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Clinical Update: Refractive
The Value and Vagaries of Sterile Technique
By Leslie Burling-Phillips, Contributing Writer
 
 

Most surgeons agree that some level of infection control should be achieved in refractive procedures, but there is little agreement about what level that should be. It is an issue unique to refractive surgery. “No authoritative institution has established any parameters. We have all adapted to what is reasonable under the circumstances by taking bits and pieces of knowledge and putting them together in a way that makes sense for this procedure,” said Mark F. Ozog, MD, in private practice in Great Falls, Mont.

Gloves or No Gloves?

As a result of this ambiguity, the selection of protective wear worn by surgeons and their staff members falls along a continuum that ranges from full garb—gown, hat, goggles, booties and gloves—to almost none at all. The choice to wear or not to wear sterile gloves during refractive procedures inspires an especially contentious debate among refractive surgeons.

Did your teacher wear gloves? Differences in medical training can influence this choice. Some surgeons were taught the “no-glove” technique, the traditional method of performing the procedure. “I trained at a time when gloves were not used with a keratome, and I do not wear gloves unless I have an open wound, hangnail or other condition where I should not be allowing my hands to come into contact with anything in the surgical field,” said Dr. Ozog. “However, the entire surgical team wears scrubs, hats and shoes that are worn only in the LASIK suite.”

Stuart A. Terry, MD, a private practitioner in San Antonio, observes a comparable protocol: “I do not wear goggles or gloves,” said Dr. Terry, who referred to a recent survey by the American Society of Cataract and Refractive Surgery, which indicate that approximately 50 percent of refractive surgeons wear gloves.1 To protect the surgical field, Dr. Terry said he “avoids touching any part of an instrument that will come into contact with the eye or lids.” In more than 12,000 procedures, only two of Dr. Terry’s patients have acquired eye infections, and, he said, “Both healed to 20/20 vision with the appropriate treatment.”

Erring on the side of gloves. J. Trevor Woodhams, MD, an ophthalmologist in private practice in Atlanta, began his career in the traditional fashion but subsequently started wearing gloves. “In the early days of anterior lamellar keratoplasty and LASIK, I did not wear gloves because I wanted to reproduce the surgery as I saw it performed by the South American doctors who originated it. However, I later switched to gloves. Once learned, gloved surgery did not offer any significant compromises in touch or feel so I have never had an occasion to operate gloveless again.”

Daniel J. Ritacca, MD, in private practice in Vernon Hills, Ill., has always worn gloves, even when he performed radial keratotomies. “I was trained at the University of Illinois in a large hospital. We did a lot of intensive surgery, and, as a result, I have always been concerned about keeping a procedure as clean as possible. Someone on the surgical staff may touch the instrument that you were previously using in the same place where you were touching it. If you don’t wear gloves, bacteria can spread everywhere.”

David G. O’Day, MD, agreed. “I’m a glove wearer; I always have been,” Dr. O’Day is in private practice in Charleston, S.C. “However, LASIK and the corneal refractive procedures that we perform are not conducted as ‘true’ sterile procedures. I treat them as aseptically as I can. Even in the operating room with sterile gloves on, there is a possibility of contamination, so gloves are just the extra safety margin that we employ.”

Simply wearing gloves does not ensure that a surgeon’s hands will remain sterile. Once an object outside of the sterile field is handled, such as a patient’s chart or the microscope oculars, the gloves are no longer sterile. “In these cases, the sterile gloves are not doing any good. But it is easy enough to cover the working surfaces that you need to touch so that you do not have to contaminate the gloves while you are performing surgery,” said Dr. O’Day. Some surgeons use sterile plastic baggies to adjust microscope oculars.

Dr. O’Day uses sterile powderless gloves in his LASIK suite, and has not encountered any problem with flap interface debris from glove use.

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12 Tips on Infection Control

  • Observe universal precautions: Assume that blood and body fluids—of both patient and provider—could be infectious.
  • Adhere to hand hygiene without exception. This is the best defense against transmitting pathogens and should be observed by staff before and after every patient encounter.
  • Use HVAC filters to thoroughly filter all air that enters the surgical environment.
  • Do not wear jewelry in surgery; jewelry can harbor microbes.
  • Sterilize equipment meticulously and conduct microscopic inspections to ensure there are no remaining particles.
  • Keep nonsterile items out of a sterile field.
  • Do not rely on alcohol to sterilize equipment; it is not an approved sterilizing method and could compromise a sterile field.
  • Use a no-touch technique so that nothing nonsterile touches the eye.
  • Never touch the working end of a surgical instrument.
  • Use sterilized covers on laser joystick knobs and change them between patients.
  • Change the speculum when operating on both eyes of a patient; the chances of bacterial contamination increase when an instrument is transferred from one eye to the other.
  • Do not reuse any instruments without sterilizing them

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Occupational Safety

Protection for the patient’s sake is only one side of the equation for infection control. The physicians and ancillary staff should also be protected from blood-borne infections that might be acquired from the patient, such as bacterial infections, hepatitis B and C, or the human immunodeficiency virus. Although the infection status of some of these patients may be documented, in others it remains unknown.

The sterile gold standard. Universal precautions delineate a set of measures designed to prevent the transmission of all blood-borne pathogens to health care workers. Under these parameters, blood and some body fluids of all patients, regardless of their history, are considered potentially infectious. These precautions do not apply to tears unless they contain visible traces of blood.

That relative risk of infection, in fact, often factors into a surgeon’s decision to wear or not wear protective barriers. Ophthalmologists have a very low risk of becoming infected by patients. More than a million cases of HIV infection have been recorded in the United States, for example, and none were in conjunction with an ophthalmic procedure.

Low risk is not no risk. “The challenge becomes determining that there is no chance of exposure. This is an important issue when you are talking about any type of invasive procedure, even if the procedure is generally bloodless and minimally invasive,” said Arjun Srinivasan, MD, who is head of the response team in the Division of Healthcare Quality Promotion at the CDC. “We encourage those who are performing invasive procedures, even when there is a perception that the risk is very, very low, to practice standard precautions because it is the prudent thing to do. And these recommendations are not solely directed at pathogens like HIV and hepatitis. They are also directed at bacterial infections such as methicillin-resistant Staphylococcus aureus [MRSA] or adenovirus.”

Protect both patient and provider. “It is a two-way street,” said Adelisa Panlilio, MD, MPH, a medical epidemiologist who also works in the Division of Healthcare Quality Promotion at the CDC. “The personal protective equipment that a surgeon wears when he or she performs a surgical procedure is also to protect the patient and prevent problems with surgical site infections. We have microorganisms living on our skin and hair and do not want to transmit those to the patient.”

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A New World of Bad Bugs

“Infection scares everyone, especially when we continue to identify bacteria that do not respond to antibiotics. And that list continues to expand,” warned Dr. Ritacca. “It is not just MRSA any more. And it is not just in the hospitals anymore. These problems are migrating into surgery centers. We used to be safe, but things are changing; caution is essential. If you get a staph infection in a cornea, it could be a disaster.”
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1 Helga P., et al. J Cataract Refract Surg 2005;31(1):221–233.
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The physicians interviewed report no related financial interests.

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