September 2009




Among the best rates

by Matt Young EyeWorld Contributing Editor

Example of endophthalmitis; the Boozman-Hof Center proves that attention to detail that can dramatically reduce infection rates Source: Daljit Singh, M.D.

The average rate of endophthalmitis for any given ophthalmic surgical center may affect one in hundreds, or even thousands, of cases. Although the incidence generally is low, usually it isn’t as low as one in every 10,000 cataract cases. It is at the Boozman-Hof Eye Surgery and Laser Center, Rogers, Ark. In fact, the rate is even lower than that. In more than 23,000 cases of cataract surgery, only one case of late-onset endophthalmitis has surfaced. “I’m not going to claim we have the best rate there ever was,” said Randall E. Cole, M.D., medical director of the center. Dr. Cole doesn’t have to. The numbers speak for themselves. September 2004 marked the first time EyeWorld published an article about Dr. Cole’s astonishing success with eradicating endophthalmitis. At that time, the clinic had no incidence of endophthalmitis in more than 15,000 cases. One case has surfaced since then, and even that taught Dr. Cole a lesson in humility. “What this points to is that you can do things according to your [prophylaxis] system and still have to be a little lucky,” Dr. Cole said. “There are factors outside of your control.”

In this case, the insulin-dependant diabetic patient’s blood sugar went wildly out of control after surgery, he did not wear an eye shield at night, and he “rubbed his eye after petting a wild ferrell cat,” Dr. Cole said. Dr. Cole isn’t making excuses, but his clinic’s outstanding endophthalmitis record is a beacon of light for other clinics worldwide that may occasionally struggle to get their infection rates under control. That isn’t to say other physicians won’t take issue with some of Boozman-Hof’s methods of prophylaxis. They are intense, and ophthalmologists can judge for themselves whether they are warranted in their own centers.

The prophylaxis regimen

Prophylaxis at Boozman-Hof begins with taking a good patient history. Clinicians take note of untreated ocular infections and whether blood sugars are running high, and have those issues corrected first before cataract surgery. Also, patients are instructed to wash their faces with antibacterial soap for three days prior to surgery. Then at 3 p.m., 5 p.m., and 7 p.m. on the night before surgery, patients shower with antibacterial soap. “This sounds basic but it’s so important,” Dr. Cole said. “We are creating as many barriers as we can and making those as high as possible.” The pre-op medicinal regimen begins with the use of Zymar (Allergan, Irvine, Calif.) or Vigamox (Alcon, Fort Worth, Texas) four times a day, three days before surgery. “Many surgeons use antibiotic drops just an hour before surgery, citing fairly good anterior chamber aqueous concentrations,” Dr. Cole said. “But the objective is not to get a high anterior chamber aqueous concentration. It is to kill bacterial flora around the eye. It’s a critical feature then to use antibiotics three days before surgery to kill off flora around the eye.” On the day of surgery, Dr. Cole applies 2.5% povidone iodine to the eye in the pre-op area. Patients are then prepped with a 10% povidone iodine swab stick. Povidone iodine is allowed to collect around the lid margins and on the eye. Lid margins are then draped, and patients are also provided with a full body and head drape. Clinicians add 10 mg of vancomycin (Vancocin, Eli Lilly, Indianapolis) and 4 mg of gentamicin (Garamycin, Schering-Plough, Kenilworth, N.J.) to the infusion bottle. “Vancomycin is key because the vast majority of [endophthalmitis-causing] organisms are Staphylococci,” Dr. Cole said. “There’s simply not anything better.” Gentamicin, meanwhile, kills off gram-positive organisms very well, he said. Using these agents, dilution errors leading to toxicity can be avoided; these might otherwise occur with use of agents like intracameral cefuroxime, which has become widely embraced in Europe for the reduction of endophthalmitis. Irrigating solution and tubing are changed after each patient. After surgery, fourth-generation fluoroquinolones are once again administered four times a day for the first week and twice a day for the second week, along with steroids and non-steroidal anti-inflammatory agents.

Dr. Cole doesn’t believe usage of these antibiotics would cause resistance to emerge in his patients at a later date. The ophthalmic usage of vancomycin, for example, is “infinitely small” compared to the usage of the drug in general medicine.

Management issues

Dr. Cole urged EyeWorld to speak with Boozman-Hof ambulatory surgery center (ASC) director Donna Acord, R.N., because Dr. Cole said management and staff are critical to achieving a low endophthalmitis rate.

“It begins with the receptionist at the front desk,” Ms. Acord said. “Patients are asked to bring an eye kit with them. The receptionist will inquire, ‘What drops do you use?’”

That’s only the beginning. Pre-op drop usage is further investigated by registered nurses. Patients are asked not only whether they filled their drop prescriptions, but how exactly the drops were used.

“Eighty-two percent of infections come from the patient’s own flora,” Ms. Acord said. “It behooves us to reduce the bacterial load prior to the procedure.” Sometimes patients are intimidated, even insulted. “But when you explain to them why you are being so thorough, they are much more understanding,” Ms. Acord said. “Excessiveness works.” Maintenance and facility temperature are thoroughly scrutinized. The temperature of the ASC, for example, is kept the same every night, whether the clinic will be in operation the next day or not. “It’s a place that I am perfectly comfortable bringing family members [for surgery],” Ms. Acord said. “I wouldn’t eat off the floor, but I would bring family members.” Steven Vold, M.D., also practices at Boozman-Hof and was even impressed before he took the job two years ago. After eight years in academic medicine and two years in private practice elsewhere, Dr. Vold was looking for a center that had high-quality care. “They had an incredible record on endophthalmitis,” Dr. Vold said. He thought, at the time, that the center was probably not counting all its cases of endophthalmitis. “You just assume it is the norm to have infections here and there,” Dr. Vold said. “But after I arrived and they taught me the system, my perspective changed dramatically.” The center’s attention to detail and many levels of care and caution were new to Dr. Vold. He soon saw firsthand how well the system worked. “I’m doing surgeries on patients who are high risk for infections,” Dr. Vold said. “I have become a converted believer. The system is different from anything I have ever seen.”

Still, the system isn’t perfect. In the wider scope of intraocular surgery, one physician at Boozman-Hof took out some corneal transplant sutures one to two years post-op, and that did result in endophthalmitis. “What that highlights to me is how relatively easy it is to get an infection if you’re not careful about the ocular surface where you’re doing the procedure,” Dr. Cole said. Keeping instruments sterile and prepping the patient properly are key to excellent results, he said. “But despite anyone’s best efforts and a good system of prophylaxis in place, there still are going to be infections from time to time,” Dr. Cole said. “That’s part of doing surgery.”

Editors’ note: Dr. Cole, Ms. Acord, and Dr. Vold have no financial interests related to their comments.

Contact information

Acord: 479-246-1751,
Cole: 479-246-1751,
Vold: 479-246-1751,

Among the best rates Among the best rates
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