We shall discuss three questions here:
1. OT fumigation in Indian setting
2. Intra cameral antibiotics as prophylaxis for endophthalmitis
3. Intra ocular surgery in pathological myopic eyes
1. As we know formalin used for fumigation of OT is carcinogenic so what is good & economical alternative for fumigation. Also from whom (manufacturer details) it can be made available. What machine to be used with it? (same as fumigation machine or different). And also safety guidelines as far as this new agent is used.
Responses:
No. 1
In Pune Lemongaurd is available , add Incidure to Mop your OT with AC on.2-3 hrs before surgery if Moping done acts for 3-5 hours according to movement in & out of OT I use the same for last more than 15 years since I stopped Formalin.
No: 2
Bacillocid, Mfg Raman & Weil, Mumbai
For OT sterilization Mix one cap full in 1 Ltr water and spray with the spraying manual unit supplied by the company like normal scent or deo spray on your table and other theatre equipment Safe and effective
2. What is the technique of using intra-cameral moxifloxacin in cataract surgery? Do we fill the chamber and leave it there? Or do we wash it out? If so, after how long? One company markets 0.5ml Unims of Moxifloxacin. Can they be used directly? Do please share your experience.
Responses:
No. 1
All doctors are using 0.1 ml or less after conclusion of surgery and injecting into the anterior chamber with a tuberculin syringe and a cannula. Most common dose is 0.06 ml of undiluted moxifloxacin. It can be left there. no need to wash it out. It is not toxic to the intra ocular tissues. Most internet discussions state that vigamox is used for this purpose. Some are using one vial per patient and others are drawing many doses from a single vial and using it for that days list. One bottle per theatre day. Cochrane Summary advises intracameral antibiotic to reduce endophthalmitis. A paper from LVP also advises the same. In general without intracameral antibiotics the endoph rate is around 1 in 1000 to 1 in 1300. With intra cameral moxi the endop rate is 1 in 3000 to 1 in 5000 cataract surgeries. Moxi will reduce isolated endop and will not reduce cluster endop. Standard precautions are always followed.
No: 2
You can use Unims 0.5ml with added 0.5ml of RL Works wonderfully. See that you remove all the viscoelastics from bag also from back of IOL.
No: 3
I have been now using Intra Cameral Moxifloxacin for close to 3 years. I have only tried Vigamox as a Brand. I have not found any Anterior Chamber reation attributable to Intra-cameral Moxifloxacin. After completing the Cataract Surgery I use the sideport to inject 0.1 ml of moxifloxacin in the Anterior chamber. I dont wash it off.
It has worked for me well.
No: 4
I am aware of the particular case regarding endothelial toxicity following the use of 4 Quin Prefilled. The surgeon who has referred the case to Dr. Abishek Saraf has in fact accepted that he injected a much larger volume of moxifloxacin 0.5% (over 0.5ml). This is what may have contributed to the occurence of endothelial damage. Literature reports, practice opnions and the marketing company has always advised that no more than 0.1ml of 0.5% moxifloxacin solution should be administered for safe prophylaxis of post operative endophthalmitis. It is important to convey this correct dose to surgeons else risk of TASS will always be a concern.
No:5
I think the question here is what is the best option for intracameral moxifloxacinnot whether it is required in the first place. There are very strong clinical as well as statistical reasons for adopting intracameral moxifloxacin. Intracameral antiobiotic use started off in Europe first and then America following the increasing rate of post-op endophthalmitis. Its not just poor OT conditions and poor sterilization techniques that increase the risk. The reason it may be on the up are the more advanced surgeries we carry out today and the lack of compliance of post-op treatments. The only way to make sure that the patient recieves adequate a/b cover during the first 24 hrs post-op is intracameral a/b. I cannot see any other way.Your OT may have the highest standards yet in countries like Canada, America and Britain , the rates are on the up. The modern surgical procedures and so called Sutureless techniques put the patient at risk. Thats why here in Britain we dont jump straight into newer techniques. With the kind of surgeries being done these days I can only see the rates increasing without intracameral a/b.Furthermore regarding the method of intracameral a/b administration what one needs to consider is that does Prof. Arshinoffs studies really replicate your OT scenario that warrants the same kind of dose and method being used in India or any other developing country? Consider the difference in your patient populations and OT staff training in extemporaneous dispensing in different countries. Are your OT staff trained to the same level as in Canada or America. Even mine arent. Do you personally supervise the preparation process of a diluted moxi eye drop? What are the risks of human error or contamination? If a diluted form of 0.5% moxi is effective in preventing endoph in Canada and Europe, then that does not mean that this dose is also effective in other countries.I for one vouch for the undiuted 0.5% strength and then inject 0.1ml from the two side ports. As long as the vehicle is Water for Injection and the solution is terminally sterilised risk of TASS is minimal. I do not believe that a higher dose of moxifloxacin can lead to TASS. That was only a theoretical assumption. Rodent corneas tolerated much higher doses of moxi. The TASS causing factor is the eye drop base/vehicle itself, and in the coming months several studies will prove that.
No:6
It is a proven fact and well mentioned in textbooks that antibiotic prophylaxis of infection is inferior to stringent sterilization of instruments and disciplined aseptic O.T. protocol and uncertain way to prevent postop. infection. May sound difficult to believe, but I have not come across even a single case of endoph.in my nearly 30 years of private practice. I never use any intracameral antibiotic towards the end of surgery and believe, the lesser the chemicals including antibiotics you put in the AC other than R.L.(I dont use B.S.S.)the better are the chances of not irritating the endothelium or the iris tissue. I feel, a special practical training of appropriate care and sterilization of instruments and aseptic precautions should be included in our PG course which is seen to be neglected and not given proper attention even during exams so that the trained surgeon who is the captain of the team will instill the discipline in his/her OT.This way we can minimize the unfortunate event.
3. Since we are in the
era of refractive surgery for high myopes in the form of
ICL, i would like to know your comments about the role of
clear lens extraction in high myopes in present day
scenario.i recently came across a young boy with bilateral
Rd following clear lens extraction as the operating surgeon
had assured the patient that he would be relieved of his
glasses.but unfortunately he ended with a bilateral
pseudophakic RD
Responses:
No: 1
Patients
do develop RD post ICL, that too with in a matter or hours
or days. This has been reported and we have see a couple of
patients such as this as well. Difficult to decide which is
the lesser evil to pass a judgement.
No: 2
As we all know clear lens extraction has a role
in reducing refractive power in Myopics. Same goes with
ICL too. But in myopics I personally feel that we should go
with other modalities like glasses, contact lenses or even
lasik (if fundus has no pathological myopia change).
Invasive procedures like clear lens extraction or ICL can
lead to more dreaded complications as you have already
mentioned.
Let it be more simple, safe and fruitful
No: 3
In eyes with PATHOLOGICAL myopia, the risk is there with any kind of intraocular intervention. Even I have seen patients who were operated filtering surgery(trab) for preventing progression of myopia ended up in RD within few weeks. These eyes are as such prone to development of RD and any kind of intraocular intervention can PRECIPITATE the eventuality. So the safer alternatives are non-invasive measures like spectacles and contact lenses. If one wants to know relative risk of each procedure, we need to have a trial comparing all invasive procedures. There is enough evidence in literature that non-invasive approach is much better than invasive approach in these eyes.
If we want to talk in terms of I have not seen in so many cases that I have done, I prefer to quote one example:
There used to be a time when all exclusive scleral buckling procedures were being performed with diathermy for retinopexy and the success rate in supposedly best hands was 75% only. Then came, cryopexy which changed the success rate to almost 99%. Now, no one uses diathermy for retinopexy!! The surgeon who got success with diathermy in 49 out of 50 cases could not claim that it is the successful procedure as most of the peers could not get same results.
One more procedure was RK which could not stand the test of time. All of us know how much hype was there behind it and how it faded within few years. There are few surgeons who still continue doing it!
LASIK stayed back as the selection criteria were made strict from beginning of its era. If someone does ICL for a NON-pathological high myopia, the risk of any intraocular event may be similar to that after LASIK. And the same procedure if done for pathological high myopia, it will definitely carry higher risk for RD (LASIK is not recommended for these eyes anyway!!). Clear lens extraction (without any complication) with IOL (it is recommended to put IOL even if it is of zero power to reduce eventualities), according to me carries the same risk as that of ICL for RD as the intraocular manipulation is almost equal with both procedures.
These pathological high myopia cases need not have any treatable lesion(like lattice) for development of RD. The word pathological itself signifies the risk. There may be zonular dehisence, entire vitreous may be pathological with unpredectable strong adherence to retina at many places. These eyes end up in RD when PVD gets induced with any intraocular manipulation (even a intravitreal anti-VEGF injection for myopic CNVM can result in RD- I saw a case). As we discussed many times before, the results of surgery for RD in these pathological eyes are much worse than in other eyes with RD.
I agree with Dr. Kaushik that there should be clear counselling before contemplating any procedure. During counselling, the gravity of a situation of having a serious complication should also be impressed upon the patient. This part of counselling should be given equal importance to the marketing part..
At Borders in Santa Clarita, CA on May 17, 2010. The Borders went defunct on Feb 16, 2011 when the company announced that it had filed for Chapter 11 bankruptcy protection, listing $1.275 billion in assets and $1.293 billion in debts in its filing.
Driving from Santa Clarita to LA on I-5 South
Driving to LA from Orange County. This is the crazy rush hour traffic on I-5 North at 7.00 AM.