Alice C. Lorch

Prophylactic antibiotics in posttraumatic infectious endophthalmitis.

Endophthalmitis is a feared complication of any intraocular surgery but is of particular concern after the repair of open globe injury. Reported rates of endophthalmitis in open globe injury are higher than for intraocular surgery, presumably because of nonsterile conditions at the time of an injury. Rates of posttraumatic endophthalmitis vary; in a review of 558 patients with open globes, Andreoli et al found a rate of 0.9% of endophthalmitis, whereas Verbraeken and Rysselaere found a rate of 4% in 615 patients, Ariyasu et al found a rate of 7.2% in 670 open globe patients, and Essex et al found a rate of 6.8% in 250 patients. The rate of endophthalmitis after intraocular surgery, by comparison, is approximately 0.001%. In addition to suffering from higher endophthalmitis rates, patients with posttraumatic endophthalmitis have worse postoperative outcomes than patients with postoperative endophthalmitis. In a study of 25 patients with endophthalmitis, Verbraeken and Rysselaere found only 38% to recover functional vision (light perception or better), compared with 60% of postoperative endophthalmitis patients resulting in functional vision in a previous study by the same author. The discrepancy in endophthalmitis rates in patients after open globe repair may be attributed to variable risk factors for endophthalmitis based on patient population but also to variable antibiotic prophylactic regimens. Despite extensive literature on open globe injuries and outcomes, there have been no randomized controlled studies to establish the best prophylactic antibiotic regimen and there is no standard protocol. This review attempts to summarize the antibiotic regimens that have been used for these patients and present the current thought in appropriate

The Impact of Preprinted Prescription Forms on Medication Prescribing Errors in an Ophthalmology Clinic in Northeast Thailand: A Non-Randomised Interventional Study

Objectives To understand the incidence and types of medication prescribing errors in a low resource setting ophthalmology clinic and to determine the impact of a preprinted prescription based on the hospital formulary (FormularyScript) on medication prescribing errors. Design Non-randomised interventional study. Setting Ophthalmology clinic in a teaching hospital in northeast Thailand. Participants 4349 handwritten prescriptions collected from October 2009 to December 2009, and 4146 FormularyScripts collected from February 2010 to May 2010. Primary and secondary outcome measures All prescriptions from the handwritten and FormularyScript groups were analysed for medication error rates by types (legibility, ambiguous, incomplete, abbreviation and accuracy) and subtypes (drug name, strength, which eye, route and dispensed amount). Results Comparison of error rates in the two groups showed a 10-fold reduction in the overall error rate using FormularyScript (32.9%–3.5%, p<0.001). FormularyScripts were associated with statistically significant (p<0.001) decreases in the following error types: legibility (16.1%–0.1%), incomplete (16.1%–0.1%) and abbreviation (3.1%–0.3%). There was no statistically significant change in accuracy errors (0.8%–0.6%, p=0.21). Ambiguous errors increased with FormularyScripts (0.6%–2.5%, p<0.001), likely due to the introduction of new ways to make errors. Decreases were seen in all legibility, abbreviation and accuracy error subtypes, and four out of six incomplete error subtypes. There were statistically significant increases in both ambiguous error subtypes: which eye (0.3%–2.5%, p<0.001) and drug name (0.3%–0.6%, p=0.03). Conclusions In our study population, outpatient medication prescribing errors were common and primarily due to legibility and incomplete error types. A preprinted prescription form has the potential to decrease medication prescribing errors related to legibility, incomplete prescribing information and use of unacceptable abbreviations without changing the overall rate of accuracy errors. However, new error types can occur.

An evidence-based approach to surgical teaching in ophthalmology

An apprenticeship model has traditionally been used in procedural and surgical teaching. As the pressures of work hours and patient outcome monitoring increase, surgical teachers need a more flexible plan for teaching procedural skills. We attempt to delineate a program of preprocedural, intraprocedural, and postprocedural teaching that can be used in the field of ophthalmology to maximize a residents skill acquisition in a constructive learning environment. We review the literature on surgical teaching from within ophthalmology as well as other surgical fields and combine this with teaching experience in an ophthalmic surgical training program to produce a collection of procedural teaching guidelines. These guidelines are structured to serve in both individual teaching settings and in curriculum design.

Pre-Operative Counseling and Intraoperative Considerations and Instruments

The pre-operative discussion with the patient and planning prior to the surgical repair is important for patient satisfaction and for a successful open globe repair. A detailed discussion should involve the patient and relevant family members. Only after the patient has a clear understanding of the plan and the associated risks, benefits, and alternatives can open globe repair proceed. Then, it is helpful to have a carefully thought out plan for the globe exploration and repair and ensure that all necessary equipment and instruments are functional and available prior to starting the surgery.

Controversies in Open Globe Injury Management

Every year, open globe injuries (OGIs) affect approximately 266,000 patients worldwide (Negrel and Thylefors B. Ophthalmic Epidemiol. 1998;5:143–69). The management of these patients remains controversial, particularly for the following areas: antibiotic prophylaxis for endophthalmitis, repair of posterior ruptures, injuries with lens disruption, repair of eyes with no light perception (NLP), and the risk for developing sympathetic ophthalmia. This chapter will review these controversial topics in the management of open globe injuries. We will first present an evidence based review of the current literature in this area, followed by an expert opinion by one of our editors.

Case 33: Delayed Zone I Open Globe Injury with Corneal Ulcer and Hypopyon

Delay in wound closure of greater than 24 h is a main risk factor for traumatic endophthalmitis. Here, a case of a delayed presentation zone 1 open globe injury complicated by the presence of a corneal ulcer is presented. Techniques to close corneal wounds associated with a corneal ulcer and the management of eyes with delayed presentation and concern for endophthalmitis are discussed. Ultimately, the clinical course of this patient was prolonged due to a secondary suture abscess, but he recovered excellent visual acuity upon completion of his treatment.

Case 37: Zone I/II/III Open Globe Injury with Orbital Fractures

Concomitant open globe injuries with facial fractures usually occur in the setting of high velocity, blunt trauma to the eye. In most cases, the visual prognosis is poor compared to other open globes without facial fractures. Here, a case is presented in which a young man sustained a Zone I/II/III open globe injury with associated facial fractures after being hit with a softball. He ultimately decided against secondary corneal and vitreoretinal surgery and retained light perception vision. Repair of the facial fractures was deemed unnecessary.

Case 27: Zone I Open Globe Injury Requiring Corneal Glue

A 67-year-old man presented with a Zone I open globe injury of the right eye from an arrow resulting in a stellate laceration at the corneal limbus. The patient underwent a standard repair of the globe injury. His post-operative course was complicated by Seidel-positive leakage from the center of the stellate wound that failed to epithelialize. This was treated with two applications of cyanoacrylate corneal glue and bandage contact lens (BCL). The patient also developed an inflammatory reaction with elevated intraocular pressure accompanied by iris and corneal neovascularization, which was presumed to be secondary to the corneal glue. He was treated with an intensive course of topical steroids following removal of the BCL and corneal glue with resolution of corneal and iris vessels, and final best-corrected visual acuity of 20/25.

Case 28: Zone I/II Open Globe Injury with Corneal Patch Graft and Corneal Glue

A 53-year-old man was struck in the right eye by barbed wire that he was cutting under tension while working on a fence. He was found to have Zone I-II open globe injury and underwent surgical repair. He was initially taken to an outside hospital in the late afternoon before being transferred to MEE for further management of his eye trauma. Between the time of his initial injury and open globe repair (which was approximately 17 h), his cornea became increasingly necrotic, making direct suture repair difficult. This necessitated a corneal patch graft, corneal glue, cultures, pathology, and intracameral antibiotics. The glue was subsequently removed over several clinic visits, and the patient healed well.

Case 48: Zone I/II/III Open Globe and Eyelid Lacerations from a Box Cutter with Post-Operative Wound Dehiscence

A 43-year-old man presented with a Zone I-II-III open globe injury of the left eye with associated facial lacerations from a box cutter knife. The patient underwent repair of this open globe injury first followed by repair of his eyelid and facial lacerations. Given his complex eyelid lacerations, Jaffe lid speculums were not able to be used for eyelid retraction and silk sutures were used through the eyelid margin to achieve appropriate exposure for repair. Post-operative follow up was complicated by a wound dehiscence after corneal suture removal. This complication can be avoided by leaving sutures in for an extended period of time in long or complex wounds and by careful patient education.