microscope is a must

12. Surgeon and scrubbed surgical
assistants
• Anyone (including doctors/staff) with any
obvious infection should not be allowed to
enter the OT.
• Face masks should also cover the area of nose.
• Shoe covers over street or external use
footwear: NOT recommended.
• Separate washable rubber OT footwear with
different color coding desirable.
• Separate bathroom slippers.

13. • Clean, washed and OT dress
• No street clothes inside OT for anyone
(including doctors/staff)
• Washing/ gowning/ gloving as per
standard protocol for all OT personnel
Surgeon and scrubbed surgical
assistants

14. Surgeon and scrubbed surgical
assistants
• Hand washing done with betadine/
chlorhexidine scrub for 6 minutes (if liquid
soaps, 5 minutes – no bar soaps to be used)
• Portable/purified water used for scrubbing.
• OT etiquette to be put on walls.
• Important do’s and don’ts on the wall.

16. Surgeon and scrubbed surgical
assistants
• Sterilized gloves: fresh new pair for every
case.
• Powder free gloves should be preferred as
allergic reactions have been reported with
powder particles of gloves.

17. • Use chemical disinfectant (70% isopropyl
alcohol with/without chlorhexidine, eg.
Sterillium/ Microshield/ Bactorub) between
cases.
• Baccishield disinfectant – 11% Hydrogen
Peroxide w/v with 0.01% w/v diluted silver
nitrate solution.
Surgeon and scrubbed surgical
assistants

18. Surgeon and scrubbed surgical
assistants
• Sterilized gown- is mandatory.
• Surgeon should not come out of OT in OT
gown. If comes out, must rescrub & change
for next case.

19. Surgeon and scrubbed surgical
assistants
• Mask should cover nose & mouth
properly.
• OT cap – to be worn properly tucking in
all hair.
• Position of hands after scrubbing &
gloving – above waist & upright in front
• Document sequence of surgeries.

20. Intraocular irrigating fluids
• One for one rule: one bottle of irrigating
fluid for one patient.
• Note the batch number of all consumables
• Use of glass bottle should be promoted
over plastic bottles.
• Ringer lactate & BSS are equally effective
• If at any point turbidity is noted, the
whole batch should be discarded.

21. Intraocular irrigating fluids
• Re-sterilization of sealed bottles is not
advocated
• If glass bottle-do vaccuum test (bubbles
on putting drip set)
• Physical inspection against light
• Microbiological work up and approval for
each batch, wherever feasible

22. Wound security
• When in doubt- sutures to be applied
• Sutures are a must for pediatric cases as
chances of infection are comparatively high.
• Anything which goes inside the eye
(including
Phacotips/Sleeve/Cannula/Vitrectomy
Cutter,etc.) to be changed for each case

23. Hygiene of patients
• Head, face and feet wash with soap and
water before surgery
• Cancel surgery when there is unusual
congestion or discharge
• Patients to wear clean, washed
clothes/OT dress with cap & gown ( no
street clothes)

24. Hygiene of patients
• Apply povidone iodine 5% on skin and
periorbital area for 3 minutes or till dry-
before draping.
• Disposable adhesive drape to be used in
each intraocular surgery
• Speculum is a must
• 5% povidone to be instilled in conjunctival
sac wait for 3 minutes before washing

25. At the end of surgery
• Subconjunctival antibiotics: not necessary in
institutional practice . However a mandate in
mass surgery.
• Topical broad spectrum antibiotic drops can
be instilled
• Intracameral antibiotic use at the discretion
of surgeon as incidence of TASS has been
reported with this practice.

26. Post operative measures

27. Post-surgery care
• For cases under topical anesthesia: patching not
required(protective glasses recommended)
• For cases done under block: patching of operated
eye preferable for at least 4-6 hrs;avoid rubbing.
• 4-6 ml of block is enough for non-co-operative
patients for a faster visual rehabilitation as topical
medications can be administered early.
• First follow up to be done within 24hrs- by an
ophthalmologist & slit lamp examination mandatory.

28. Post-surgery care
• Subsequent follow up on 3rd – 7th day is
optional & then 25-30 days after surgery.
• However instruction should be given to the
patient to report immediately in case he/she
experiences any discomfort.
• Check visual acuity with pin hole during each
visit.
• Topical antibiotics for 7-10 days
• Topical steroids/NSAIDS for 4-6 weeks
• Systemic antibiotics preferable ciprofloxacin
considered only in high risk cases

29. Post-surgery care
• Personal hygiene to be emphasised
• Document all post operative findings and
same to be preserved by surgeon.
• Emergency services by a qualified
ophthalmologist to be made available, at
least for 1 week.

30. OT
Sterilisation/Disinfection
(eye surgeries preferably
in dedicated eye OT)

31. Suggested layout

32. Suggested layout
• Outer zone/protective zone-reception.
• Mid zone/clean zone/common area-changing
room/transfer zone.
• Aseptic zone/sterile zone –
scrubbing/gowning/gloving/operation
room/autoclave room.
• Disposal zone-equipment & supplies are
processed.

33. • a)The outer zone is a reception area and is
accessible to all persons and supplies.
• b)The clean zone is the space for circulation of OR
staff after changing. It encompasses the (i)changing
room located near the entrance of the OR complex;
and (ii)transfer zone which is the space where
patients are shifted from the transfer point to the
OR.
Operating room layout

34. Operating room layout
• c)The aseptic zone is the sterile area within the OR
complex consisting of the scrub and gowning area,
the preparation room and the OR. The OR should
have one entrance and a separate opening towards a
sterile area marked for instrument packing and
sterilisation. Floors and walls should preferably be of
non-porous material with minimum joints to enable
proper cleaning and carbolisation. The head end of
the operating table should be directed away from the
entrance

35. Operating room layout
• d)The disposal zone is the area where used
equipment and supplies are processed.
Disposal of biohazardous waste is also done in
this zone.

36. Fumigation
• Starting OT for the first time/ after long time/
after civil work : at least 3 OT washings
followed by fumigations & get 3 consecutive
negative cultures of OT mandatory
• Fumigation is not required if there is positive
pressure ventilation in OT

37. Fumigation
• Running OT – single
Fumigation/Disinfective
Mopping/Fogging weekly is enough
• Use of fogger machine is preferable
• Formalin can be used for fumigation but
usually avoided as it causes eye irritation
even after the fumigation is over.

38. Other methods of
fumigation
• a) Permanganate method
Five ounces of potassium permanganate for
every 1000 cu.ft. of space are placed in a jar
and on top of this 10-15 ounces of 40%
formalin diluted with an equal amount of
water is poured. As soon as the reagents are
mixed, a violet effervescence takes place and
formaldehyde is set free.

39. Other methods of
fumigation
• b) Paraform method
On heating formalin, the aldehyde changes into
the solid polymeride - paraform. Gas is
generated by heating paraform tablets. 25-30
tablets are required for every 1000 cu. ft. of
space.

40. Other methods of
fumigation
• c) Formalin spray / vapouriser
Aeromax vapouriser can be used to fumigate an OR.
250 cc of 40% formalin dissolved in 5000 cc tap
water makes a dilution of 1:20. One litre of the
solution is used per 1000 cu.ft. of space.

41. Newer protocols as below
Bacillocid special/desnet
• Active ingredients are glutaral
100mg/g,benzyl-C12-18-
alkyldimethylammonium chlorides
60mg/g, didecyldimethylammonium
chloride 60mg/g
• Provides complete asepsis within 30-60
minutes

42. • Cleaning with detergent or carbolic acid is
not required
-Bacilloacid fumigation
• Can be done using 2% bacilloacid (100ml in 5
litres of water).room must be kept closed for
6 hours before use by housekeeping
personnel
• Bacillol
Newer protocols as below

43. Newer protocols as below
• Contains ethanol,2-propanol, 1-propanol
can be used as spray for instant surface
disinfection, does not act on spores
• Ultraviolet radiation(preferable-not
mandatory)
• Daily for 12-16 hours; switched off 2 hours
before entering OT

44. Important considerations
• Studies show no consensus of benefit of
benefit of HEPA(High Efficiency
Particulate Air) filters.
• Central AC not necessary
• Split AC is OK
• Need for AHU is questionable

45. Air conditioner maintenance
• Clean filters every week
• Servicing and cleaning every month and
document this
• Floor, microscope, surfaces, sinks and
drains, horizontal surfaces must be
cleaned daily

46. Air conditioner maintenance
• Walls should be washed up to minimum
of 4 feet height
• Floor may be washed/ wet mopped at
end of OT
• 2% bacilloacid special
• No dry dusting or vacuum cleaning

47. Space/OT size
• 160 sq ft/4 persons;(400 sq feet as
desired by NABH is not practical)
• Can reduce proportionate to number of
people

48. Sterilisation of instruments
• Adequate reserve sets should be available
• Preferably ETO/ autoclave or flash autoclave
• In between cases- autoclaving to be done
and documented
• Class B autoclaves- recommended for long
tubings re-sterilisation
• Class sterilisation/ formalin boxes/ and
cidex not recommended

49. Monitoring of sterilisation
• Chemical indicators-3 indicators: 1 on the
outside wrap;2nd on inside wrap, 3rd
inside the tray.
• Biological indicators testing once every 1-
3 months
• Log book to be maintained
• Maximum use of disposable instruments
• Surprise checks to be done

50. Periodic cultures(pre and post
disinfection)
• To be taken (at least 1-3 months interval)
• Moist swabs taken from microscope and
head end of table and
• 10cm blood agar plates kept open at head
end of table for 30 minutes( colony count
of < 10 with not even a single gram
negative bacillus or fungal colony
acceptable)

51. Use
• Autoclaved/ ETO instruments
• Standard quality irrigating fluids/ dyes/
viscoelastics/ eye drops

52. Training
• Periodic assessment and training of OT
personnel through seminars and
educational videos

53. What to do in case of
infection?
(Presumed sporadic)
• Rule out possibility of cluster infection (recall
patients operated in same session on same
day of review)
• Have dialogue with patients and relatives
• Explain :
- Mechanics of infection
- It is still treatable
- Need for co-operation & referral

54. What to do in case of
infection?
• Treat promptly with intravitreal antibiotics
and supportive therapy
• Document all findings
• Refer to higher center after initiating
treatment
• Review all sterility factors
• Review all sterilisation protocols

55. In cluster infections or
outbreak
• A cluster infection is defined as the
occurrence of two or more than two
infections in a single day from 1 theatre or
the occurrence of repeated postoperative
infection
• Take cultures from OT

56. • Note batch numbers of all solutions used &
send samples for culture
• Keep all solutions used in safe custody
• Institute appropriate treatment and refer to
higher centre.
In cluster infections or
outbreak

57. In cluster infections or
outbreak
• Inform authorities : hospital authority/
hospital infection control committees – in
writing (only for NPCB related surgeries;
inform govt. authorities, IMA local chapter,
state ophthalmic society, deputy director/
civil surgeon)
• Stop surgery & review all protocols
• Inform AIOS & state ophthalmological
society & seek help

58. In cluster infections or
outbreak
• Engage & seek help of lawyer/legal cells of
AIOS
• Interact with press & media and inform
the truth; give press release in writing
• Peep group/ hospital committee should
handle press

59. Operative room waste disposal
• Operating room biohazardous waste including
infected linen, disposable syringes and needles,
intravenous (IV) drip sets, IV fluids, and infected
and diseased excised pathological tissue poses a
significant health hazard to the OR personnel and
public. Safe disposal is imperative to prevent
spread of infection and possible recycling of
hazardous disposable products.

60. Operative room waste disposal
• Over the last decade, the disposal of operating
room and hospital waste has received much
attention. Incineration has been advocated as a
viable method of hospital waste disposal.
• Recently, attention has been directed at preventing
air pollution from incineration, and to find
alternative medical waste treatment technologies.
These options include gasification, steam
sterilisation or heat disinfection of certain clinical
wastes prior to disposal in a landfill.

61. Checklist for elective
intraocular surgery
• RBS </=200/ FBS </=140 mandatory
• BP <160/95mmhg
• Physician or anaesthesist clearance in cases
with systemic disease
• Pre operative topical antibiotics preferable
• Written informed consent & post operative
instruction s in patient’s language
• No contact procedures/ syringing on day of
surgery

62. • Use of microscope is must for eye surgery
• Separate sterilized gloves for every case
• Disposable adhesive drape to isolate lid
margins & lashes
• Betadine on skin & periorbital area for 3
minutes
• 5% betadine in conjunctival sac for 3 minutes
• Note batch number of irrigating fluids
Checklist for elective
intraocular surgery

63. • Document all findings
• Instruments autoclaved/ ETO
• ‘NO’ chemical sterilisation
• Maximise use of disposables
• In case of doubt of infection
-talk to patients/relatives
-institute prompt appropriate treatment
-seek help from collegues/higher authorities
Checklist for elective
intraocular surgery

64. Acknowledgment
• AIOS Guidelines to prevent Intraocular Infections
• Sterlization methods in Ophthalmology, Raj.
Journal of Ophthalmology, Yr. 2005
• WHO
• Miss Neha Sharma(Optometrist)
• Mrs. Diksha Bishnoi (Optometrist)
• Dr. Anushree Naidu (Post Graduate)
• Dr. Sujeet Prakash (Post Graduate)
• Dr. Sonalika Gogia (Post Graduate)

65. THANKS