- Email: [email protected]
Technique to exclude temporal lash incursion in phacoemulsification surgery
TECHNIQUE
Technique to exclude temporal lash incursion in phacoemulsification surgery Olivia J.K. Fox, BMSc(Hons), Benjamin W.C. Sim, MB BS, Sai Win, MB BS, Ravjit Singh, BSc, Shahriar Amjadi, BSc, MB BS, Ashish Agar, FRANZCO, PhD, Allan Bank, FRANZCO, FRACS, Ian C. Francis, FASOPRS, PhD
We describe the use of a Steri-Strip to exclude lashes in cataract surgery cases in which the lashes impinge on the operative field. The technique has been used in 25 cases and achieved uniformly successful lash exclusion. In 6 cases, the strip became partially dislodged and required repositioning intraoperatively, after which it achieved complete lash exclusion. No complications have been observed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2012; 38:1885–1887 Q 2012 ASCRS and ESCRS Online Video
The exclusion of lashes from the operative field in modern cataract surgery using either temporal or superior clear corneal incisions may help to prevent acute postoperative bacterial endophthalmitis.1 Although we recognise that wound suturing is one of the most important factors in preventing acute postoperative bacterial endophthalmitis,1–5 we believe lash exclusion must also be considered. Temporal lash exclusion assists in maintaining a sterile surgical environment as it precludes incursion of temporal lashes and the temporal eyelid from the operative field. This is particularly important in patients with deep-set eyes, relative enophthalmos, or short palpebral fissures. Lash exclusion prevents
Submitted: June 16, 2012. Final revision submitted: July 16, 2012. Accepted: July 23, 2012. From the Department of Ophthalmology (Sim, Win, Singh, Amjadi, Agar, Bank, Francis), Prince of Wales Hospital, the University of New South Wales (Sim, Win, Singh, Amjadi, Agar, Bank, Francis), the University of Notre Dame (Fox), and the Ophthalmic Surgery Centre (Fox, Sim, Win, Singh, Amjadi, Bank, Francis), Sydney, Australia. Presented at the COSSOM Scientific Meeting, Prince of Wales Hospital, Sydney, Australia, December, 2011. Corresponding author: Ian C. Francis, FASOPRS, PhD, Suite 12, 12-14 Malvern Avenue, Chatswood, 2067, New South Wales, Australia. E-mail: [email protected]. Q 2012 ASCRS and ESCRS Published by Elsevier Inc.
the phaco tip and/or the second instrument from contacting the lashes or the lid. The cumulative cataract surgical experience in our group is 73 years. Recently, we developed a technique of residual lash exclusion following draping for phacoemulsification surgery. Although we have always attempted to exclude eyelash incursion with rigorous draping at the commencement of cataract surgery, the drape occasionally leaves a small section of the lateral canthus, particularly the upper lid, exposed, allowing lashes to enter the operative field. Traditionally, temporal lashes have been excluded by placing an extra Steri-Strip (R1547, 3M Health Care) with the ribbing perpendicular to the lid margin. Because of the elasticity and inertia of the ribbing, the strip often dislodges. We describe a method of lash exclusion by placing the strip with the ribbing parallel to the lid margin. SURGICAL TECHNIQUE It was serendipitously observed that a 1.0 cm length of Steri-Strip with the ribbing placed parallel to the lid margin (Figure 1) ensured definitive lash exclusion for the duration of the surgical procedure. This technique was first used in 2011, when the scrub nurse was asked for a short strip to achieve lash exclusion. The scrub nurse conveniently trimmed the protruding 1.0 cm of the strip from its backing paper (Figure 2) and then applied the segment with the ribbing parallel to the lid margin. At the end of the case, the segment remained in perfect position (Figure 3). 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.09.005
1885
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TECHNIQUE: EYELASH EXCLUSION
Figure 1. Left upper lid retracted, with blue lines indicating reorientation of Steri-Strip placement. Note that the ribbing of the strip is parallel to the lid margin.
Figure 2. Protruding 1.0 cm segment of the strip is cut from the backing paper and applied to the lid margin with the ribbing parallel to the eyelid margin.
Eyelash exclusion begins once the protruding 1.0 cm of strip segment has been trimmed. The trimmed segment is removed from the trimming scissors with a plain forceps. With a single movement of the forceps, the distal third of the segment is placed under the lid to exclude the aberrant lashes. The exposed remaining segment is pressed onto the anterior surface of the lid drape for several seconds to secure it firmly before tears wet its adhesive surface (Video, available at http://jcrsjournal.org).
determine its effectiveness in excluding lashes. Lash exclusion was required in 25 of the 156 cases (16%). The cohort comprised 52% women, with 68% of the cohort being right eyes. The mean age was 69.0 years G 7.20 (SD) with a mean intraocular lens (IOL) power of 20.0 G 3.15 diopters. There was no association between IOL power and requirement for use of the lash exclusion technique. Superior oblique clear corneal incisions were used in all the cases. In 6 of the 25 cases, the strip became partially dislodged intraoperatively and required repositioning. Once repositioned, the effectiveness of the strip was satisfactory in complete lash exclusion. All 25 cases achieved successful lash exclusion. This contrasts with traditional Steri-Strip placement in
Results The Steri-Strip eyelash exclusion technique was evaluated in 156 cases of phacoemulsification to
Figure 3. A: Left eye with strip applied. All lashes have been excluded by the strip, and the strip is oriented with the ribbing parallel to the lid margin. The arrow indicates the strip extending inferior to the lateral commissure. Note that in this case, the segment of strip extending beyond the commissure is tending to elevate away from the posterior lid surface. In this case, ideally a shorter segment should have been used for upper lid lash exclusion and a second segment used for the lower lid. B: Right eye with strip applied. The arrow indicates ideal placement of the strip ending superior to the lateral commissure. J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012
TECHNIQUE: EYELASH EXCLUSION
which the strip is frequently dislodged. The Steri-Strip eyelash exclusion technique was performed in fewer than 10 seconds. There were no complications as a result of the use of this technique. DISCUSSION The Steri-Strip eyelash exclusion technique demonstrated that lash exclusion is a straightforward technique. The value of this technique may become more important as the number of patients using topical prostaglandin analogues for treatment of glaucoma increases. Thus, the issue of excluding exuberant lashes may become more significant. Equally important is the exclusion of lashes from the operative field in modern cataract surgery using temporal or superior clear corneal incisions to prevent acute postoperative bacterial endophthalmitis.1 We documented IOL powers because of the possible association between axial length (AL) and IOL powers in relation to horizontal eyelid length.6 In a study by Hori-Komai et al.,6 laser in situ keratomileusis resulted in an increase of the vertical palpebral aperture. It is possible that eyelid length and AL are associated, but a Medline search revealed that this has not been explored. A future study could examine horizontal eyelid length and AL of the eye, potentially allowing preoperative prediction of the likelihood of the SteriStrip eyelash exclusion technique being required. Note that the patient documented in Figure 3, A, had short horizontal palpebral fissures and once the lid speculum had been placed, the lateral commissure and lids ran almost vertically. This anatomical variation is not uncommon and may be a factor in lash exposure despite adequate draping techniques. If the standard protruding length of the strip in such a patient is too long for upper lid lash exclusion and impinges on the lateral commissure, it should be trimmed to cover only the upper lid. In that case, if lower lid lash incursion also needs exclusion, a second segment should be used to cover the intruding lashes (Figure 3, A). The learning curve using this eyelash exclusion technique has been minimal. Thus, the scrub nurses have been accepting of the technique and the actual placement of the strip segment has been rapid and effective.
1887
In conclusion, the Steri-Strip eyelash exclusion technique allowed effective lash exclusion in a cohort of 25 patients. The technique is inexpensive and safe and may help in preventing acute postoperative bacterial endophthalmitis. WHAT WAS KNOWN Temporal lash exposure and incursion can compromise sterility of the operative field and particularly the wound. This is mainly because standard plastic ophthalmic drapes may leave a small section of the lateral canthal skin exposed, particularly the upper lid. WHAT THIS PAPER ADDS Temporal eyelash exclusion from the operative field is easily and effectively achieved with the placement of a segment of Steri-Strip with the ribbing parallel to the lid margin.
REFERENCES 1. Francis IC, Roufas A, Figueira EC, Pandya VB, Bhardwaj G, Chui J. Endophthalmitis following cataract surgery: the sucking corneal wound. J Cataract Refract Surg 2009; 35:1643–1645 2. Dubey R, Brettell DJ, Monfort J, Coroneo MT, Francis IC. Obviating endophthalmitis after cataract surgery: excellent wound closure is the key [letter]. Arch Ophthalmol 2011; 129:1504–1505; reply by MB Raizman, 1505 3. Karaconji T, Dubey R, Yassine Z, Singh R, Agar A, Francis IC. Bacterial-sized particle ingress promoted by suturing: is this true in the real world? [letter] J Cataract Refract Surg 2011; 37:2235–2236; reply by JM Castro, WN May, 2236 2237 4. Lauschke JL, Singh R, Wei M, Bhardwaj G, Figueira E, Montfort J, Francis IC. Factors influencing the incidence of postoperative endophthalmitis [letter]. Am J Ophthalmol 2011; 151:732; reply by CC Wykoff, HW Flynn Jr, EC Alfonso, 733 5. Ku JJY, Wei MC, Amjadi S, Montfort JM, Singh R, Francis IC. Role of adequate wound closure in preventing acute postoperative bacterial endophthalmitis [letter]. J Cataract Refract Surg 2012; 38:1301–1302; reply by M Packer, DF Chang, SH Dewey, BC Little, N Mamalis, TA Oetting, A Talley-Rostov, SH Yoo, 1302 6. Hori-Komai Y, Toda I, Tsubota K. Laser in situ keratomileusis: association with increased width of palpebral fissure. Am J Ophthalmol 2001; 131:254–255
J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012
Technique to exclude temporal lash incursion in phacoemulsification surgery Olivia J.K. Fox, BMSc(Hons), Benjamin W.C. Sim, MB BS, Sai Win, MB BS, Ravjit Singh, BSc, Shahriar Amjadi, BSc, MB BS, Ashish Agar, FRANZCO, PhD, Allan Bank, FRANZCO, FRACS, Ian C. Francis, FASOPRS, PhD
We describe the use of a Steri-Strip to exclude lashes in cataract surgery cases in which the lashes impinge on the operative field. The technique has been used in 25 cases and achieved uniformly successful lash exclusion. In 6 cases, the strip became partially dislodged and required repositioning intraoperatively, after which it achieved complete lash exclusion. No complications have been observed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2012; 38:1885–1887 Q 2012 ASCRS and ESCRS Online Video
The exclusion of lashes from the operative field in modern cataract surgery using either temporal or superior clear corneal incisions may help to prevent acute postoperative bacterial endophthalmitis.1 Although we recognise that wound suturing is one of the most important factors in preventing acute postoperative bacterial endophthalmitis,1–5 we believe lash exclusion must also be considered. Temporal lash exclusion assists in maintaining a sterile surgical environment as it precludes incursion of temporal lashes and the temporal eyelid from the operative field. This is particularly important in patients with deep-set eyes, relative enophthalmos, or short palpebral fissures. Lash exclusion prevents
Submitted: June 16, 2012. Final revision submitted: July 16, 2012. Accepted: July 23, 2012. From the Department of Ophthalmology (Sim, Win, Singh, Amjadi, Agar, Bank, Francis), Prince of Wales Hospital, the University of New South Wales (Sim, Win, Singh, Amjadi, Agar, Bank, Francis), the University of Notre Dame (Fox), and the Ophthalmic Surgery Centre (Fox, Sim, Win, Singh, Amjadi, Bank, Francis), Sydney, Australia. Presented at the COSSOM Scientific Meeting, Prince of Wales Hospital, Sydney, Australia, December, 2011. Corresponding author: Ian C. Francis, FASOPRS, PhD, Suite 12, 12-14 Malvern Avenue, Chatswood, 2067, New South Wales, Australia. E-mail: [email protected]. Q 2012 ASCRS and ESCRS Published by Elsevier Inc.
the phaco tip and/or the second instrument from contacting the lashes or the lid. The cumulative cataract surgical experience in our group is 73 years. Recently, we developed a technique of residual lash exclusion following draping for phacoemulsification surgery. Although we have always attempted to exclude eyelash incursion with rigorous draping at the commencement of cataract surgery, the drape occasionally leaves a small section of the lateral canthus, particularly the upper lid, exposed, allowing lashes to enter the operative field. Traditionally, temporal lashes have been excluded by placing an extra Steri-Strip (R1547, 3M Health Care) with the ribbing perpendicular to the lid margin. Because of the elasticity and inertia of the ribbing, the strip often dislodges. We describe a method of lash exclusion by placing the strip with the ribbing parallel to the lid margin. SURGICAL TECHNIQUE It was serendipitously observed that a 1.0 cm length of Steri-Strip with the ribbing placed parallel to the lid margin (Figure 1) ensured definitive lash exclusion for the duration of the surgical procedure. This technique was first used in 2011, when the scrub nurse was asked for a short strip to achieve lash exclusion. The scrub nurse conveniently trimmed the protruding 1.0 cm of the strip from its backing paper (Figure 2) and then applied the segment with the ribbing parallel to the lid margin. At the end of the case, the segment remained in perfect position (Figure 3). 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.09.005
1885
1886
TECHNIQUE: EYELASH EXCLUSION
Figure 1. Left upper lid retracted, with blue lines indicating reorientation of Steri-Strip placement. Note that the ribbing of the strip is parallel to the lid margin.
Figure 2. Protruding 1.0 cm segment of the strip is cut from the backing paper and applied to the lid margin with the ribbing parallel to the eyelid margin.
Eyelash exclusion begins once the protruding 1.0 cm of strip segment has been trimmed. The trimmed segment is removed from the trimming scissors with a plain forceps. With a single movement of the forceps, the distal third of the segment is placed under the lid to exclude the aberrant lashes. The exposed remaining segment is pressed onto the anterior surface of the lid drape for several seconds to secure it firmly before tears wet its adhesive surface (Video, available at http://jcrsjournal.org).
determine its effectiveness in excluding lashes. Lash exclusion was required in 25 of the 156 cases (16%). The cohort comprised 52% women, with 68% of the cohort being right eyes. The mean age was 69.0 years G 7.20 (SD) with a mean intraocular lens (IOL) power of 20.0 G 3.15 diopters. There was no association between IOL power and requirement for use of the lash exclusion technique. Superior oblique clear corneal incisions were used in all the cases. In 6 of the 25 cases, the strip became partially dislodged intraoperatively and required repositioning. Once repositioned, the effectiveness of the strip was satisfactory in complete lash exclusion. All 25 cases achieved successful lash exclusion. This contrasts with traditional Steri-Strip placement in
Results The Steri-Strip eyelash exclusion technique was evaluated in 156 cases of phacoemulsification to
Figure 3. A: Left eye with strip applied. All lashes have been excluded by the strip, and the strip is oriented with the ribbing parallel to the lid margin. The arrow indicates the strip extending inferior to the lateral commissure. Note that in this case, the segment of strip extending beyond the commissure is tending to elevate away from the posterior lid surface. In this case, ideally a shorter segment should have been used for upper lid lash exclusion and a second segment used for the lower lid. B: Right eye with strip applied. The arrow indicates ideal placement of the strip ending superior to the lateral commissure. J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012
TECHNIQUE: EYELASH EXCLUSION
which the strip is frequently dislodged. The Steri-Strip eyelash exclusion technique was performed in fewer than 10 seconds. There were no complications as a result of the use of this technique. DISCUSSION The Steri-Strip eyelash exclusion technique demonstrated that lash exclusion is a straightforward technique. The value of this technique may become more important as the number of patients using topical prostaglandin analogues for treatment of glaucoma increases. Thus, the issue of excluding exuberant lashes may become more significant. Equally important is the exclusion of lashes from the operative field in modern cataract surgery using temporal or superior clear corneal incisions to prevent acute postoperative bacterial endophthalmitis.1 We documented IOL powers because of the possible association between axial length (AL) and IOL powers in relation to horizontal eyelid length.6 In a study by Hori-Komai et al.,6 laser in situ keratomileusis resulted in an increase of the vertical palpebral aperture. It is possible that eyelid length and AL are associated, but a Medline search revealed that this has not been explored. A future study could examine horizontal eyelid length and AL of the eye, potentially allowing preoperative prediction of the likelihood of the SteriStrip eyelash exclusion technique being required. Note that the patient documented in Figure 3, A, had short horizontal palpebral fissures and once the lid speculum had been placed, the lateral commissure and lids ran almost vertically. This anatomical variation is not uncommon and may be a factor in lash exposure despite adequate draping techniques. If the standard protruding length of the strip in such a patient is too long for upper lid lash exclusion and impinges on the lateral commissure, it should be trimmed to cover only the upper lid. In that case, if lower lid lash incursion also needs exclusion, a second segment should be used to cover the intruding lashes (Figure 3, A). The learning curve using this eyelash exclusion technique has been minimal. Thus, the scrub nurses have been accepting of the technique and the actual placement of the strip segment has been rapid and effective.
1887
In conclusion, the Steri-Strip eyelash exclusion technique allowed effective lash exclusion in a cohort of 25 patients. The technique is inexpensive and safe and may help in preventing acute postoperative bacterial endophthalmitis. WHAT WAS KNOWN Temporal lash exposure and incursion can compromise sterility of the operative field and particularly the wound. This is mainly because standard plastic ophthalmic drapes may leave a small section of the lateral canthal skin exposed, particularly the upper lid. WHAT THIS PAPER ADDS Temporal eyelash exclusion from the operative field is easily and effectively achieved with the placement of a segment of Steri-Strip with the ribbing parallel to the lid margin.
REFERENCES 1. Francis IC, Roufas A, Figueira EC, Pandya VB, Bhardwaj G, Chui J. Endophthalmitis following cataract surgery: the sucking corneal wound. J Cataract Refract Surg 2009; 35:1643–1645 2. Dubey R, Brettell DJ, Monfort J, Coroneo MT, Francis IC. Obviating endophthalmitis after cataract surgery: excellent wound closure is the key [letter]. Arch Ophthalmol 2011; 129:1504–1505; reply by MB Raizman, 1505 3. Karaconji T, Dubey R, Yassine Z, Singh R, Agar A, Francis IC. Bacterial-sized particle ingress promoted by suturing: is this true in the real world? [letter] J Cataract Refract Surg 2011; 37:2235–2236; reply by JM Castro, WN May, 2236 2237 4. Lauschke JL, Singh R, Wei M, Bhardwaj G, Figueira E, Montfort J, Francis IC. Factors influencing the incidence of postoperative endophthalmitis [letter]. Am J Ophthalmol 2011; 151:732; reply by CC Wykoff, HW Flynn Jr, EC Alfonso, 733 5. Ku JJY, Wei MC, Amjadi S, Montfort JM, Singh R, Francis IC. Role of adequate wound closure in preventing acute postoperative bacterial endophthalmitis [letter]. J Cataract Refract Surg 2012; 38:1301–1302; reply by M Packer, DF Chang, SH Dewey, BC Little, N Mamalis, TA Oetting, A Talley-Rostov, SH Yoo, 1302 6. Hori-Komai Y, Toda I, Tsubota K. Laser in situ keratomileusis: association with increased width of palpebral fissure. Am J Ophthalmol 2001; 131:254–255
J CATARACT REFRACT SURG - VOL 38, NOVEMBER 2012