Postoperative endophthalmitis can severely damage ocular tissues. The most common infecting agents are Staphylococcus aureus, from the bacterial flora of the eyelid, and Propionibacterium acnes, present on the meibomian and sebaceous glands. It has been reported that endophthalmitis occurs when these agents gain entry into the eye through a contaminated surgical field.1-3 Therefore, pre- and intraoperative infection control is crucial to prevent endophthalmitis.
Preoperative prophylaxis to minimize contamination of the surgical field includes topical antibiotics, thorough disinfection, and appropriate draping. Among these measures, appropriate draping prevents exposure of the eyelashes and eyelids to the surgical field and thus reduces bacterial contamination. Conventional draping includes using an adhesive drape to cover the eyelashes and eyelids and a metallic lid speculum to hold the eyelids open. However, conventional draping does not completely cover the eyelashes and eyelids at the medial and lateral angles of the eye, and meibomian secretions can enter the surgical field from gaps between the adhesive drape and eyelids. We recently designed a simple and reliable draping system using a new lid speculum, which is described below. A video highlighting use of this device can be viewed at http://eyetube.net/?v=pomep.
LID SPECULUM WITH A DRAPE
Description. The lid speculum with a drape is a cylindrical device consisting of two rings, an upper (58 mm) and a lower (five sizes: 25, 26, 27, 28, and 29 mm), each made of thermoplastic resin, and a transparent elastic silicone membrane that attaches to the rings (Figure 1). The eyelids are sandwiched between the upper and lower rings, and the opening of the rings is the surgical field. The eyelids are kept open by the tension of the thermoplastic resin. Eyelashes, eyelids, and the meibomian glands are physically blocked by the transparent elastic silicone membrane, preventing contact with surgical instruments and with the surgical field. Tension is also applied to the entire eyelid, preventing damage that can sometimes occur with a conventional metallic lid speculum. Our lid speculum is disposable.
Installation and removal. To select the appropriately sized lower ring, measure the width of the patient’s palpebral fissure and select a ring of the same size or one size smaller. Installation of the lid speculum with drape is simple: Fold the upper ring, pull the upper eyelid up, and insert the lower ring first into the conjunctival sac of the upper eyelid and then into the lower eyelid in a similar manner. Removal is also easily achieved by reversing the procedure.
CLINICAL APPLICATIONS
We have used our novel lid speculum with drape for several clinical applications, including cataract surgery, intravitreal injection, vitreous surgery, and glaucoma surgery.
Cataract surgery. We typically perform cataract surgery with a superior corneoscleral incision, and this lid speculum provides an adequate surgical field intraoperatively. Additionally, insertion of surgical instruments is not impeded, and the speculum does not come loose due to blinking during surgery. In summary, this device fulfills its original function as a speculum. Draping is perfect, eyelashes are kept out of the surgical field, and no meibomian secretions enter the eye to contaminate the surgical field (Figure 2).
Intravitreal injection. During intravitreal injections, the contact of surgical instruments with eyelashes and eyelids has not occurred. An adequate surgical field can be secured, and injections can be completed without trouble. In clinical practice, the intravitreal injection of anti-vascular endothelial growth factor agents is increasing. Because this lid speculum is disposable and does not require sterilization, it is costeffective in treating many patients.
Vitreous surgery. When using a wide-angle viewing system with a conventional lid speculum, the patient’s exhalations can leak from the space under the drape and sometimes cloud the lens. Our lid speculum design attaches completely and does not cause such problem. This lid speculum provides a somewhat tight surgical field for 23- or 25-gauge, three-port pars plana vitrectomy; however, compression and other treatments can be performed without problem (Figure 3).
Glaucoma surgery. In trabeculectomy, view of the surgical field is adequate, and the filtration bleb remains unaffected at the time of speculum removal.
Appropriate draping prevents the prolapse of eyelashes into the surgical field and contamination of the surgical field from exposed eyelids and meibomian secretions. The newly developed speculum with a drape completely drapes the eyelashes and eyelids. It can be easily installed and removed, and the silicone material is friendly to eyelids and provides an adequate surgical field for the surgeon. Intra- and postoperative complications have not been seen. Because this new lid speculum is disposable and does not require sterilization, it is a cost-effective device.
Masataka Kasaoka, MD, practices in the Department of Ophthalmology, Kurume University School of Medicine, Fukuoka, Japan. Dr. Kasaoka states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +81 942 31 7574; fax: +81 942 37 0324; email: kasaoka@med.kurume-u.ac.jp.
Toru Urano, MD, practices in the Department of Ophthalmology, Kurume University School of Medicine, Fukuoka, Japan. Dr. Urano states that he has no financial interest in the products or companies mentioned.
Ryoji Yamakawa, MD, PhD, practices in the Department of Ophthalmology, Kurume University School of Medicine, Fukuoka, Japan. Dr. Yamakawa states that he has no financial interest in the products or companies mentioned.
- Han DP,Wisniewski SR,Wilson LA,et al.Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study.Am J Ophthalmol.1996;122:1-17. 2.Bannerman TL,Rhoden DL,McAllister SK,Miller JM,Wilson LA.The source of coagulase-negative staphylococci in the Endophthalmitis Vitrectomy Study.A comparison of eyelid and intraocular isolates using pulsed-field gel electrophoresis. Arch Ophthalmol.1997;115:357-361. 3.Speaker MG,Milch FA,Shah MK,Eisner W,Kreiswirth BN.Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis.Ophthalmology.1991;98:639-649;discussion 1991;98:650
TAKE-HOME MESSAGE
• Using this lid speculum, the eyelids are sandwiched between the upper and lower rings, and the opening of the rings is the surgical field.
• The lid speculum is disposable and does not require sterilization.
WATCH IT NOW ON THE CATARACT SURGERY CHANNEL AT WWW.EYETUBE.NET
Using your smartphone, photograph the QR code to watch the video on Eyetube. If you do not have a QR reader on your phone, you can download one at www.getscanlife.com.
direct link to video:
http://eyetube.net/?v=pomep
