Abstract
Aim
To describe a surgical technique suitable for cataract surgery in regions with a high prevalence of HIV infection.
Methods
We reviewed the medical records of 20 consecutive AIDS patients with cataract who underwent modified small-incision cataract surgery (mSICS) with posterior chamber lens implantation. Classic extracapsular cataract extraction (ECCE) was compared to mSICS. The number of potentially risky steps for contamination during surgery and duration of surgery were analyzed. A risky step was defined as any time when the surgeon had to use a sharp instrument. Student's paired
Results
Twenty patients were included in the study, 13 males (65%) and seven females (35%). The mean age was 46.3 ± 13.6 years (range 22–70 years). The number of potentially risky steps for contamination was significantly higher in the classical ECCE than in mSICS (
Conclusion
Conversion to mSICS is essential in order to reduce accidental injuries during cataract surgery in sub-Saharan countries. Sharp instruments should be passed through a neutral zone to ensure that the surgeon and nurse do not touch the same instrument at the same time.
Introduction
Cataract is the leading cause of blindness worldwide. 1 Surgery is the only solution to restore sight to cataract patients. In sub-Saharan countries, healthcare workers, especially surgeons, are at particular risk of acquiring HIV through needle pricks or cuts from other sharp instruments during operative procedures. Hospital-based studies revealed an HIV prevalence of 3% among patients presenting for ocular surgery at ESUT Teaching Hospital Enugu in Nigeria. 2 In Cameroon, Wilhelm et al obtained a positive HIV test result in 29 (5.5%) of the 525 patients who were scheduled for cataract surgery. 3 In the majority of cases, the seropositive status of the HIV positive patients was unsuspected.
Rahmati et al reported that the total incidence of exposures was 66.3% of healthcare workers per year, and the highest percentage of percutaneous injuries occurred during surgical operations (22.8%). 4 To reduce this risk, it is essential for ophthalmologists in these areas to modify their technique in order to reduce accidental percutaneous injuries during cataract surgery. The objective of this study was to describe the modified small-incision cataract surgery (mSICS) technique in HIV patients.
Material and Methods
Patients
In this retrospective study, we reviewed operation protocols of 20 patients with AIDS and cataract who underwent mSICS at the Yaoundé University Teaching Hospital (YUTH) between January 2008 and December 2012. Written informed consent was obtained from all the patients. The research was exempted from the requirement for ethics committee approval because it was a retrospective study of anonymized medical records. The parameters analyzed included the number of sharp instruments used, the number of times that each sharp instrument was touched by the surgeon, and the duration of the procedure. Risky steps (Fig. 1) were defined as any time when the surgeon had to use a sharp instrument. Regarding these parameters, classical extracapsular cataract excision (ECCE) was compared to mSICS. The surgical steps of both techniques are summarized in Table 1.
Risky steps by mSICS: (
Surgical steps of the classical ECCE and mSICs and the instruments used.
Statistical Analysis
Data were entered and analyzed using IBM-SPSS version 20 (IBM Corp.). Qualitative variables were presented as percentages (%), while continuous variables were presented as mean ± standard deviation. Student's paired
Results
During a single cataract surgery using the ECCE technique, at least six different sharp instruments are needed (4.0 suture, 9.0 suture, scissors, needle 25G, blade, and cystotoma), and the surgeon touched them at least 20 times. With mSICS, only three sharp instruments (scissors, needle 25G, and keratome) are needed, and they were touched as few as three times (one time each,
Discussion
Cataract surgery is the most frequently performed surgery in the world. Ophthalmic surgeons in developing countries using ECCE run a higher risk of contracting a blood-borne infection because of frequent handling of sharp instruments and objects during operative procedures. Some methods have been proposed for reducing injuries during surgery, such as double-glove wearing during surgery and hands-free technique.5,6 In this technique, instruments are indirectly transferred between surgeons and other personnel through the neutral zone within the surgical field or a container. Recently, Rahmati et al reported the effectiveness of using a magnetic needle in reducing the risk of sharp injuries in the operating room. 4 This device has magnetic properties that attract the sharp pointed articles during surgery and preserve them in a protected space. In ECCE, six sharp instruments are used. The surgeon touches and changes them at least 20 times during a single procedure. In mSICS, only three sharp instruments (conjunctiva scissors, keratome, and 25G needle for subconjunctival depot) are needed. Each of them is used only once. With mSICS, a single use of the keratome replaces five sharp instruments used in ECCE for scleral incision, entry to anterior chamber, scleral incision enlargement, and anterior capsulotomy. The most frequently used sharp instrument in ECCE is the suture needle (seven times). Lopez et al reported that the suture needle was the cause in 91% of intraoperative sharp injury cases in their series. 7 Zhang et al also found that the suture needle was the most common cause of percutaneous injuries among healthcare workers in a general hospital in China. 5 In the study by Mingoli et al, sharp needles were responsible for all injuries. 8 They also proved that blunt needles reduce sharp injuries and improve safety for surgeons. In the mSICS technique, a sharp needle is used only once while injecting the subconjunctival medication at the end of the procedure. The mSICS presented in this study differs from the classical ECCE and SICS, as concerns the number of sharp instruments used and the duration of the procedure. However, the clinical outcome is similar. The National Institute for Occupational Safety and Health at the Centers for Disease Control and Prevention has recommended that healthcare workers avoid the use of needles where safe and effective alternatives are available. 9
Conclusion
Awareness of the risks and factors associated with injuries during cataract surgery and adoption of safer intraoperative measures are important strategies for preventing potentially serious and life-threatening accidents. It is, therefore, imperative for ophthalmologists in the sub-Saharan region to convert to mSICS.
Author Contributions
This work was carried out in collaboration between all authors. Designed the study and wrote the protocol: KG, PW. Analyzed the data and wrote the first draft of the manuscript: KG, EMC, GN-T, CD. Contributed to the writing of the manuscript and were responsible for manuscript results and conclusions: KG, CD, EMC. All the authors reviewed and approved the final manuscript.
Footnotes
Acknowledgement
The authors sincerely thank theater staff members of the Yaoundé University Teaching Hospital, in particular Fred Tila for technical assistance during operation.