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LETTER TO EDITOR
Year : 2004  |  Volume : 52  |  Issue : 1  |  Page : 80-81

Debris in phacoemulsification handsets. A potential cause of endophthalmitis after cataract surgery?



Correspondence Address:
Srinivas K Rao


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Source of Support: None, Conflict of Interest: None


PMID: 15132390

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How to cite this article:
Rao SK, Baskaran M, Kumar P J, Vijaya L, Madhavan HN. Debris in phacoemulsification handsets. A potential cause of endophthalmitis after cataract surgery?. Indian J Ophthalmol 2004;52:80-1

How to cite this URL:
Rao SK, Baskaran M, Kumar P J, Vijaya L, Madhavan HN. Debris in phacoemulsification handsets. A potential cause of endophthalmitis after cataract surgery?. Indian J Ophthalmol [serial online] 2004 [cited 2019 Jul 18];52:80-1. Available from: http://www.ijo.in/text.asp?2004/52/1/80/14621

Dear Editor,

Postoperative infections in the eye can have devastating effects on visual outcome after surgery, and are unfortunately not uncommon in India.[1] In the absence of an organised reporting system, such infections are often underreported, but outbreaks have been described. Recently, the increasing popularity of phacoemulsification has improved the success rate of cataract surgery though postoperative infections including epidemics continue to occur. They have been traced to internal contamination of the tubings in the phacoemulsification machine.[2]

We experienced a cluster of infections after phacoemulsification for cataract extraction at our centre. This communication describes the results of our investigations and highlights a potential new source of such infections. From January to August 2003, we had 10 culture-proven infections in 5,706 patients undergoing phacoemulsification for cataract. This rate of 0.18% was higher than the 0.04% (3 infections among 6997 phacoemulsification procedures), recorded during 2002, and 0.02% (1 of 4,335 surgeries) of non-phacoemulsification cataract surgery performed during the same period. Our suspicion was directed towards the phacoemulsifiers and associated equipment. We performed the following procedures on the phacoemulsification and irrigation-aspiration (IA) handsets. After routine scrubbing and gloving, the autoclaved instrument trays were set up and the phacoemulsifier was connected. A bottle of Ringers Lactate solution (Sri Krishna Keshav Laboratories, Gujarat, India) was hung on the pole of the instrument and a sterile intravenous (IV) infusion set was connected. Fluid from the bottle was collected in a sterile container through the IV set, and sent for microbiological analysis. After this was done, the fluid from the bottle was collected in a sterile bowl and a 20 ml syringe was used to flush 100 ml of the fluid through the irrigation and aspiration lines of the phacoemulsification and IA handsets. This washing was collected in sterile containers and sent for microbiological analysis. In addition to cultures, the washings were also centrifuged (Remi Laboratory Centrifuge, India) and the deposits were studied under light microscopy. Seven pairs of phacoemulsification and IA handsets were studied, and in two pairs only the irrigation lines were flushed, providing 24 samples of washings.

While none of the samples of fluid taken from the bottle were positive for microorganisms 11 of 24 samples collected after flushing the phacoemulsification and IA handsets were culture positive. These included Acinetobacter calcoaceticus and Alkaligenes fecalis . Similar organisms were cultured from the intraocular fluids in 7 patients with post-phacoemulsification endo-phthalmitis. The sediments obtained from the washings were examined by light microscopy. This showed presence of deposits 5 to 40 m in size; these were needle shaped and suggestive of lens matter. To further confirm the presence of such debris accumulation in the bore of the handset tubings we procured a flexible fibre optic micro-endoscope (Storz) with a diameter of 1 mm, which allowed us to image the inner surface of the handset tubings. This examination confirmed the presence of significant deposits in the aspiration lines [Figure - 1] of all the 5 handsets examined.

Such materials, even if sterile, are capable of inciting a sterile inflammatory reaction due to their pyrogenic nature. It is also likely that in the presence of such organic debris, microorganisms sequestered in these regions are protected from routine sterilisation procedures. When the debris buildup in the handsets exceeds a critical level, some of it can be washed into the eye during surgery and cause infection. Similar incidences have been reported from Glasgow,[3] although the authors did not include direct endoscopic visualisation of these deposits.

The relatively infrequent episodes of infections despite the prevalence of such deposits in the handsets may be because routine cleaning and sterilisation procedures retain some of their effectiveness in this milieu.

The manufacturers of the phacoemulsifiers were contacted and although they did not have an established protocol for the treatment of such deposits, a protocol was worked out which uses an enzyme cleaner (Endozime, Ruhof, Minnesota, USA) to reduce these deposits. The use of this cleaner has reduced the size of the established deposits, although its true value may be in preventing such buildup from occurring, if used regularly in new probes. An automated flushing system using distilled water and air has also been proposed as an effective measure. Considering the increased longevity of the current generation phacoemulsification handsets the maintenance protocols will have to be more robust.

In conclusion, we report another possible source of contamination in phacoemulsification surgery that could lead to postoperative endophthalmitis. It is important that phacosurgeons devise reliable protocols for the care of their handsets. Since most surgeons use more than one handset for surgeries, it may be prudent to note the serial number of the handset in the case notes as this can aid epidemiological investigations if infections occur.



 
  References Top

1.
Das T. National endophthalmitis survey. Indian J Ophthalmol 2003;51:117-18.  Back to cited text no. 1
[PUBMED]    
2.
Zaluski S, Clayman HM, Karsenti G, Bourzeix S, Tournemire A, Faliu B et al. Pseudomonas aeruginosa endophthalmitis caused by contamination of the internal fluid pathways of phacoemulsifiers. J Cataract Refract Surg 1999;25:540-45.  Back to cited text no. 2
    
3.
Leslie T, Aitken DA, Barrie T, Kirkness CM. Residual debris as a potential cause of post phacoemulsification endophthalmitis. Eye 2003;17:506-12.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  


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