Infection rates raise vigilance level for ROP screening regimens

Single-use instruments are gaining ground for examining retinopathy of prematurity patients.

Pediatric ophthalmologists who screen premature infants for retinopathy of prematurity already face challenges when it comes to medical liability. They also face the increasingly daunting prospect of infection.

Adenovirus, methicillin-resistant Staphylococcus aureus, Pseudomonas and other organisms may aggravate respiratory disease and lead to death in some premature infants who have underdeveloped respiratory systems and are most vulnerable to infection.

The pediatric ophthalmologist’s armamentarium against infection includes standard sterilization techniques, safe instrument handling practices and disposable instrumentation, experts told Ocular Surgery News.

Robert W. Hered

In telephone interviews, pediatric ophthalmologists Robert S. Gold, MD, Robert W. Hered, MD, and Denise Hug, MD, discussed the importance of performing retinopathy of prematurity (ROP) exams with sterile instruments in neonatal intensive care units (NICUs).

“It’s very important for the pediatric ophthalmologists that screen ROP babies to be cognizant of the fact that all types of organisms and infections run rampant in NICUs,” Dr. Gold said.

Infection from unsterilized ROP exam tools is not a recent phenomenon, Dr. Hered said.

“It’s probably something that’s been going on all along, under the radar,” he said.

Dr. Hug said many pre-term infants are particularly vulnerable to infection.

“Any infection can be devastating to their health,” she said.

Shortcomings of sterilization practices

To underscore the concern about the sterility of ROP exam instruments, in 2005 Dr. Hered published the results of a survey showing that 36% of NICUs reported adhering to best practices, such as using separate sterile scleral depressors and eyelid specula for each ROP exam.

Also, re-use of non-sterilized instruments was more common in NICUs that did not supply instruments to ophthalmologists, Dr. Hered reported in the Journal of Pediatrics.

Many pediatric ophthalmologists visit NICUs to perform eye exams and may not be aware of infections that develop after they leave the NICU, he said.

“Usually, conjunctivitis in the nursery is not necessarily something that the ophthalmologist would be asked to handle,” Dr. Hered said.

Some recent practices also raise concern, such as flash sterilization, in which instruments are cleansed rapidly in an autoclave.

“There’s a growing concern that not all flash sterilization is a complete sterilization of the instruments,” he said, adding that the American Academy of Ophthalmology recently recommended that ophthalmologists avoid using the term flash sterilization when describing their cleansing technique.

“[The AAO said it feels] that it’s important to specifically state how the autoclave was used in order to document that it was used properly,” Dr. Hered said.

Existing guidelines from the Association for Professionals in Infection Control and Epidemiology (APIC) recommend the sterilization of instruments between patients.

“The APIC has recommendations for how instruments in contact with a mucus membrane such as the conjunctiva should be handled,” he said. “So we know that the recommendation is that a sterile instrument be used.”

Preferred practices

Autoclaving is the most common method of sterilization, the experts said.

Dr. Gold said his staff regularly sterilizes instruments in autoclaves and sometimes uses disposable instruments.

“I think it’s something that many of us may do, but if you’re not doing it, you should consider doing it,” he said.

Dr. Hug said her group practice has an adequate supply of instruments. They use the instruments only once in a day, and then they are sterilized.

“What we have are metal instruments that we re-use, but we only use them once, then they get washed and autoclaved, then re-packaged in a sterile manner,” she said. “The next week, we use those same instruments. Officially, they’re going through a wash and an autoclave.”

Moria recently began marketing the Moria ROP Examination Kit, a set of disposable instruments. Dr. Hered invented the kit, which includes a disposable eyelid speculum and scleral depressor.

A majority of survey respondents expressed a preference for disposable instruments over those that have to be sterilized between exams, according to Dr. Hered.

Dr. Hug lauded the kit but questioned its cost-effectiveness for practices with tight finances.

“I’m not sure in terms of cost-effectiveness, whether it will become a mainline method of examination or not, but I think it’s a great idea,” she said.

Delicate balance

Pediatric ophthalmologists must perform safe and timely ROP exams, Dr. Hered said.

“Sometimes a difference between 1 week and the next is a critical one as far as performing these examinations,” he said. “We certainly don’t want to recommend delaying examinations, but at the same time, we don’t want to look the other way when we know that examinations are being performed with instruments that aren’t sterile.”

Growing awareness of infection risk may bolster practitioners’ efforts to obtain adequate instrumentation from their institutions, Dr. Hered said.

“I think that as more ophthalmologists become aware of concerns over having sterile instruments, that they will perhaps be able to lobby their NICU to obtain more instruments, either re-usable instruments that are properly sterilized or obtain the single-use instruments, either as a backup when they’re running low on reusables or as their primary approach,” he said. – by Matt Hasson

Pre-term infants are particularly vulnerable to infection. Sterilized instruments should be used for ophthalmic examinations. Neonatal intensive care units should be aware of this need and be prepared. The numbers of infections caused by ophthalmic examinations in pre-term infants should be identified and compared before and after use of only sterilized instrumentation, preferably disposable.

– José G. Cunha-Vaz, MD, PhD
Editorial Board Member, OSN Europe/Asia-Pacific Edition

For more information:

• Faden H, Wynn RJ, Campagna L, Ryan RM. Outbreak of adenovirus type 30 in a neonatal intensive care unit. J Pediatr. 2005;146:523-527.
• Hered RW. Use of nonsterile instruments for examination for retinopathy of prematurity in the neonatal intensive care unit. J Pediatr. 2004;145:308-311.