7/27/2019 7-focus2b

1/11

OT Techniques-Expert interaction

Dr. MSR(KN): 2 x 2 ft full body vitrified tiles from agood company, laid with 5 mm gaps,

which is filled and levelled withEpoxy grout.

Dr. GP(MMJEI): a. Ceramic tiles are used from floor toceiling on all walls. Our OT was lastdone in 1995. Have not renovated.

Dr. MK(NN): Floor is epoxy

Dr. MSR(KN): Same as those applied to the wall. Allthe borders and edges are coved, sothat there are no acute angles, whichcollects dirt & grit. The ceiling isprepared and made dust free usingPoly vinyl putty base and paint.

Dr. GP(MMJEI): Floor is vinyl in 2 0f the 5 theatres andvitrified ceramic in the remaining.

Dr. HMR(DEH): Vitrified tiles

Dr. MK(NN): Easy to clean and maintain. The jointbetween the steel walls and the floor isnot a sharp corner that may accumulatedirt

Dr. MSR(KN): Believe this is the best, everlasting,rugged material, and being totallywater proof, do not encourage growthof microbia. Do not shred fineparticles over time, like marble andgranite.

Dr. MK(NN): chemical disinfection is performed for allsurfaces daily. The air supply in theinstitute is as per NABH standards and is alaminar flow system. The air handlingunit is cleaned and maintained as well asthe operation theatre.

2) What i s your rou tine schedule o f OT

disinfection/sterilisation procedure? kindlyelaborate

How the roof/walls/floor/ OT air conditioning /laminar flow are disinfected?

Dr. MK(NN): Walls Are Stainess Steel

a. Walls (steel/power coated GI/ epoxy paint over the regular brick wall/tiles/any other specify?

1) Sir, what material has been used for your OT

Dr. HMR(DEH): Vitrified tiles

1. Sir, what material has been used for your OT b. Floor vinyl/ epoxy/ vitrified tiles/any other

specify

Why did you choose this particular material??

Dr. MSR(KN): Thorough cleaning, cleaning and

cleaning! The ceiling walls and floor are cleaned periodically, frequencydepends upon the load on OT. Floor and reachable walls 2 to 3 times aday, high walls once a week, andceiling once a month in our OT. Firstcleaning is done with neutraldetergent, followed by disinfectant,the brands of which are changedperiodically. The AC, ducts, Laminar flow etc are opened once a month,and the filters and fan surfaces arecleaned with detergent followed bydisinfectants. This is very elaborativeand difficult and needs half a day! TheAC technician will not do this!!

Dr. HMR(DEH): Easy Maintenance and cleaning

Dr. GP(MMJEI): Formalin fumigation once a week atweekend and Bacillocid disinfectionfor interim disinfection. Only filters of the OT ACs are cleaned once a month.

37Vol.29, No.2, Aug.

7/27/2019 7-focus2b

2/11

Dr. HMR(DEH): Daily morning we wipe the floor withde te rgen t s us ing two bucke t smethod(water in one bucket anddetergents in another bucket, dip theclean towel in detergents bucket and

wipe the floor then clean the towel inwater bucket rpt the procedure )wespray BASCILOLL 0.25% over the ottable, trollies , roofs and walls daily.

We use the same wiping technique withdetergents for the walls also twice inthe week .

3) Some of the ophthal OT now do not routinely perform formalin fumigation and have shifted to fogging / contact disinfection methods- anycomments?

Dr. HMR(DEH): We have also stopped fumigating the

O T and mechanical cleaning, if donereligiously there is absolutely no needfor fumigation by formalin or by anyother agent

Dr. MK(NN): In this case quality and peace of mindcome at a cost!

Dr. MSR(KN): Hope they will understand themechanisms of Ophthal OT andchange their stature!

Dr. HMR(DEH): The ORs should be well ventilated and airconditioned with a split air conditioner.I don't think you should compare orthoOT to ophthal OT, as air is never sourceof infection in ophthalmic cases, theseexpens ive equ ipmen t s a re no tnecessary.

Expert comments (DR SK): Cleaning anddisinfection should be done in the morning

(before the start of the list, between cases,end of the list and a detailed washdownperiodically. The protocols for each of theseare different and can also vary from one OTto another.Roof and walls may be cleaned anddisinfected 2-3 times a week or wheneversoiled (daily cleaning is not necessary). Airconditioners cannot be disinfected. Airhandling systems need to be maintained atleast once a year with duct cleaning included.Putting formalin in the ducting is not useful.

Dr. MK(NN): No formalin fumigation is performed inview of occupation health concerns. Wedo contact disinfection daily with

lysoformin and fogging with the samechemical on weekends

Dr. MSR(KN): We neither perform Fumigation nor fogging. It is not needed, if you havegood OT structure and functioning.

Dr. GP(MMJEI): I think there are different schools of thought on this. Scientifically seencontact disinfection is the best.

Expert comments(DR SK): Formalin should be stopped it does not provide any benefitin the way most people use it and using it inthe proper concentration is not practical.Fogging is a means of uniform application of the reagent and should not be consideredany more than that. The word fumigation is

a misnomer and should be replaced by theterm terminal disinfection instead.Fumigation DOES NOT sterilize OT (this is a

big misconception many surgeons have!).

4) Various accreditation agencies are applying stricter norms for OT and now have laminar flowwith a specified number of air exchanges for ophthalmic OT as a prerequisite for accreditation.

a) Do you think that all of us should have these systems- obviously cost of instal ling and maintaining is huge- is there a way out?

Dr. GP(MMJEI) : If accreditation agencies are enforcingit, it is good for us. The closer to idealthe better.

38 Vol.29, No.2, Aug.

7/27/2019 7-focus2b

3/11

Dr. GP(MMJEI): That calls for cleaning the microscopeas well. We better do it for our own

safety. I am sure general surgeons willbe cleaning their shadow less lampsand other specialty micro surgeonswill be cleaning their microscopes aswell.

Dr. MK(NN): Surgical site infection in cases withimplant is one year from the date of surgery while for surgeries withoutimplants it is only 3 months. OTguidelines are based on the presence orabsence of implants. So the stringentguidelines for ophthalmic theatres are inkeeping with the fact that nearly allcataract surgeries that account formajority of ophthalmic surgeries havean intraocular lens implant.

It is true that the microscope and otherfittings in the OT cannot be sterilized.But the microscope and other fittingsneed to be disinfected like all othersurfaces in the ot. Monitoring theeffectiveness of this disinfectionprocess is critical to minimizing surgicalsite infections.

Dr. MSR(KN): Cost is not huge! Actually it is lesser than many gadgets that we invest on.But is it not better to spend rather thanfacing the cost and agony of TASS &endophthalmitis?

I don't think all these issues should beused as an excuse for beingincomplete. A microbia is so tiny, andcan get into the eye, even if there is a35 G incision used for cataractt o m o r r o w ! I h a v e s e e n a nendophthalmitis in a child whopresented from Mysore following avery trivial needle injury, the needletrack was barely visible!

Expert comments (DR SK): I agree verystrongly with you Sir. There is DEFINITLY agreat need to customize the guidelines forophthalmic surgery. Copying measures fromother countries / hospitals can be dangerous.Each surgical specialty has it's uniquefeatures which need to be considered. Thismeans some infection control measures may

be shared in general but some will be unique.Add to this, each hospital will have differentresources, so one protocol will never fit all.Thus, customization has to be done atvarious levels guideline development,actual protocol steps and at implementation

in the individual set up. Unfortunately,accreditation agencies in India have notcarried out a detailed study of the indianhospitals before deciding the measures - therisk here is some measures may actuallyincrease the risk of infection in theory atleast (the unsterile microscope for example).

Expert comments (DR SK): Laminar air flowsystems are beneficial in theory but no direct

benefit in reducing surgical site infectionrates has been demonstrated even in theWest. Studies are 50-50 on the matter (mostare in orthopedic surgery). The way out is weneed our own studies and a logical manner of approaching the problem. We don't evenhave basic infection statistics on which to

base a raional conclusion!

4b) Sometimes i (editor) personally feel that variousnorms for other surgical specialities theatres are

just picked and incorporated in to theseaccreditation guidelines without proper clinical evidence for ophthalmology in particular? Do you

agree with it? For example our incisions areclosed/ self sealing micro-incisions even during surgery compared to the exposure in a general surgery OT. Also there is a relatively unsterilemicroscope in between the proposed laminar flowair above the patient table and the operating area(eye) -will the air under positive pressure

from the laminar flow carry unsterile particleswhen moving over the microscope??. Do you think there is need to customise the OT guidelines for ophthalmic needs?

Dr HMR(DEH): Yes, there is need to customise OTguidelines for ophthalmic needs.

39Vol.29, No.2, Aug.

7/27/2019 7-focus2b

4/11

Dr. MK(NN): If the ot is a laminar flow systemthe air purifier inside may createturbulence and also add to theparticle count creating confusionabout the hepa (high efficiencyparticle arrester) filter efficiency.

However, air purifiers may have arole if the surgeries are beingconducted in rooms with window orsplit air-conditoners.

5) Do you see a role for some of the air purifiersinstalled inside the OT?

Dr. MSR(KN): HEPA filters (FFU) can be retrofitted inany OT, and I personally feel they are

essential.

Dr. GP(MMJEI): Yes, the 5 stage filters are quiteconvincing

Dr. HMR(DEH): No. I have air purifier in my OT.Sometimes back it was not workingfor 6 months did not make anydifference in our cases. It is more of psychological advantage to surgeons.

Expert comments (DR SK): Yes air purifiersdo have a role to play in keeping the

bioburden to low levels. How low will varyfrom OT to OT as it depends on multiplefactors.

6) What are the various steps one need to followwhen commissioning a new OT-

a. kindly elaborate on the various cultures we need to send

b. How do you take the culture swab to avoid contamination? Which material is used totransport / do you do direct plating on culturemedia?

c. How often would repeat the cultures from a regular running OT

Dr. MK(NN): in an OT with laminar flow the airquality is the most important. A remote controlled air sampler isused. It is placed in the OT with thelaminar flow system on and then air

sampling is activated from outsidewith the remote control after 20minutes to allow for the air changesto remove any comtaminationbrought in by the technician. Thisprevents false positives.In centers without a remoteactivated air sampler a settle platemethod may be used.Surface swabs need to be taken fromthe microscope, instrument trayswalls and floor after thorough

contact disinfection. All cultures are taken using sterileprecautions and direct plating ispreferred to the use of transpostmedia as far as possibleWhen comissioning a new OTc o m p l e x , t h o r o u g h c o n t a c tdisinfection is performed for 3consecutive days. Then air andsurface cultures are performedfollowed by disinfection on another 3consecutive days. When the cultures

are negative on all 3 days after atleast 48 hours incubation the OTmay be comissioned.If negative:Microbiological surveillance of airquality in a running ot with laminarflow are recommended monthly(there are no guidelines for surfacecultures; we are performing thosealso monthly)Daily log of the physical properties of air cludes temperature, relative

humidity and positive pressureinside the ot. Quarlerly air qualitysurveillance includes testing hepafilter integrity by particle count,bypass leakage by dop testing, filterefficiency by air velocity andcalculated air changes per hour.

40 Vol.29, No.2, Aug.

7/27/2019 7-focus2b

5/11

Dr. HMR(DEH): Clean the OT thoroughly both floorand walls.

Fumigate and close for 24 hrs. Send cultures for aerobics organisms# O T Table# Walls# Floor# A C# MicroscopeNon aerobic and fungus. I don't think it

is necessary I use direct plating onculture media.Once in six months.

Expert comments (DR SK): Are OT swabsreally reliable? They are not even arepresentative sample. This issue needs to bediscussed in detail with all the pros and cons.I find that too much reliance is placed ont h e s e s a m p l e s b y m o s t p e r s o n s .Interpretations of the results is also not donecorrectly many times.

7) Do you use reusable phaco- tubings? If yes whichtype of autoclave is best for these kinds of phacotubings and why is it important? What are thecleaning protocols that you follow and anyimportant tips regarding the same?

Dr. MK(NN): We use only disposable phaco tubings. If reusable tubings are being used then it isbest to use a class b autoclave that willevacuate all the non condensible gassesbefore the steam charge allowing thesteam to penetrate into the full length of the tubings and sterilize the inside of thetube. The actual time, temperature andpressure required for this needs to beconfirmed for each autoclave and tubeinglength and bore combination by the helixtest. Dr. Deepak megur had presented anexcellent paper in AIOS a couple of yearsago on this topic.

Dr. GP(MMJEI): No experience No comments. Butcleanliness more important thandisinfection

Dr. MSR(KN): At Karthik Netralaya, once in 3months we use Blood, Chocoloate &Saboraouds agars. 6 To 8 pies aremade on the glass bottom, they arenumbered, and on each agar pie, Idirectly inoculate after a weeklycleaning protocol. One other plate iskept open on the head end of OT tablefor one hour, with AC & HEPA filter on, and microscope in position tocatch the air particles that settle down.Sterile swab sticks are dipped indistilled water, and than swabbed onthe surface. They are sent for incubation immediately.

8) During steam autoclave which water do you use eg. RO/distilled/routine uv filteredwater?

Expert comments (DR SK): An autoclavewith a pre-vacuum cycle should be used.

Dr. MSR(KN): B class autoclaves are the best, as theyhave vacuum cycles. Standardautoclaving is better than flash

autoclave. Change your autoclave &insist on B class, & Indian models areextremely good, and very affordable.Table tops are again not veryexpensive, and best is to buy theimported ones. I don't know if goodIndian made is available.

DR GP(MMJEI): We use reusable phaco tubings. Fulllong cycle autoclaving is better thanflash autoclave ideally speaking.

Dr. HMR(DEH): Yes we do use reusable phaco tubing,class B autoclave is best for the phacotubing because of vacuum cycle. Primethe tubing with distilled water for threetimes and then with the air for two timesimmediately after the surgery.

Dr. MK(NN): Reverse osmosis water and if not availabledistilled water. UV filtered water cannotbe used

41Vol.29, No.2, Aug.

7/27/2019 7-focus2b

6/11

9) Regarding autoclaves it is said that horizontal autoclaves are better than vertical? Have you

found that this claim is validated by your experience over the years? Meaning was there anincreased risk of infection that you noticed whenusing a vertical autoclave?

DR MSR(KN):DR MSR(KN): dry cycles, and repeated purging oncethe pressure and temperature havereached the desirable is a must, as wedo use tubings. Inside of tubings canonly be sterilised with this. Not allhorizontal autoclaves have vacuumfacility!

Horizontal with pre vacuum and post

DR GP(MMJEI): Yes horizontal autoclaves with vacuumbefore and after the sterilisation cycleare better. It is a long time since weused vertical autoclaves at a time whenour work load was a quarter of the

present. Some modifications arehowever possible with the verticalautoclave to drive out the air initially.

Expert comments (DR SK): RO/ DistilledWater follow manufacture recondition

DR MK(NN): a class b autoclave or fractionatedautoclave uses vacuum to remove thenon condensible gasses followed by asteam charge. Usually this is repeated 2-

3 times and then the actual autclavingprocess happens. Gravity feedautoclaves are unable to vent the air andnoncondensible gasses in the autoclaveprior to the autoclave cycle and so thereis a risk of incomplete sterilization. Asincidence of endophthalmitis is itself solow and so multifactorial to proveincreased rates would be difficult but inthe war against microbes it is best toreduce the confounders to the maximumextent possible.

Dr HMR(DEH): I have two autoclaves, one class ' B' usedfor phaco tubings and instruments,vertical autoclave for linens. I agreehorizontal autoclave is better, thinking of buying it in near future replace myvertical autoclave.

Expert comments (DR SK): Horizontal /vertical has nothing to do with efficacy of themachine. Pre-vacuum autoclaves should beused. Infection has multiple reasons so,without randomized controlled trials, it will

be impossible to decide whether infections ina particular situation were due to faultysterilization alone. Hospital infection is morelike algebra with the value of the factorschanging in every patient. This is in contrastto what we learn as clinicians that onepathology causes a pattern of signs andsymptoms. Perhaps this is why we often tryto find just ONE cause for an infected case. Inreality, it it is often multiple factors actingtogether

10) Buying a correct autoclave is the most important decision. We spend huge money on various other equipments in the OT and one tends to compromisein other areas.......... Various companies maketheir own claims.... How to choose the right autoclave for ophthalmic practice? How to make awell informed choice and what specification oneneeds to ask the dealers so that we are not taken for a ride....

Dr. MSR(KN): RO or acid base ion filter or commercially available distilledwater. Check if the dissolved saltturbidity is less than 100. The water does not have to be sterile!

Aquaguard does not remove the TDS(total dissolved solids) from water,and so is useless. Corporation water in Bangalore has a TDS of 200 to 300and bore wells 600 to 1000. TDS canbe measured by small thermometer like gadgets.

Dr. GP(MMJEI): RO water.

Dr. HMR(DEH): Distilled water

42 Vol.29, No.2, Aug.

7/27/2019 7-focus2b

7/11

Dr.MK(NN): The most common cycle is a wrappedinstrument cycle. Initial 3cycles of vacuum / steam charges are responsiblefor the removal of the non condensiblegasses followed by 134 degrees for 7minutes holding time followed by dryingtime as per recommendation.

DR MSR(KN): After desired temperature and pressureis reached, do 3 purges, and than startthe cycle of 30 minutes for 20 lb cycle.A nano solenoid controlled can do allthese, and you don't have to waste your time!. Ask if they have this facility.Repeat Bowie Dick test periodically.Have a cycle recording facility, whichwill give graphic illustration of the

entire cycle.

Dr HMR(DEH): I totally agree with this, we spend lakhstogether to buy a B Scan which is usedtwice a week, but the most importantequipment autoclave is of tenneglected. The reason Probably is you

can not show to patients. One episodeof cluster of endophthalmitis made meto buy class B Autoclave next day.

11) Can you kindly elaborate on the autoclave cyclesthat you use commonly?

Expert comments (DR SK): Get a pre-vacuummachine, Check the parameters of variouslsterilization cycles. Calculate the daily loadof sterilization to decide capacity (includefuture developments also). Consider heatcompatibility of the items you will be

autoclaving are there any items which arerecommended to be autoclaved at 121 andnot at 132 deg C?

Dr. GP(MMJEI): Temperature, Pressure, vacuum ,drying and availability of automaticoption, Power consumption andcapacity are the features to belooked for.

Expert comments(DR SK): Full cycle fordaily sterilization. Flash for droppedinstrument only.

12)What are the various tests that you routinely applyin every day OT practice to check the completenessof the autoclave procedure? Meaning how to youknow that your autoclaving is effective and safe?

Dr. MK(NN): surveillance for the effectiveness of acycle is monitored by the print out givenby the machine which documents eachstep of the autoclaving process. Furtherindicators with each load show a colourchange for time, temperature, pressureand removal of non condensible gasses.

Dr HMR(DEH): Class B autoclave first vacuum,sterilisation, dry then exhaust. invertical autoclave when pressure isreached the sterilisation conditionrelease the steam for three times sothat the air in the chamber is gone

th,when it reaches 4 time then note thetiming and keep it for 30 min (121')after 30 min switch off the autoclave

Dr. MK(NN): A class b autoclave is preferred. Thecapacity of the chamber depends on thedaily number of surgeries and the size of theinstrument pack. Surveillancemeasures to validate the properfunctioning include a daily bowie dicktest to ensure complete evacuation of noncondensible gasses and quarterlymicrobiological validation.

Dr. MSR(KN): Buy an autoclave that has both 20 & 30PSI capability. 30 PSI one is builtsturdy, even if you don't use the 30 Lbs!20 lb cycle is better than 30 lbs.

43Vol.29, No.2, Aug.

7/27/2019 7-focus2b

8/11

DR MSR(KN): The duty cycle recorder is very useful.Every pack has a temperature indicator tape in its depth. Once in 3 months, wedo Bowie Dick test or the test strip thatconfirms temperature, pressure and

duration. The tapes should turn JETBLACK and not just or even deep gray!!Avoid surgical bins totally. Use packsdirectly loaded into autoclave.

Dr. GP(MMJEI): Signaloc tape and biological indicator

Dr HMR(DEH): We use class 5 steam indicator (everyinstruments bin) for every cycle of autoclave if the indicator does notchange, we rpt the whole procedure.

Dr. MK(NN): Prevention of surgical site infection(endophthalmitis) is a 6 prongedstrategy. patient factors surgeon factors consumables sterilization techniques for reusables enviornmental factors access controlThere is unfortunately no single mostimportant step that may save the day if other factors are ignored.

Dr. MSR(KN): 24 hours antibiotic drops. Put Povidoneiodine as soon as the patient comes.Scrub the skin around the eye withPovidone Iodine 5%. I r r iga teconjunctival sac with 0.5% povidoneiodine . METICULOUS drapingtechnique is a MUST.

Dr. GP(MMJEI): slit lamp exam, ROPLAS test, Facescrub, Removing facial ornaments,Clean shave, betadine 2% in theconjunctival sac, sterile disposableadhesive drape

DR MK(NN):W e currently use ultrasonic cleaners

DR MSR(KN): Clean them as soon as the surgery isover! Don't allow the debris to hardenon the surface. Ultrasound is a must for every instrument after every surgery,followed by soft toothbrush cleaning

under running water. Detergents andmultenzymes when used, should bethoroughly cleaned to avoid TASS.

Dr. GP(MMJEI): Enzyme liquid / Tooth brush andultrasonic cleaner

Expert comments (DR SK): Autoclavingshould be monitored by physical, chemicaland biological monitors. It is a blind processand sterilization is not an absolute but aPROBABILITY even when the process is donecorrectly!

13) How do you clean your delicate instruments? Do you use any cleaning agent/ special solution/ ultrasonic cleaners?

Dr. HMR(DEH): Immediately after surgery dip theinstruments in savlon 2% solution andgently clean with the toothbrush allthe joints hinged areas then washwith water wipe them thoroughly

send for sterilisation

Expert comments (DR SK): Ultrasonic cleaners.May be combined with enzymatic cleanersolutions. Keep wet until taken for cleaning.

14)What is your routine pre-operative/per-operative preparation before surgery with special focus on preventing infection/ endophthalmitis? Which do you think is the most important step and how you

ensure the same in your day to day busy practice?

44 Vol.29, No.2, Aug.

7/27/2019 7-focus2b

9/11

Dr. MK(NN): One never knows whether a case of endophthalmitis is a single one related topatient factors or whether it is the first of a cluster related to a systems breakdown.Documenta t ion i s e ssen t ia l toinvestigate a cluster infection. The 6point strategy for prevention alsoincorporates an ability to track and tracecommonalities between cases and arriveat statistical probability of a root cause.

Sporadic outbreak is said to be due topatient factors, although you reallycannot rule out OT issues. Investigatethem as cluser outbreaks.

Dr. MSR(KN): You should become a very criticalinvestigator, and think that the OTbelongs to an another hospital! Thereare really thousands of ways bywhich the germ can enter an eyeduring surgery! Most of the time, it isunsterile fluid, instrument or technique.

Dr. GP(MMJEI): Check patient records for risk factors,Check the surgical team for anychanges, Check surgical time, Checkfor any new brand of consumablesused, Retrospect on any out of routinehappenings in the OT includingdiscipline lapse. In case of multicaseoutbreak Check Autoclave, Fluidsused, Other consumables used.

16) Once in a while in spite of all precautions we doe n c o u n t e r a n u n f o r t u n a t e e v e n t o f endophthalmitis...... more often than not we try tolook at patient factors to fix responsibility thanintrospecting!!! Do you have a protocol to

investigate an endophthalmitis outbreak to go tothe root cause problem so that corrective and preventive action can be taken?

a) How do you investigate a single case of endopthalmitis occurrence?

b) How do you investigate multi-case outbreak of endophthamitis?

Dr. MSR(KN): I always use BSS from a reputedcompany. No reautoclaving!

Dr. GP(MMJEI): No preference and no autoclaving.Only be cautious while changingbrands.

Dr HMR(DEH): We use balanced salt solution 500ml,there is no need to autoclave

Expert comments (DR SK): These can beautoclaved. But how many infections areprevented by this? I really doubt how much ithelps. On the other hand it may give a falsefeeling of security! If there is gram negativecontamination, risk of TASS may beincreased after autoclaving.

Dr. MK(NN): Autoclaving irrigating fluids in glassbottles only sterilizes the outside surfaceof the bottle. My preference is to useconsumables from a reputed companyand to keep track of all the batchnumbers so that at the first sign of trouble we can track people at risk.

Dr HMR(DEH): Ask the male patients to shave beard andfor the female patients ask to combneatly, remove nose ornaments. Washthe face twice before coming to O T. Paintthe area around the eye with iodine 5%

before giving block and one drop of microdine eye drop before surgery, startthe antibiotic eye drop 1 day beforesurgery.

15) Irrigating fluids are the most common source of infection in ophthalmic practice. Do you have any

preference for the same and do you re-autoclavethem? If yes how kindly elaborate.

45Vol.29, No.2, Aug.

7/27/2019 7-focus2b

10/11

Expert comments (DR SK): In an outbreak(large number of cases), there can be one ortwo major lapses that may be identifed andchanged. In a sporadic series, there is rarelyone single cause but multiple factors acting

together. So trying to identify one rootcause will not work. In both cases, athourough review of the case and theinfection control measures being followedshould be done.

Dr. GP(MMJEI): Make a check list and follow itreligiously.

Dr. HMR(DEH): All instruments for surgery should besterile. Single-use is even more robust,as there have been occasions recentlywhen instruments have not beenwashed properly prior to sterilisingwhich itself may have been faulty. Careis required with both washing theinstruments and autoclaving them, asthe latter is Neither absolute nor anexact science! Both matters should beinvestigated if there is an ongoing' e p i d e m i c ' o f p o s t o p e r a t i v eendophthalmitis with different types of skin bacteria viz. coagulase-negativestaphylococci within a surgical unit forno obvious reason. Single-use of tubingand other equipment that becomes wetwithin the operative procedure isalways preferable, if cost allows. Tubingis not easy to effectively sterilise unlessan ethylene oxide gas steriliser isavailable. Bottles of solution containingBSS (balanced salt solution) etc. shouldnever be kept or used for more than oneoperating session. Any air vent appliedto these bottles should be protected bya bacterial filter. Wet areas are easilycontaminated with Pseudomonasaeruginosa, which can then causedevastating endophthalmitis.

Dr. MSR(KN): I have seen repeatedly that the injectionof Adrenaline or antibiotic into BSS isdone vary callously in an OT. Manytimes the ampoule will have a glasspiece inside, which obviously iscontaminated! The eye lashes and lid

17) Do you have any personal experience /innovative techniques / things that arecommonly neglected but are important regarding OT sterilisation? Kindly share them

so that it would benefit the ophthalmic

community

Dr. MK(NN): most surgeons do not have a correcttechnique of scrubbing. The iodine in thepovidone iodine (betadine) scrub is inthe form of an iodophore and needsadequate contact time for release of thefree iodine that is responsible for thebactericidal action. This is facilitated bymositening and constant lathering for a 5minute contact time. The use of ascrubbing brush with bristles isunnecessary and probably harmful.

Dr HMR(DEH): a) It t is single case try to find a cause inpatient.

b) If it is multiple, I often try to look forthe cause OT send culture of Visco,Irrigating solutions, blue.

c) Repeat OT culture as routine.

d) I had one episode of cluster

endophthalmitis the source wastraced to ringer lactate.

margins exposed to the surgical fields isanother big cause. Reuse of phacoprobes and tubings, is the biggestbugbear, and even many a teachinginstitutions do it. There is no reason

why the entire phaco handlipce sets arenot autoclaved, for each case. Whenyou buy the Phacomachine, bundle 3handpieces, and use all of them inrotation after proper autoclaving.

46 Vol.29, No.2, Aug.

7/27/2019 7-focus2b

11/11

Expert comments(DR SK): Wrong reagent, wrong reagent concentration, wrong applicationmethod, excessive use, malfuntioning equipment, inadequate time for the reagent to act, usingexhaust fan after formalin fumigation, leaving door open after formalin use, applying reagentwithout cleaning the OT first, relying too much on OT swabs are some of the mistakes I have seen

across many OTs. There is no one single mistake done by everybody but there a highly variablepattern of mistakes by everybody.

My answers will be quite different from those of other I guess. All the questions do not have aclear answer. I hope the replies are satisfactory and stimulate a deeper enquiry.

Regarding accreditation issue, I really hope that all surgeons wake up and come together as soonas possible to get the infection control measures rationalized. Otherwise they may end up havingAmerican type OTs with Indian patients and budgets! I wonder how long they will be able tomaintain that! And once the system fails, infections will be more than what they are today andthe surgeons will be taking the blame again.

Megur Eye Care Centre and Drushti foundationBidar, Karnataka

Invites application for posts for consultants (post MS / DNB/DOMS) incomprehensive ophthalmology and various sub-specialties in ophthalmology.Interested candidates kindly apply with academic details and CV. Remunerationcommensurate with experience and qualification. Megur Eye Care Centre andDrushti Foundation Bidar also announces a 1 year long term Fellowship programsin Comprehensive ophthalmology, Glaucoma and Phacoemulsification . Interestedcandidates can apply with their complete CV . Contact : by email to Dr Deepak Megurdmegur@yahoo,com , 09446457242.

Megur Eye Care CentreBehind Akkamahadevi College

Bidar 585401. Karnataka.

47Vol.29, No.2, Aug.