At what points are sterilisation most frequently impaired in phacoemulsification surgeries?

Authors

Abstract

Aim The aim of this study was to determine the points that sterilisation cannot be achieved fully and that the probability of loss of sterilisation is highest in phacoemulsification surgery.
Materials and Methods A questionnaire consisting of 13 items including sterilisation problems that may occur during this period was prepared. Surgeons were asked to allocate 100 points to these 13 items according to the frequency which they were encountered. The percentage of the relevant item was calculated by taking the arithmetic mean of the responses.
ResultsTwo hundred surgeons, 108 males and 92 females, participated in the study. It was determined that the point at which sterility impaired with the highest rate was during the adjustment of view of the microscope, with a rate of 35%. This was followed by contamination during phaco handpiece removal with a rate of 10%, contamination while wearing gloves with a rate of 9.375%, contamination during surgical area cleaning with a rate of 7.5%, and contamination during the closure of the case with a rate of 7.5%. Contamination during hand drying was found to be 1.875% with the lowest rate.
Discussion In an uncomplicated cataract surgery, it was found that the point at which sterilisation problems were most likely to occur was during the adjustment of the microscope. New regulations for the contamination types can reduce the risks of infection and help increase safer surgery and effective treatment.

Keywords

Introduction

The increase in life expectancy causes an increase in the prevalence of senile diseases such as cataracts. Cataract is one of the leading causes of vision loss in the world [1]. With cataract surgery, an effective level of vision is achieved in most cases and the quality of life for patients is improved [2, 3]. Cataract surgery is among the most frequently performed ocular surgeries all over the world, and the need for cataract surgery will increase with increasing life expectancy [4]. Postoperative infection, one of the main complications of cataract surgery, is a potential complication with a high healthcare cost burden. These surgical infections, which can be caused by many factors related to the patient, the surgical team, the conditions of the operating room environment and the devices used, constitute an important problem in the field of ophthalmology. Various clinical manifestations can be seen, from conjunctivitis to endophthalmitis which can lead to vision loss [5]. With the changing surgical techniques, antibiotic prophylaxis and developments in intraocular lens (IOL) technology, attempts are being made to prevent infection due to cataract surgery, but the surgical infection is still a problem for underdeveloped and developing countries [5, 6]. Sterilisation of the surgical area and the surgical instruments to be used, as well as the asepsis and antisepsis of the surgical team, are the most controllable rules in the prevention of infection. In this study, we aimed to determine the most common sterilisation problems experienced in phacoemulsification surgery and therefore the stage at which the infection risk of the surgery may be high.

Materials and Methods

This study was conducted as a survey study. The study was performed in accordance with the Declaration of Helsinki. Before the study, informed consent was obtained from all the participants. Ophthalmologists working in the Ministry of Health of the Republic of Turkey and private hospitals were included in the study. Included ophthalmologists were required to have experience of at least 1000 phacoemulsification surgeries over a period of at least 5 years as an ophthalmologist. The basic demographic information of the participants, including their age and gender, was collected within the scope of the survey. The two hundred ophthalmologists who participated in the survey were asked to evaluate the phacoemulsification surgeries they completed without complications. No device or method distinction was made for phacoemulsification surgery. The time from the surgeon’s initiation of hand sterilisation for the operation to the completion of the operation and the closure of the eye was evaluated. A 12-item questionnaire, consisting of the possibilities that sterilisation could be impaired and/or sterilisation could not be fully achieved, was developed. For those who wanted to add other reasons apart from these possibilities, 1 more item was added as “Other reasons”, thus, the surgeons were subjected to an evaluation consisting of 13 items. The surgeons were asked to rate these problems, consisting of 13 items, from 0 to 100 according to the frequency they experienced them. The percentage of the relevant item was calculated by taking the arithmetic mean of the responses. They were asked to explain the reasons they stated as other reasons and their experiences in each item. The questionnaire form is presented below:
During hand drying:
During the wearing the surgical gown:
During the wearing gloves:
During the surgical area cleaning:
During the adjustment of the view of the microscope: Surgical instruments with poor sterilisation quality:
During the surgical instrument change (forceps, rhexis forceps, viscoelastic, antibiotics, etc.):
While taking the phaco handpiece:
While taking the irrigation/aspiration (I/A) cannula: During the lens folding and implantation:
During the stromal hydration:
While closing the eye:
Other:
Statistical Analysis
Data processing and analysis were performed using the Statistical Package for Social Sciences (SPSS) software, version 25. Categorical data are presented as number (n) and percentage (%), while numerical variables are presented as mean and standard deviation.
Ethical Approval
This study was approved by the Ethics Committee of Niğde Ömer Halisdemir University (Date: 2022-11-08, No: 2022/91).

Results

Two hundred surgeons, 108 males and 92 females, participated in the study. The mean age was 39,4±4,13 years. The mean duration of surgical experience was 10.03±3.71 years. According to the questionnaire results, it was determined that the point which sterility impaired at the highest rate was during the adjustment of the view of the microscope, with a rate of 35%. This was followed by contamination during the phaco handpiece removal with a rate of 10%, contamination while wearing gloves with a rate of 9.375%, contamination during surgical area cleaning with a rate of 7.5%, and contamination during the closure of the case with a rate of 7.5%. Among other items, contamination in I/A taking was found to be at a rate of 5.625%, other causes at a rate of 5%, contamination during instrument change at a rate of 4.375%, exposure to instruments with poor sterilisation quality at a rate of 3.75%, contamination during lens folding and implantation at a rate of 3.75%, contamination during stromal hydration at a rate of 3.75%, contamination during wearing gown at a rate of 2.5% and contamination during hand drying was found to be at a rate of 1.875% with the lowest rate (Table 1). It has been reported that the contamination during hand drying was due to surgeons’ contact with themselves or a nonsterile environment. Reasons for contamination during gown dressing were reported as the surgeon’s contact with the nonsterile area and the gown being torn or gown’s sterilisation failure. It has been reported that contamination during wearing gloves was caused when the glove is torn or by contact with the personnel assisting the wearing of gloves. The surgeons stated that the contamination during surgical area cleaning was caused by the patients’ hands touching the surgical area. It was stated that foreign body and eyelashes were found in instruments with poor sterilisation quality. It was stated that the contamination occurred due to the falling of the instruments during the instrument change. Contact with the nonsterile area was mentioned during phaco handpiece and I/A taking and during microscope adjustment. It was stated that the lens could fall and fly off during lens folding. In stromal hydration, it was reported that sterilisation was impaired due to the flying out the injector tip and the injector tip could damage the eye tissues. The surgeons stated that while closing the eye, the patient’s hands touched the surgical area. Among the other reasons included in the questionnaire, the surgeons reported that sterility could be impaired while the serum set is changed and, while preparing the surgical instrument table and opening the instruments when new instruments are needed during the surgical procedure.

Discussion

Surgical infections are among the most feared complications of ocular surgeries, as in all surgical specialities. Endophthalmitis is one of the most serious infections in phacoemulsification surgery, and its incidence has been reported to be between 0.05% and 0.2% [7, 8, 9]. Postoperative endophthalmitis, which can cause severe vision loss in the affected eye, reduces the quality of life and increases the financial burden. The most important way to prevent postoperative infections is to ensure complete sterilisation and to avoid contamination. For this reason, this study focused on the points at which sterilisation is not adequately provided or the possibility of contamination is highest. The main finding was that the most common contamination point according to surgeons was during adjusting the microscope. This was followed by the problems experienced during taking phaco handpiece and wearing gloves. Over time, simplifying and time-saving developments in phacoemulsification surgery, from incision type to capsulorhexis, from phaco operation to IOL placement, have shortened the operation times and the operations have become safer. It is known that shortening the operation time reduces the possibility of exposure of the patient to iatrogenic damage such as maculopathy due to microscope light [10]. The application of povidone iodine to the area around the eyes to be operated on and the conjunctival sac and the use of preoperative intraoperative-postoperative antibiotics resulted in significant reductions in postoperative infection rates [11, 12, 13, 14, 15]. Preoperative preparation, sterilisation of the equipment used during the operation and of the surgical team, and postoperative care are very important in preventing infection. Equipment that is not fully sterilised and the resulting contaminations will increase the possibility of infection and decrease the safety of the surgery. In addition, time will be lost due to resterilisation, and this will lead to prolonged surgical time and perhaps a decrease in patient compliance. In our study, we found that surgeons most frequently had problems during adjusting the view under the microscope. Although vision can be clarified with foot movements, vision loss which the microscope foot adjustments are not sufficient to fix, may occur with patient’s head movements. In this case, re-adjustment by holding the microscope increases the risk of contact with nonsterile areas. Maybe in the future, methods that can make the surfaces of the microscope sterile can be developed. Surgeons also reported contamination during taking phaco handpiece. There may be difficulties during taking phaco handpiece and I/A cannulas as require double competence due to both their body and connecting cables. It was reported by the participants that the loss of sterilisation during the wearing of gloves is due to encountering defective gloves and contacting with the assistant staff, especially when the assistant staff puts gloves on the surgical team members. It can be said that this can be more controlled for surgeons if they wear their own gloves. It was reported that the most common problem during the cleaning of the surgical area with povidone iodine, during removal of the drape and during the closure of the eye was patients’ contact with the the surgical area with their hands. This, once again, increases the importance of informing patients before operations. The attention level of surgeon and the surgical team gains importance in the contamination that occurs during hand drying, surgical gown dressing, and surgical instrument change. Double-sided control is achieved with the sterilisation control of the instruments and equipment prepared for surgery both by the surgeon and the assistant team. Problems such as dropping the lens during lens folding can be solved with intraocular lens application systems, in which lenses are preloaded into the cartridge and are ready to be injected into the eye. A more controlled surgery can be achieved by fixing the injector tip during stromal hydration. In this way, damaging the eye tissues and the risk of contamination of the protruding tip can be prevented.

Limitations

As far as we know, the absence of a study sample similar to our study is the strength of our study, but the limited number of participants creates a limitation. The most important limitation of our study is that the questionnaire we prepared was developed from the experiences of the authors and the reliability of the questionnaire was not tested. Our study results can give an idea for future studies.

Conclusion

In conclusion, according to our survey study, it was reported that the point at which most sterilisation problems are | Annals of Clinical and Analytical Medicine Sterilization problems in phacoemulsification surgery 4 experienced during an uncomplicated cataract surgery is during the microscope view adjustment. With the global population growth, the need for cataract surgery will increase and more safe and efficient surgical environments will be needed. The risks that can be reduced with the arrangements to be made can contribute to a safer surgery and more effective treatment. The results of our study, which we conducted as a survey, need to be supported by prospective studies with higher participants.

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