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Quick procedure tests integrity of cataract surgery wounds
The povidone-iodine test outlines aqueous leakage while it sterilizes the surface of the eye.
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Recently I visited a colleague, and I noted that he consistently was unsure about the integrity of his wounds. As he hydrated and rehydrated the wounds, he commented that this is more critical with toric IOL and Bausch + Lomb Crystalens placement.
Steven B. Siepser
For many years, I have been using Betadine 5% (povidone-iodine, Alcon) at the end of each case not only to sterilize the surface of the eye but also as a disclosing dye to demonstrate any wound leaks. I thought it was common practice, but this incident told me otherwise.
Furthermore, in the quest to check out new technology for laser-assisted cataract surgery, which we are well into, my colleagues and I observed femtosecond laser procedures. Accompanying us was a senior surgical sales consultant. He mentioned that he had never seen this Betadine maneuver and wondered if anyone knew of it. Assuming it was common knowledge, I never wrote about it. This effective technique replaces the extra step of a Seidel test.
Quick, effective test
The procedure is simple and straightforward. It is easily performed, and the findings are precise. Once everything is “sealed up” near the end of the case, the globe is inflated to a normal pressure. A finger tension ballottement is used to make sure the globe is firm. The nurse then administers several drops of Betadine 5% over the wounds. If there is leaking aqueous, it is obvious. The Betadine discloses the clear flow from the eye, outlining leaking aqueous. This quick test allows for assurance of wound integrity and a watertight closure before the patient leaves the OR. The side benefit is that Betadine applied at the end of a surgical procedure sterilizes the surface of the eye. More sensitive patients might mention a burning sensation, and some tetracaine is added just before placing the Betadine. At the end of the case, it is important to fully flush out all traces of the Betadine to limit discomfort and avoid any secondary inflammation or corneal changes.
Aqueous leak delineated by Sieps Betadine test.
Hydrogel ocular sealant and tested corneal wound..
Source: Siepser SB
Betadine acts as a riverbank for the outflow of aqueous, outlining the speed, location and quantity of the leak.
A more accurate determination of wound integrity is needed. The literature is replete with examples of complications and endophthalmitis as a result of wound leaks, with one study showing the incidence of contamination is 44 times more frequent. In more recent studies, wound leaks have been reported to occur up to 85% of the time.
My personal observation for this effect is simple. If you have ever used a bulb air syringe for a camera lens to blow off dust, then you know that if you push on the bulb syringe to blow out air, when you let it go, it sucks in fresh air. This is what happens with a leaky clear corneal incision: If fluid is coming out at some point, most likely after a blink, the eye wound sucks in fluid from the eye surface, leading to intraocular contamination. Sealing leaking ocular incisions is critical to decreasing the incidence of endophthalmitis.
Name of test
The “Sieps test” name is derived from my college nickname, Sieps. I have always had to spell my name and people constantly mispronounce it, so I got into the habit of saying, “Siepser, it rhymes with leaks sir.” My college friends shortened this to Sieps and ran with it. This has stuck with me, and those who know me well still refer to me as “Sieps.” The double meaning here works well, and my moniker defines the problem.
The Betadine Sieps test can assure a surgeon that he has a watertight wound while he is sterilizing the ocular surface at the end of a surgical case. In addition, it avoids further complications from the ingress of fluids and debris on the ocular surface. This is especially important with new wound closure adhesives. A surgeon can now leave the operative arena knowing that the incision site is closed and watertight, reducing the chance of low eye pressure, lens rotation, lens dislocation or endophthalmitis.
See video of this technique at http://video.healio.com/video/Sieps-test-ensures-proper-wound;Ophthalmology.
References:
Mifflin MD, et al. J Cataract Refract Surg. 2012;doi:10.1016/j.jcrs.2012.04.019.Wallin T, et al. J Cataract Refract Surg. 2005;doi:10.1016/j.jcrs.2004.10.057.
For more information:
Steven B. Siepser, MD, FACS, can be reached at Siepser Laser Eyecare, 860 E. Swedesford Road, Wayne, PA 19087; 610-265-1637; email: ssiepser@siepservision.com.Disclosure: Siepser receives minimal royalties for the instrumentation made by Escalon Trek and Moria.