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Instrument cleaning protocols: working to avoid complications

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Refractive surgeon John F. Doane, MD, came up with an equipment cleaning protocol in an effort to battle bacteria and its implications on surgery. The cleaning procedure includes that at the end of the surgical day, the instruments are placed in distilled water with a small amount of soap. The instruments are scrubbed. Instruments such as cannulas should be flushed with distilled water followed by forced air from a syringe. Soap residue is removed. Instruments are dipped and soaked in a new bowl of distilled water or run under warm tap water. Instruments are sterilized using only the manufacturer-recommended specifications for water in the sterilizer and not exceeding the manufacturer’s bioload recommendations. Dr. Doane recommends that external motor surfaces of automated motorized keratomes be swabbed with isopropyl alcohol. Also, the 3 mm end of the motor/gearbox drive tip should be advanced and reversed while submerged in ethanol or acetone, if appropriate according to manufacturer specifications. Dr. Doane suggests through his protocol that if diffuse lamellar keratitis (DLK) is encountered, all surgical instruments and the autoclave need to be tested for endotoxin levels. If a large outbreak of DLK occurs, it is likely due to contamination of the reservoir or internal tubing of the autoclave with endotoxin-containing gram-negative bacteria in biofilm form that must be cleaned from the autoclave.

Eric J. Linebarger, MD’s, DLK protocol consists of an identification, staging and intervention approach. Stage 1 DLK is seen on postoperative day 1 with white granular cells in the periphery with sparing of the visual axis. Stage 2, seen on postoperative day 2 or day 3, shows white cells in the visual axis. According to Dr. Linebarger’s method, both stage 1 and stage 2 should be treated with intensive topical corticosteroids, which will most likely resolve by postoperative day 10. Stage 3 DLK involves an aggregation of cells clumped in the visual axis, and the patient experiences haze and reduced vision. This should be identified, followed by lifting of the flap and interface irrigation to prevent progression to stage 4. Stage 4 DLK involves stromal necrosis, melt, secondary hyperopia and irregular astigmatism. Proper identification and early intervention can prevent this more severe condition from occurring.

See related article, "What do we know about diffuse lamellar keratitis?"

For Your Information:

• John F. Doane, MD, can be reached at Discover Vision Centers, 4801 Cliff Ave., Ste. 100, Kansas City, MO 64055 U.S.A.; +(1) 816-478-1230; fax: +(1) 913-327-5807. Dr. Doane has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Eric J. Linebarger, MD, can be reached at Shiley Eye Center, University of California San Diego, La Jolla, CA 92093 U.S.A.; +(1) 858-534-6290; fax: +(1) 858-822-2872. Dr. Linebarger has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.