|Year : 1983 | Volume
| Issue : 7 | Page : 912-916
Retinal detachment surgery
PK Khosla, HK Tewari, Rajvardhan Azad
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, India
P K Khosla
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Khosla P K, Tewari H K, Azad R. Retinal detachment surgery. Indian J Ophthalmol 1983;31, Suppl S1:912-6
Infection after retinal detachment surgery has been minimized with the shift of adhesive modality to cryo and widespread use of solid silicon material for buckling but it jeopardises the visual outcome whefiever it occurs. There is lack of correlation between organisms cultured from preoperative conjunctival swab and organisms responsible for clinical infection, so treatment becomes a real difficult job. In this study, we have tried to correlate the flora cultured from conjunctiva, lid margins preoperatively, operation area, lid margin at time of operation and organisms responsible for infection. We have also analysed the sensitivity of the different organisms cultured to available antibiotics so as to prevent and treat clinical infection as early as possible.
| Materials and methods|| |
One hundred and fifty consecutive cases taken up for retinal detachment surgery were included in the study. Swab cultures were taken from the conjunctival sac and lid margin preoperatively. No antibiotics were put routinely preoperatively but appropriate antibiotic drops were administred to eradicate pathogens before surgery. Preoperative preparation included clipping off of eyelashes and washing patient's face at least three times on the night prior to surgery. Surgical preparation of the area around the eye was done with 2% Aqueous Mercurochrcme and conjunctival sac was irrigated with normal saline. Culture counts from the operation theatre atmosphere are frequently taken to avoid infection from atmosphere. Strict asepsis is observed in sterilizing the instruments, buckling material and sutures. Swab for culture was taken from the area of the buckle site or encirclage and lid margin at the end of surgery. In case of suspected infection postoperatively, material was taken from conjunctival sac or area of discharge from conjunctival suture site or any other relevant place. All swabs were carried in glucose broth so as to prevent drying before they reach laboratory. Sensitivity of organisms including Staphylococcus albus isolated before surgery was tested against Penicillin, Streptomycin, Tetracycline, Chloramphanicol, Erythromycein, Framycetin, Gentamicin and Cloxacillin by disc diffusion techinque and results interpreted as recommended by Bauer et al.
| Observations|| |
[Table - 1] shows bacterial flora from various areas before and during surgery indicating maximum contaminants from lid margin before operation (46%) and during operation (24.7%) as compared to those from conjunctiva preoperatively (33%) and buckle area (16.66%). Staphylococcus albus was the predominant organism and Staphylococcus aureus was the next frequent. [Table - 2] shows sensitivity of the Staphylococci to antibiotics. Most of the strains were resistant to Penicillin while Cloxacillin was the most effective. [Table - 3] shows details of presentation of cases of clinical infection either extraocular or intraocular.
| Discussion|| |
Scleral buckling procedures for retinal detachment surgery are thought to be associated more with infection due to harbouring of organisms in the dead spaces either between buckle and encircling element in solid silicones or in the pores in silicone sponge,,, apart from their course inside the eye through the opening made for subretinal fluid drainage. The study of genesis of postoperative infection in these cases is hampered by the fact that there is lack of correlation amongst bacterial contaminants identified from conjunctival sac preoperatively with that responsible for infection as seen from the isolates from the conjunctival wound, hence, predictability of causative organism responsible for the clinical infection on this basis seems problematical. Severe intraocular infection (endophthalmitis) is reported even when conjunctival swab preoperatively were sterile so we shifted our attention to isolating organisms from the buckle area or being harboured on the lid margin.
The incidence of clinical infection (3.33%) in this series is similar to found by other authors., Infective process may pursue basically two types of course either extraocular or intraocular. Three cases showed infective process of intraocular variety with aqueous flare, KPs, hazy media and low tension. Staphylococcus aureus was cultured from two cases postoperatively although their conjunctival swabs were sterile. Staphylococcus albus was cultured from the lid margin in one case preoperatively and at the operation table. No organism was cultured in one case although this case showed staphylococcus albus from the lid margin preoperatively and also at the operation table. The organism cultured either preoperatively or postoperatively in all cases were sensitive to cloxacillin. The infection could be controlled in all of them in about 4 weeks with conservative treatment including cycloplegics and ssteroids and antibiotics. including cloxacillin systemically and in form of local drugs and Gentamicin systemically subconjunctivally but with resultant satisfactory vision only in one case.
Two cases had red congested weeping eye with no intraocular signs and were thus thought to be due to external infection involving area surrounding the buckle. The buckle was seen pointing beneath the conjunctiva but was not rejected due to prompt treatment. Postoperative conjunctival cultures were sterile in both the cases. Preoperative conjunctival lid and operative buckle cultures were sterile although lid culture at the time of operation showed Staphylococcus albus in one case. Staphylococcus albus isolated was sensitive to Cloxacillin.
The patients were given intensive conservative treatment and antibiotics in the form of Cloxacilline (systemic and toczl) based emperically on our experience and sensitivity of Staphylococcus albus to Cloxiacilline and they responded well within two weeks. This indicated the efficiency of Cloxacillin in both varieties of infective process associated with surgery of the retinal detachment.
Subretinal fluid drainage was done in all the cases hence we feel that intraocular infection is not a must if infection does occur in these cases as it remained confined extraocularly in two cases, however, SRF drainage is a major factor for infection in the intraocular variety as is evident from one case who showed fibrous tissue mass in the region of SRF drainage so care should be taken to meticulously avoid bacterial contamination in the cases where subretinal fluid drainage is done.
Staphylococci as isolated in this series were found to be the most sensitive to Cloxacillin [Table - 2] and hence it was considered to be the most effective antibiotic if we assume that the infection is caused by these organisms. It is thus suggested that in addition to other appropriate measures, systemic and local use of cloxacillin in the following regime (1) 250500 mg. Cloxacillin orally 6 hourly (2) topical 2.5% Cloxacillin 4 times a day or more. Subconjunctival Cloxacillin is not advocated as it causes necrosis with even 10 mg. Staphylococci have been found to be resistant to Penicillin as in earlier studies, and the modification of antibiotic sensitivity may have occurred because of previous chemotherapy or antibiotic administration. Gerramycein did not increase the range of sensitivity when given with Cloxacillin but subconjunctival route and even intravitreal route is available which is an added advantage in view of the problems of necrosis faced when Cloxacillin is given. It will also take care of other organisms (Gram-ve organisms) which may be responsible and have not been isolated and not sensitive to Cloxacilline. Combining with Chloromycetin may cover more cases of Staphylococci but the alternate route is not available and its spectrum is nearly the same as Cloxacillin.
Staphylococcus albus is a commensal frequently present over skin and lid margin and contrary to general belief may he pathogenic on number of occasions. On correlating type of organisms isolated in cases of clinical infection, we found that Staphylococcus albus was cultured from lid margins either preoperatively or on operation table and patient responded favourably to therapy found on the basis of sensitivity test. It comfirms the contention of Khosla who indicated that Staphylococcus albus is not as innocuous as is made out and Mahajan has indicated that isolations of Staphylococci (including coagulase negative) should be tested for sensitivity to antibiotics and infection if it occurs in the postoperative period should be treated accordingly. We belief, therefore, that if infection occurs in a case where these organisms were cultured preoperatively it may be presumed that these may be responsible for postoperative infection in some cases and hence appropriate antibiotic must be administered for these.
A more pragmatic approach, thus will be to free the lid margin from where these organisms were mostly cultured from any contamination preoperatively which can be achieved by (1) clipping of eye lashes as soon as patient is admitted in the ward for surgery (2) massage of lid margin and cleaning it with cotton applicators soaked in antibiotics preferably cloxacillin at least three times a day (3) washing of face on the night before surgery at least 3-4 times (4) thorough cleaning of conjunctival sac and lid margin with antibiotics once patient is put on operation table.
| Summary|| |
Staphylococci (albus and aureus) seem to be organisms related to clinical infection and as these were present mostly in lid margin cultures and infection responded to appropriate antibiotic. Cloxacillin is the most effective antibiotic so its use is both prophylaxis and therapy is advocated. A more pragmatic approach to keep the lid margin devoid of these organisms is suggested to ward ott postoperative infection.
| References|| |
Azad, Rajvardhan, Tewari, H.K and Khosla, P.K, 1979. East. Arch. Ophthalmol 7: 134.
Bauer, A.W., Kirby, W.M.M., Sherries, J.C. and Rurck, M. 1966. Amer. J. Clinic Pathol. 45,493.
Corse, J, and Williams R.E.O. 1968. Journ..Clin. Path. 21, 722.
Khosla, P.K, Angra, S.K and Agarwal, L.P., 1964. Orient.Arch. Ophthalmol 2:240.
Lincoff, H., Nadelaa and O'Conner, P, 1970. Arch. Ophthalmol 84:421.
Mahajan, V.M., 1979. Journ. Clin. Path. 32: 396
MeMeel, J.W. and Warner, J.M., 1965. Arch. Ophthalmol. 74:42.
[Table - 1], [Table - 2], [Table - 3]