(1)
Newcastle Eye Centre Royal Victoria Infirmary, Newcastle upon Tyne, UK
Endopthalmitis rates after cataract surgery are thankfully low, with worldwide reported rates currently between 0.03 and 0.2% [1]. The use of 5% povidone–iodine solution instilled pre-operatively into the lower fornix, and intracameral antibiotics instilled at the end of surgery, have contributed to this low incidence. Despite this, it remains essential to minimise any peri-operative exposure to microbes. Meticulous preparation of the ocular surgical field to ensure adequate antisepsis of the eye and surrounding periocular area will inhibit the patient’s own ocular flora. And good hand-washing, and aseptic technique when donning the surgical gown and sterile gloves, will reduce the likelihood of introducing external pathogenic organisms during surgery.
Safe preparation for surgery is also a crucial part of the modern operating theatre. The use of “pre-flight” checklists helps ensure that theatre staff are prepared (e.g. right patient, right operation, right equipment); that they all have the same expectations (e.g. “this case may be more technically challenging because…”) to enable everyone to act as a team. Explaining in advance which aspects of surgery will be devolved to the Trainee forms an important aspect of a pre-operative briefing.
With rear-ended modular training, it is recommended that the Trainer takes responsibility for the safety aspect of surgery right up until the point where the Trainee is nearly able to work independently.
This chapter covers those essential aspects of surgery that a Trainee will have to be competent at in order to work solo. This includes: draping and sterility, awareness of safety checks, and ensuring the surgeon is always physically comfortable during surgery.
15.1 Skin Preparation
Each Trainer will have their own technique for preparing the surgical field before an ocular drape is applied. Skin preparation can vary from performing a lid scrub, to cleaning the whole face, to simply applying the disinfecting solution to the periocular area. A step-by-step overview of the latter, more common method, is described:
- 1.
Pause to ensure the correct eye in the correct patient for surgery is identified (see section on safety).
- 2.
Apply a generous amount aqueous povidone-iodine using suitable applicator to the periocular skin (or chlorhexidine if allergic to povidone-iodine). The surface should be coated in systematic fashion (Fig. 15.1):
- (a)
With the patient’s eyes closed, start at the medial canthus and work outwards towards the lateral canthus.
Solution will flood the ocular surface, the upper and lower lid margin and lashes.
- (b)
Starting again at the medial canthus, wipe one of the lids, proceeding towards the lateral canthus.
- (c)
Repeat for the other lid.
- (d)
Apply further solution to the periocular skin (lids, eyebrow and side of the nose) in an enlarging concentric fashion. Commence medially and work out laterally with each wipe.
- (e)
Pause to allow time for the bactericidal effect to work (the time taken to cover patient with linen drapes is usually sufficient).
- 3.
Dry the periocular surface in a similar fashion (Fig. 15.2). Start at the medial canthus and work systemically outwards in concentric fashion, remembering to start medially after each dry wipe.
- 4.
Once completed, although the periocular skin will appear dry, the lower lid margin and lashes often are still wet (Fig. 15.3). This can remain unnoticed until the patient is asked to open their eye, (usually when the surgeon is about to apply the drape). Any residual moisture can prevent the transparent drape adhering to the eyes lashes and periocular skin. After drying the periocular skin, ask the patient to look up and ensure lower lid is wiped dry (wiping from medial canthus along the lid margin towards the lateral canthus).
- 5.
The ocular drape can now be applied.
Fig. 15.1
Periocular skin preparation. (a) Topical anaesthetic and preoperative povidone-iodine 5% instilled into patient’s right eye. (b) Starting at the medial canthus antiseptic is applied outwards towards the lateral canthus. (c) Periocular skin prepared starting at the medial canthus and wiping outwards in a concentric fashion (arrows)
Fig. 15.2
Drying of periocular skin -1. (a) Linin towel with facial aperture covers patient. Starting at the medial canthus and wiping towards the lateral canthus, excess skin antiseptic solution is wiped dry (arrow). (b) Remaining periocular skin is dried: wiping outwards from the medial canthus in a concentric fashion (arrows)
Fig. 15.3
Drying of periocular skin -2. After periocular skin is dried the patient is requested to look up and any residual moisture on lower lid wiped dry
Box 15.1 Surgical Tip
When discarding skin preparation forceps (holding wet, used swabs) place the forceps all facing the same way the trolley surface. This makes it easier for theatre staff to pick up the forceps and avoid getting their own hands dirty when cleaning up (Fig. 15.4).
Fig. 15.4
Discarding forceps. (a) Dirty swabs placed on trolley surface in haphazard fashion for theatre staff to remove. (b) Forceps all facing the same way allow staff to conveniently remove them with minimal risk of contaminating themselves
15.2 Draping
The ocular drape is applied to the skin to maintain the sterile ocular field and act a barrier, holding the patient’s eyelashes out of the way during surgery (Fig. 15.5).
