OT Techniques-Expert interaction

1)

Sir, what material has been used for your OT

a. Walls (steel/power coated GI/ epoxy paint over the regular brick wall/tiles/any other specify? Dr. MK(NN): Walls Are Stainess Steel Dr. MSR(KN): 2 x 2 ft full body vitrified tiles from a good company, laid with 5 mm gaps, which is filled and levelled with Epoxy grout. Dr. GP(MMJEI): a. Ceramic tiles are used from floor to ceiling on all walls. Our OT was last done in 1995. Have not renovated. Dr. HMR(DEH): Vitrified tiles 1. Sir, what material has been used for your OT b. Floor vinyl/ epoxy/ vitrified tiles/any other specify Dr. MK(NN): Floor is epoxy Dr. MSR(KN): Same as those applied to the wall. All the borders and edges are coved, so that there are no acute angles, which collects dirt & grit. The ceiling is prepared and made dust free using Poly vinyl putty base and paint. Dr. GP(MMJEI): Floor is vinyl in 2 0f the 5 theatres and vitrified ceramic in the remaining.

Dr. MSR(KN): Believe this is the best, everlasting, rugged material, and being totally water proof, do not encourage growth of microbia. Do not shred fine particles over time, like marble and granite. Dr. HMR(DEH): Easy Maintenance and cleaning 2) What is your routine schedule of OT disinfection/sterilisation procedure? kindly elaborate How the roof/walls/floor/ OT air conditioning /laminar flow are disinfected? Dr. MK(NN): chemical disinfection is performed for all surfaces daily. The air supply in the institute is as per NABH standards and is a laminar flow system. The air handling unit is cleaned and maintained as well as the operation theatre. Dr. MSR(KN):Thorough cleaning, cleaning and cleaning! The ceiling walls and floor are cleaned periodically, frequency depends upon the load on OT. Floor and reachable walls 2 to 3 times a day, high walls once a week, and ceiling once a month in our OT. First cleaning is done with neutral detergent, followed by disinfectant, the brands of which are changed periodically. The AC, ducts, Laminar flow etc are opened once a month, and the filters and fan surfaces are cleaned with detergent followed by disinfectants. This is very elaborative and difficult and needs half a day! The AC technician will not do this!! Dr. GP(MMJEI): Formalin fumigation once a week at weekend and Bacillocid disinfection for interim disinfection. Only filters of the OT ACs are cleaned once a month.

Dr. HMR(DEH): Vitrified tiles

Why did you choose this particular material?? Dr. MK(NN): Easy to clean and maintain. The joint between the steel walls and the floor is not a sharp corner that may accumulate dirt Vol.29, No.2, Aug.

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Dr. HMR(DEH): Daily morning we wipe the floor with d e te rge nt s u s i n g t wo b u c ke t s method(water in one bucket and detergents in another bucket, dip the clean towel in detergents bucket and wipe the floor then clean the towel in water bucket rpt the procedure )we spray BASCILOLL 0.25% over the ot table, trollies , roofs and walls daily. We use the same wiping technique with detergents for the walls also twice in the week .

Dr. GP(MMJEI): I think there are different schools of thought on this. Scientifically seen contact disinfection is the best. Dr. HMR(DEH): We have also stopped fumigating the O T and mechanical cleaning, if done religiously there is absolutely no need for fumigation by formalin or by any other agent Expert comments(DR SK): Formalin should be stopped it does not provide any benefit in the way most people use it and using it in the proper concentration is not practical. Fogging is a means of uniform application of the reagent and should not be considered any more than that. The word fumigation is a misnomer and should be replaced by the term terminal disinfection instead. Fumigation DOES NOT sterilize OT (this is a big misconception many surgeons have!). 4) Various accreditation agencies are applying stricter norms for OT and now have laminar flow with a specified number of air exchanges for ophthalmic OT as a prerequisite for accreditation. a) Do you think that all of us should have these systems- obviously cost of installing and maintaining is huge- is there a way out? Dr. MK(NN): In this case quality and peace of mind come at a cost!

Expert comments (DR SK): Cleaning and disinfection should be done in the morning (before the start of the list, between cases, end of the list and a detailed washdown periodically. The protocols for each of these are different and can also vary from one OT to another. Roof and walls may be cleaned and disinfected 2-3 times a week or whenever soiled (daily cleaning is not necessary). Air conditioners cannot be disinfected. Air handling systems need to be maintained at least once a year with duct cleaning included. Putting formalin in the ducting is not useful.

3) Some of the ophthal OT now do not routinely perform formalin fumigation and have shifted to fogging / contact disinfection methods- any comments?

Dr. MSR(KN): Hope they will understand the mechanisms of Ophthal OT and change their stature! Dr. GP(MMJEI) : If accreditation agencies are enforcing it, it is good for us. The closer to ideal the better. Dr. HMR(DEH): The ORs should be well ventilated and air conditioned with a split air conditioner. I don't think you should compare ortho OT to ophthal OT, as air is never source of infection in ophthalmic cases, these expensive equipments are not necessary. Vol.29, No.2, Aug.

Dr. MK(NN): No formalin fumigation is performed in view of occupation health concerns. We do contact disinfection daily with lysoformin and fogging with the same chemical on weekends

Dr. MSR(KN): We neither perform Fumigation nor fogging. It is not needed, if you have good OT structure and functioning.

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Expert comments (DR SK): Laminar air flow systems are beneficial in theory but no direct benefit in reducing surgical site infection rates has been demonstrated even in the West. Studies are 50-50 on the matter (most are in orthopedic surgery). The way out is we need our own studies and a logical manner of approaching the problem. We don't even have basic infection statistics on which to base a raional conclusion!

Dr. MSR(KN): Cost is not huge! Actually it is lesser than many gadgets that we invest on. But is it not better to spend rather than facing the cost and agony of TASS & endophthalmitis? I don't think all these issues should be used as an excuse for being incomplete. A microbia is so tiny, and can get into the eye, even if there is a 35 G incision used for cataract tomorrow! I have seen an endophthalmitis in a child who presented from Mysore following a very trivial needle injury, the needle track was barely visible! Dr. GP(MMJEI): That calls for cleaning the microscope as well. We better do it for our own safety. I am sure general surgeons will be cleaning their shadow less lamps and other specialty micro surgeons will be cleaning their microscopes as well. Dr HMR(DEH): Yes, there is need to customise OT guidelines for ophthalmic needs. Expert comments (DR SK): I agree very strongly with you Sir. There is DEFINITLY a great need to customize the guidelines for ophthalmic surgery. Copying measures from other countries / hospitals can be dangerous. Each surgical specialty has it's unique features which need to be considered. This means some infection control measures may be shared in general but some will be unique. Add to this, each hospital will have different resources, so one protocol will never fit all. Thus, customization has to be done at various levels guideline development, actual protocol steps and at implementation in the individual set up. Unfortunately, accreditation agencies in India have not carried out a detailed study of the indian hospitals before deciding the measures - the risk here is some measures may actually increase the risk of infection in theory at least (the unsterile microscope for example).

4b) Sometimes i (editor) personally feel that various norms for other surgical specialities theatres are just picked and incorporated into these accreditation guidelines without proper clinical evidence for ophthalmology in particular? Do you agree with it? For example our incisions are closed/ self sealing micro-incisions even during surgery compared to the exposure in a general surgery OT. Also there is a relatively unsterile microscope in between the proposed laminar flow air above the patient table and the operating area(eye) -will the air under positive pressure from the laminar flow carry unsterile particles when moving over the microscope??. Do you think there is need to customise the OT guidelines for ophthalmic needs? Dr. MK(NN): Surgical site infection in cases with implant is one year from the date of surgery while for surgeries without implants it is only 3 months. OT guidelines are based on the presence or absence of implants. So the stringent guidelines for ophthalmic theatres are in keeping with the fact that nearly all cataract surgeries that account for majority of ophthalmic surgeries have an intraocular lens implant. It is true that the microscope and other fittings in the OT cannot be sterilized. But the microscope and other fittings need to be disinfected like all other surfaces in the ot. Monitoring the effectiveness of this disinfection process is critical to minimizing surgical site infections. Vol.29, No.2, Aug.

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5) Do you see a role for some of the air purifiers installed inside the OT? Dr. MK(NN): If the ot is a laminar flow system the air purifier inside may create turbulence and also add to the particle count creating confusion about the hepa (high efficiency particle arrester) filter efficiency. However, air purifiers may have a role if the surgeries are being conducted in rooms with window or split air-conditoners. Dr. MSR(KN): HEPA filters (FFU) can be retrofitted in any OT, and I personally feel they are essential. Dr. GP(MMJEI): Yes, the 5 stage filters are quite convincing Dr. HMR(DEH): No. I have air purifier in my OT. Sometimes back it was not working for 6 months did not make any difference in our cases. It is more of psychological advantage to surgeons.

Expert comments (DR SK): Yes air purifiers do have a role to play in keeping the bioburden to low levels. How low will vary from OT to OT as it depends on multiple factors.

What are the various steps one need to follow when commissioning a new OTa. kindly elaborate on the various cultures we need to send b. How do you take the culture swab to avoid contamination? Which material is used to transport / do you do direct plating on culture media? c. How often would repeat the cultures from a regular running OT

6)

Dr. MK(NN): in an OT with laminar flow the air quality is the most important. A remote controlled air sampler is used. It is placed in the OT with the laminar flow system on and then air sampling is activated from outside with the remote control after 20 minutes to allow for the air changes to remove any comtamination brought in by the technician. This prevents false positives. In centers without a remote activated air sampler a settle plate method may be used. Surface swabs need to be taken from the microscope, instrument trays walls and floor after thorough contact disinfection. All cultures are taken using sterile precautions and direct plating is preferred to the use of transpost media as far as possible When comissioning a new OT complex, thorough contact disinfection is performed for 3 consecutive days. Then air and surface cultures are performed followed by disinfection on another 3 consecutive days. When the cultures are negative on all 3 days after at least 48 hours incubation the OT may be comissioned. If negative: Microbiological surveillance of air quality in a running ot with laminar flow are recommended monthly (there are no guidelines for surface cultures; we are performing those also monthly) Daily log of the physical properties of air cludes temperature, relative humidity and positive pressure inside the ot. Quarlerly air quality surveillance includes testing hepa filter integrity by particle count, bypass leakage by dop testing, filter efficiency by air velocity and calculated air changes per hour.

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Dr. MSR(KN): At Karthik Netralaya, once in 3 months we use Blood, Chocoloate & Saboraouds agars. 6 To 8 pies are made on the glass bottom, they are numbered, and on each agar pie, I directly inoculate after a weekly cleaning protocol. One other plate is kept open on the head end of OT table for one hour, with AC & HEPA filter on, and microscope in position to catch the air particles that settle down. Sterile swab sticks are dipped in distilled water, and than swabbed on the surface. They are sent for incubation immediately. Dr. GP(MMJEI): No experience No comments. But cleanliness more important than disinfection Dr. HMR(DEH): Clean the OT thoroughly both floor and walls. Fumigate and close for 24 hrs. Send cultures for aerobics organisms # O T Table # Walls # Floor # AC # Microscope Non aerobic and fungus. I don't think it is necessary I use direct plating on culture media. Once in six months. Expert comments (DR SK): Are OT swabs really reliable? They are not even a representative sample. This issue needs to be discussed in detail with all the pros and cons. I find that too much reliance is placed on these samples by most persons. Interpretations of the results is also not done correctly many times.

Dr. MK(NN): We use only disposable phaco tubings. If reusable tubings are being used then it is best to use a class b autoclave that will evacuate all the non condensible gasses before the steam charge allowing the steam to penetrate into the full length of the tubings and sterilize the inside of the tube. The actual time, temperature and pressure required for this needs to be confirmed for each autoclave and tubeing length and bore combination by the helix test. Dr. Deepak megur had presented an excellent paper in AIOS a couple of years ago on this topic. Dr. MSR(KN): B class autoclaves are the best, as they have vacuum cycles. Standard autoclaving is better than flash autoclave. Change your autoclave & insist on B class, & Indian models are extremely good, and very affordable. Table tops are again not very expensive, and best is to buy the imported ones. I don't know if good Indian made is available. DR GP(MMJEI): We use reusable phaco tubings. Full long cycle autoclaving is better than flash autoclave ideally speaking. Dr. HMR(DEH): Yes we do use reusable phaco tubing, class B autoclave is best for the phaco tubing because of vacuum cycle. Prime the tubing with distilled water for three times and then with the air for two times immediately after the surgery. Expert comments (DR SK): An autoclave with a pre-vacuum cycle should be used. 8) During steam autoclave which water do you use eg. RO/distilled/routine uv filtered water?

7) Do you use reusable phaco- tubings? If yes which type of autoclave is best for these kinds of phaco tubings and why is it important? What are the cleaning protocols that you follow and any important tips regarding the same?

Dr. MK(NN): Reverse osmosis water and if not available distilled water. UV filtered water cannot be used

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Dr. MSR(KN):

RO or acid base ion filter or commercially available distilled water. Check if the dissolved salt turbidity is less than 100. The water does not have to be sterile! Aquaguard does not remove the TDS (total dissolved solids) from water, and so is useless. Corporation water in Bangalore has a TDS of 200 to 300 and bore wells 600 to 1000. TDS can be measured by small thermometer like gadgets.

DR GP(MMJEI): Yes horizontal autoclaves with vacuum before and after the sterilisation cycle are better. It is a long time since we used vertical autoclaves at a time when our work load was a quarter of the present. Some modifications are however possible with the vertical autoclave to drive out the air initially.

Dr. GP(MMJEI): RO water. Dr. HMR(DEH): Distilled water Expert comments (DR SK): RO/ Distilled Water follow manufacture recondition 9) Regarding autoclaves it is said that horizontal autoclaves are better than vertical? Have you found that this claim is validated by your experience over the years? Meaning was there an increased risk of infection that you noticed when using a vertical autoclave? DR MK(NN): a class b autoclave or fractionated autoclave uses vacuum to remove the non condensible gasses followed by a steam charge. Usually this is repeated 23 times and then the actual autclaving process happens. Gravity feed autoclaves are unable to vent the air and noncondensible gasses in the autoclave prior to the autoclave cycle and so there is a risk of incomplete sterilization. As incidence of endophthalmitis is itself so low and so multifactorial to prove increased rates would be difficult but in the war against microbes it is best to reduce the confounders to the maximum extent possible. DR MSR(KN): Horizontal with pre vacuum and post dry cycles, and repeated purging once the pressure and temperature have reached the desirable is a must, as we do use tubings. Inside of tubings can only be sterilised with this. Not all horizontal autoclaves have vacuum facility!

Dr HMR(DEH): I have two autoclaves, one class ' B' used for phaco tubings and instruments, vertical autoclave for linens. I agree horizontal autoclave is better, thinking of buying it in near future replace my vertical autoclave.

Expert comments (DR SK): Horizontal / vertical has nothing to do with efficacy of the machine. Pre-vacuum autoclaves should be used. Infection has multiple reasons so, without randomized controlled trials, it will be impossible to decide whether infections in a particular situation were due to faulty sterilization alone. Hospital infection is more like algebra with the value of the factors changing in every patient. This is in contrast to what we learn as clinicians that one pathology causes a pattern of signs and symptoms. Perhaps this is why we often try to find just ONE cause for an infected case. In reality, it it is often multiple factors acting together

10) Buying a correct autoclave is the most important decision. We spend huge money on various other equipments in the OT and one tends to compromise in other areas.......... Various companies make their own claims.... How to choose the right autoclave for ophthalmic practice? How to make a well informed choice and what specification one needs to ask the dealers so that we are not taken for a ride.... Vol.29, No.2, Aug.

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Dr. MK(NN):A class b autoclave is preferred. The capacity of the chamber depends on the daily number of surgeries and the size of theinstrument pack. Surveillance measures to validate the proper functioning include a daily bowie dick test to ensure complete evacuation of non condensible gasses and quarterly microbiological validation.

Dr.MK(NN): The most common cycle is a wrapped instrument cycle. Initial 3cycles of vacuum / steam charges are responsible for the removal of the non condensible gasses followed by 134 degrees for 7 minutes holding time followed by drying time as per recommendation. DR MSR(KN): After desired temperature and pressure is reached, do 3 purges, and than start the cycle of 30 minutes for 20 lb cycle. A nano solenoid controlled can do all these, and you don't have to waste your time!. Ask if they have this facility. Repeat Bowie Dick test periodically. Have a cycle recording facility, which will give graphic illustration of the entire cycle. Dr HMR(DEH): Class B autoclave first vacuum, sterilisation, dry then exhaust. in vertical autoclave when pressure is reached the sterilisation condition release the steam for three times so that the air in the chamber is gone th ,when it reaches 4 time then note the timing and keep it for 30 min (121') after 30 min switch off the autoclave

Dr. MSR(KN): Buy an autoclave that has both 20 & 30 PSI capability. 30 PSI one is built sturdy, even if you don't use the 30 Lbs! 20 lb cycle is better than 30 lbs.

Dr. GP(MMJEI): Temperature, Pressure, vacuum , drying and availability of automatic option, Power consumption and capacity are the features to be looked for.

Dr HMR(DEH):

I totally agree with this, we spend lakhs together to buy a B Scan which is used twice a week, but the most important equipment autoclave is often neglected. The reason Probably is you can not show to patients. One episode of cluster of endophthalmitis made me to buy class B Autoclave next day.

Expert comments(DR SK): Full cycle for daily sterilization. Flash for dropped instrument only.

Expert comments (DR SK): Get a pre-vacuum machine, Check the parameters of variousl sterilization cycles. Calculate the daily load of sterilization to decide capacity (include future developments also). Consider heat compatibility of the items you will be autoclaving are there any items which are recommended to be autoclaved at 121 and not at 132 deg C?

12)What are the various tests that you routinely apply in every day OT practice to check the completeness of the autoclave procedure? Meaning how to you know that your autoclaving is effective and safe?

11) Can you kindly elaborate on the autoclave cycles that you use commonly? Vol.29, No.2, Aug.

Dr. MK(NN): surveillance for the effectiveness of a cycle is monitored by the print out given by the machine which documents each step of the autoclaving process. Further indicators with each load show a colour change for time, temperature, pressure and removal of non condensible gasses.

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DR MSR(KN): The duty cycle recorder is very useful. Every pack has a temperature indicator tape in its depth. Once in 3 months, we do Bowie Dick test or the test strip that confirms temperature, pressure and duration. The tapes should turn JET BLACK and not just or even deep gray!! Avoid surgical bins totally. Use packs directly loaded into autoclave. Dr. GP(MMJEI): Signaloc tape and biological indicator Dr HMR(DEH): We use class 5 steam indicator (every instruments bin) for every cycle of autoclave if the indicator does not change, we rpt the whole procedure.

Dr. HMR(DEH):

Immediately after surgery dip the instruments in savlon 2% solution and gently clean with the toothbrush all the joints hinged areas then wash with water wipe them thoroughly send for sterilisation

Expert comments (DR SK): Ultrasonic cleaners. May be combined with enzymatic cleaner solutions. Keep wet until taken for cleaning.

14)What is your routine pre-operative/per-operative preparation before surgery with special focus on preventing infection/ endophthalmitis? Which do you think is the most important step and how you ensure the same in your day to day busy practice?

Expert comments (DR SK): Autoclaving should be monitored by physical, chemical and biological monitors. It is a blind process and sterilization is not an absolute but a PROBABILITY even when the process is done correctly!

13) How do you clean your delicate instruments? Do you use any cleaning agent/ special solution/ ultrasonic cleaners? DR MK(NN):We currently use ultrasonic cleaners DR MSR(KN): Clean them as soon as the surgery is over! Don't allow the debris to harden on the surface. Ultrasound is a must for every instrument after every surgery, followed by soft toothbrush cleaning under running water. Detergents and multenzymes when used, should be thoroughly cleaned to avoid TASS.

Dr. MK(NN): Prevention of surgical site infection (endophthalmitis) is a 6 pronged strategy. patient factors surgeon factors consumables sterilization techniques for reusables enviornmental factors access control There is unfortunately no single most important step that may save the day if other factors are ignored.

Dr. MSR(KN): 24 hours antibiotic drops. Put Povidone iodine as soon as the patient comes. Scrub the skin around the eye with Povidone Iodine 5%. Irrigate conjunctival sac with 0.5% povidone iodine. METICULOUS draping technique is a MUST. Dr. GP(MMJEI): slit lamp exam, ROPLAS test, Face scrub, Removing facial ornaments, Clean shave, betadine 2% in the conjunctival sac, sterile disposable adhesive drape

Dr. GP(MMJEI): Enzyme liquid / Tooth brush and ultrasonic cleaner

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Dr HMR(DEH): Ask the male patients to shave beard and for the female patients ask to comb neatly, remove nose ornaments. Wash the face twice before coming to O T. Paint the area around the eye with iodine 5% before giving block and one drop of microdine eye drop before surgery, start the antibiotic eye drop 1 day before surgery.

16) Once in a while in spite of all precautions we do encounter an unfortunate event of endophthalmitis...... more often than not we try to look at patient factors to fix responsibility than introspecting!!! Do you have a protocol to investigate an endophthalmitis outbreak to go to the root cause problem so that corrective and preventive action can be taken? a) b) How do you investigate a single case of endopthalmitis occurrence? How do you investigate multi-case outbreak of endophthamitis?

15) Irrigating fluids are the most common source of infection in ophthalmic practice. Do you have any preference for the same and do you re-autoclave them? If yes how kindly elaborate.

Dr. MK(NN): Autoclaving irrigating fluids in glass bottles only sterilizes the outside surface of the bottle. My preference is to use consumables from a reputed company and to keep track of all the batch numbers so that at the first sign of trouble we can track people at risk.

Dr. MK(NN): One never knows whether a case of endophthalmitis is a single one related to patient factors or whether it is the first of a cluster related to a systems breakdown. Documentation is essential to investigate a cluster infection. The 6 point strategy for prevention also incorporates an ability to track and trace commonalities between cases and arrive at statistical probability of a root cause. Sporadic outbreak is said to be due to patient factors, although you really cannot rule out OT issues. Investigate them as cluser outbreaks. Dr. MSR(KN): You should become a very critical investigator, and think that the OT belongs to an another hospital! There are really thousands of ways by which the germ can enter an eye during surgery! Most of the time, it is unsterile fluid, instrument or technique. Dr. GP(MMJEI): Check patient records for risk factors, Check the surgical team for any changes, Check surgical time, Check for any new brand of consumables used, Retrospect on any out of routine happenings in the OT including discipline lapse. In case of multicase outbreak Check Autoclave, Fluids used, Other consumables used.

Dr. MSR(KN): I always use BSS from a reputed company. No reautoclaving!

Dr. GP(MMJEI): No preference and no autoclaving. Only be cautious while changing brands.

Dr HMR(DEH): We use balanced salt solution 500ml, there is no need to autoclave

Expert comments (DR SK): These can be autoclaved. But how many infections are prevented by this? I really doubt how much it helps. On the other hand it may give a false feeling of security! If there is gram negative contamination, risk of TASS may be increased after autoclaving.

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Dr HMR(DEH): a) It t is single case try to find a cause in patient. b) If it is multiple, I often try to look for the cause OT send culture of Visco, Irrigating solutions, blue. c) Repeat OT culture as routine. d) I had one episode of cluster endophthalmitis the source was traced to ringer lactate. Expert comments (DR SK): In an outbreak (large number of cases), there can be one or two major lapses that may be identifed and changed. In a sporadic series, there is rarely one single cause but multiple factors acting together. So trying to identify one root cause will not work. In both cases, a thourough review of the case and the infection control measures being followed should be done.

margins exposed to the surgical fields is another big cause. Reuse of phaco probes and tubings, is the biggest bugbear, and even many a teaching institutions do it. There is no reason why the entire phaco handlipce sets are not autoclaved, for each case. When you buy the Phacomachine, bundle 3 handpieces, and use all of them in rotation after proper autoclaving.

Dr. GP(MMJEI): Make a check list and follow it religiously. Dr. HMR(DEH): All instruments for surgery should be sterile. Single-use is even more robust, as there have been occasions recently when instruments have not been washed properly prior to sterilising which itself may have been faulty. Care is required with both washing the instruments and autoclaving them, as the latter is Neither absolute nor an exact science! Both matters should be investigated if there is an ongoing 'epidemic' of postoperative endophthalmitis with different types of skin bacteria viz. coagulase-negative staphylococci within a surgical unit for no obvious reason. Single-use of tubing and other equipment that becomes wet within the operative procedure is always preferable, if cost allows. Tubing is not easy to effectively sterilise unless an ethylene oxide gas steriliser is available. Bottles of solution containing BSS (balanced salt solution) etc. should never be kept or used for more than one operating session. Any air vent applied to these bottles should be protected by a bacterial filter. Wet areas are easily contaminated with Pseudomonas aeruginosa, which can then cause devastating endophthalmitis. Vol.29, No.2, Aug.

17)

Do you have any personal experience /innovative techniques / things that are commonly neglected but are important regarding OT sterilisation? Kindly share them so that it would benefit the ophthalmic community

Dr. MK(NN): most surgeons do not have a correct technique of scrubbing. The iodine in the povidone iodine (betadine) scrub is in the form of an iodophore and needs adequate contact time for release of the free iodine that is responsible for the bactericidal action. This is facilitated by mositening and constant lathering for a 5 minute contact time. The use of a scrubbing brush with bristles is unnecessary and probably harmful. Dr. MSR(KN): I have seen repeatedly that the injection of Adrenaline or antibiotic into BSS is done vary callously in an OT. Many times the ampoule will have a glass piece inside, which obviously is contaminated! The eye lashes and lid

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Expert comments(DR SK): Wrong reagent, wrong reagent concentration, wrong application method, excessive use, malfuntioning equipment, inadequate time for the reagent to act, using exhaust fan after formalin fumigation, leaving door open after formalin use, applying reagent without cleaning the OT first, relying too much on OT swabs are some of the mistakes I have seen across many OTs. There is no one single mistake done by everybody but there a highly variable pattern of mistakes by everybody. My answers will be quite different from those of other I guess. All the questions do not have a clear answer. I hope the replies are satisfactory and stimulate a deeper enquiry. Regarding accreditation issue, I really hope that all surgeons wake up and come together as soon as possible to get the infection control measures rationalized. Otherwise they may end up having American type OTs with Indian patients and budgets! I wonder how long they will be able to maintain that! And once the system fails, infections will be more than what they are today and the surgeons will be taking the blame again.

Megur Eye Care Centre and Drushti foundation

Bidar, Karnataka
Invites application for posts for consultants (post MS / DNB/DOMS) in comprehensive ophthalmology and various sub-specialties in ophthalmology. Interested candidates kindly apply with academic details and CV. Remuneration commensurate with experience and qualification. Megur Eye Care Centre and Drushti Foundation Bidar also announces a 1 year long term Fellowship programs in Comprehensive ophthalmology, Glaucoma and Phacoemulsification . Interested candidates can apply with their complete CV . Contact : by email to Dr Deepak Megur dmegur@yahoo,com , 09446457242.

Megur Eye Care Centre

Behind Akkamahadevi College Bidar 585401. Karnataka.

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