In my experience, cleaning the eyelids and surrounding area as well as topical instillation of povidone -iodine into conjunctival sac has significantly reduced occurrence of postoperative infection (endophthalmitis) in intraocular surgery such as cataract surgery, glaucoma and vitreoretinal procedures. What do you think?
I fully agree with that treatment that I'm presently currently using for all intraocular surgery.
I routinely practice the same for all my surgeries. I clean the skin with 10 % Povidone-Iodine. Before that, I instill few drops of 5% povidone-iodine in the cul-de-sac of the conjunctiva.
It is true that i use topical drops of 5% povidone iodine ( available iodine is 0.5%)drops as routine pre operative and leaving the drops in the cul de sac for a minute , really helps.
Topical application of povidone Iodine 5% into conjunctival sac is safe and effective in reducing postoperative endophthalmitis as proved by several studies;1.Mendivil Soto A, Mendivil MP. The effect of topical povidone-iodine, intraocular vancomycin, or both on aqueous humor cultures at the time ofcataract surgery. Am J Ophthalmol. 2001 Mar;131(3):293-300.
2. Quiroga LP, Lansingh V, Laspina F, Samudio M, Stanley J, Kaspar HM, Cibils D, Cibils P. A prospective study demonstrating the effect of 5% povidone-iodine application for anterior segment intraocularsurgery in Paraguay. Arq Bras Oftalmol. 2010 Mar-Apr;73(2):125-8.
3. Carrim ZI, Mackie G, Gallacher G, Wykes WNThe efficacy of 5% povidone-iodine for 3 minutes prior to cataract surgery. Eur J Ophthalmol. 2009 ;19(4):560-4.
4. Ferguson AW, Scott JA, McGavigan J, Elton RA, McLean J, Schmidt U, Kelkar R, Dhillon B.Comparison of 5% povidone-iodine solution against 1% povidone-iodine solution in preoperative cataract surgery antisepsis: a prospective randomised double blind study. Br J Ophthalmol. 2003 Feb;87(2):163-7.
In this study Ferguson et al found that 5% povidone Iodine is more effective than 1% povidone iodine in decreasing the human conjunctival bacterial flora in vivo, particularly in the presence of heavier initial bacterial load.
However; even concentration of 1% or 0.5% has been used in few studies and is found effective. Precaution should be taken in patients with dry eyes etc to use lower concentration of povidone iodine.
I totally agree with the use of povidone iodine 10% on the eye lids and povidone iodine 5% irrigating the conjunctival sac for one minute in every kind of ophthalmic surgery BEFORE application of the sterile drap (and in some special cases EVEN AFTER the application of the sterile drap..).
we use 10 % externaly and 5 % for the conjunctiva pre - OP and the 5 % also post OP, there is a study thyt 1 % might be enough : Binder C, de Kaspar HM, Engelbert M, Klauss V, Kampik A (1998) Bacterial colonization of conjunctiva with Propionibacterium acnes before and after polyvidon iodine administration before intraocular interventions. Ophthalmologe 95(6): 438-441.
Binder CA, Mino de Kaspar H, Klauß V, Kampik A (1999) Präoperative Infektionsprophylaxe mit 1 %iger Polyvidon-Jod-Lösung am Beispiel von konjunktivalen Staphylokokken. Ophthalmologe 96: 663-667
I think all the eye surgeons are using Povidone iodine these days. I also use same after giving the block to clean the eye in the block room as well as on the table to clean the cul de sac and the skin around the eye.
I do clear temporal corneal phako emulsification with foldable IOL implantation under topical anesthesia.I don't patch the eye after surgery.I also agree that pre and post op use of topical povidine iodine 5% has very effective anti bacterial ,viral and fungal effects.
5% TOPICAL POVIDINE IODINE is in use in all NHS ophthalmic depts for cataract/intraocular surgery -unless patient allergy. Not to use this is madness
The only question is of duration. Many of us think 10minutes of topical pov iodine is required
Some years ago we had 3 cases of sterile endophthalmitis after quite uneventful surgery within a week. Samples from the vitreous gave no answer. We ended up with a suspision of having left Povidone in the sac, from where it entered the eye through the incision. Since that incidence we have payed much attention to a thorough and complete irrigation of the external eye incl the sac, before we preceed the surgery. Povidone is extremly toxic in the anterior chamber.
I agree with ur comments sir.A 5% povidone iodine application in the cul de sac pre and post intraocular surgeries prevent post operative endophthalmitis
We routinely use 5% povidone iodine. However, we recently had to dlilute 10% iodine to make 5% iodine because there was a State wide shortage of povidone iodine in Western Australia. At our institute, we use iodine before intravitreal injections and the rate of endophthalmitis is 1 in 5,000.
In my experience using povidone iodine before and after the surgery is the only really useful tool to prevent ocular endophthalmitis
Hello, I'd like to answer: why don't you use hospisept for the same aims? According to it's annotation this medication have good tolerance using for skin preparation and as I can judge it has more extensive antibacterial and antivirus (including HIV and hepatitis ). I have no any financial disclosure, it is interesting for me for educational aim. Sorry for my unperfect English.
I meaned cleaning the eyelids and surrouding skin area with hospisept. This solution can not be used for instillations! Here is its composition http://mike-morrison.com/lysoform/product%20text/Hospisepttext.htm. Sorry if I have not understood you clearly before.
In my opinion the application of povidone iodide (5% only) is the main tool to prevent post operative infections, 10% concentrations are too high and this may lead to ocular damage,if on the cornea epithelial loss resulting in some cases in poor visualization of surgical field or if accidentally panetrated in anterior chamber endothelial damage or sterile intraocular reactoin and also late onset endophthalmitis
Treating the conjunctival sac and lid margins with 5% Povidone Iodine reduced the rate of endophthalmitis substantially. Additionally conjunctival sac treatment with Povidone iodine helps reduce meibobian gland secretion over the corneal surface, to enhance visibility during surgery.
And moreover at the end of procedure indicates eventually leakage frome the incision (seidl +)
Enzo Vingolo sir: YES, If one is planning to instill povidone iodine 5% beside before surgery also at the end of surgical procedure; one has to hydrate all the phaco incisions well so that povidone iodine 5% may not enter the anterior chamber as it may produce Tass like picture.
Usually IOP avoids the uptake of povidone iodide inside the incisions because there is a positive pressure inside the eye that flush the povidone away...try it!
Dear Enzo, true that positive pressure inside the eye will not allow povidone iodine entery into eye where as negative pressure i.e hypotonous eye or where anterior chamber in not formed with fluid, the povidone iodine will enter into anterior chamber and which mat produce TASS ( toxic anterior segment syndrome).
Yes but in that case it is due to a surgical incorrect manouvre...
I have also a large experience of povidone iodine. since its use i haven't faced a single case of postoperative infection. regarding staining in dry eye, it is true but for a short time.
You are very lucky man also with povidone endophthalmitis may occurin a percentage of 0.2 to .5 probably the number of procedures is not so high our 2012 data with povidone are of 5 cheratoipopion in 3200 surgeries
I use povidone 10% for lids and 5% for conj, one time 5 minutes before surgery and an other time just after drap application. In italy we have a company that provide 5% one in sterile bottle just for ocular surgical needings and the instruction say to use it 5 minutes before in order to work propertly. I never had experience of corneal or conj melting with that. I think that using it is crucial, but we don't have to forget to pay attention also to all the other details.
I use preoperative povidone iodinr 5% i addition i use one drop in conjuctival sac before removal of eye speculum. For the last foive years no patient experienced endopthalmitis.
Working in an environment where we still use reusable (not disposable) consumables, and working in outreach areas where hygiene may not be optimal, the use of povidone iodine in skin preparation and conjunctival instillation both before and after surgery has worked for us prevent post operative infection even in our outreach or eye camp surgical cases. In the last 3 years I saw only 2 cases of endophthalmitis, one of which which I believe was from post operative injury not surgery. I think it is a most wonderful medication, which I cannot go to the field without.
http://www.ncbi.nlm.nih.gov/m/pubmed/23680628
We've always used povidone iodine in our practice, and endophthalmitis has thankfully been rare. Even though a direct cause and effect relationship cannot be assumed in these instances, I believe it has played a role.
Time of iodopovidone action starts after 30 seconds after the instillation and it is due to a denaturation of wall protein of bacteria in the lids, so that a very short time is need to start the procedure (i reccomend 1-2 min immediately before the surgery. Lasting for more is unuseful and may have toxic effects on the cornea even if the concentration is too low to damage corneal epithelium and to cause problems in surgical visualization.
Obviously the surgeon may use iodopovidone 5 min and 1 min before the drap positioning, but in my personal opinion the application of lid retractor may open enough the operative fieald to reach every location in the fornix and eyeball. So using before that time is only time consuming.
I used 10% for sterilization of the lid 5 min before surgery and 2% iodine to wash the conj after drape application . I had no complications with that
We use 5% pre op. This is more beneficial in reducing flora than antibiotics, and I am not aware of better measures for routine surgery...
Knowing that in Cataract surgery, the main recognized source of bacteria for endophthalmitis is the patient's tear film, we apply several drops of Povidone Iodine 5% solution, leaving them there for a minute and then thoroughly rinse, just prior to begin intraocular surgery (on an already draped patient's eye). This has worked just fine for us with several years of experience.
This should be the universal primary method of endophthalmitis prevention in ophthalmic surgery.
I strongly agree with james and luis, as already suggested by my previously post ed answers
I have been practicing instillation of 5% povidone iodine intraoperatively before entring the globe as well as one drop postoperatvely. for the last five years in about 1200 surgeries no case of endopthalmitis took place
I agree with Dr Enzo 5% Povidine Iodine is used for instillation into conjunctival sac before and at the end of surgery
I agree with Dr Enzo 5% Povidine Iodine is used for instillation into conjunctival sac before and at the end of surgery. It will be instilled 3 minutes before starting the surgery
I agree too, and should be emphasised in developing countries
5% topical povidone iodine is a gold standard and the comment about leaving it in the conjunctival sac for 3 minutes to achieve its full effect is good practice. We concentrated on that preoperatively, along with promoting intracameral cefuroxime postoperatively and had a run of 10,000 cases of phacoemulsification with IOL without a case endophthalmitis at the Birmingham and Midland Eye Centre.
Definitely agree, including intraocular procedures such as intravitreal injections. Studies have reported to leave it on ocular surface for 30 seconds to eliminate or microbes, less than that still significantly reduces colony counts.
We have been using standard OR protocol of using 5% Povdone Iodine pre and post intraocular surgery with no antibiotics at all. We do about 250-300 surgeries every day with very low rates of ost infection. We recommend contact time of one minute.
I agree too and we recommended cleaning the eyelids with 10% solution of povidone iodine for every intraocular surgery procedure (including intravitreal injections) and instill 5% Iodine in the beginning and in the end of surgery. Also, at the end of cataract or glaucoma surgery procedure or vitreoretinal surgery procedure we instill cefuroxime. We haven't any case of endophthalmitis last nine months (we do about 20-25 surgeries every day).
Dear Kajo Bucan I (Dr Jagat Ram) fully agree with this approach of cleaning the eye lids with 10% povidone iodine and instillation of 5% povidone iodine in the beginning and end of intraocular surgery such as cataract which significantly reduce the rate of postoperative endophthalmitis.
Nearly everything has been said. 5% for the ocular surface and 10 % for the skin is the widely used standard. Let me add some remarks on side effects. Povidone iodine may cause severe epithelial lesion, keratitis, or conjunctivitis if not adequadely used. Two factors may be responsible for this: 1. the concentration, 2. the mode of application, 3. rinsing after application. 10% for the anterior segment of the eye is clearly a critical concentration. If you use that, than you should leave it only for a short period (30 seconds) and then perform an intensive rinsing of the anterior segment with NaCl or BSS in order to remove. As has been pointed out 5% is the gold standerd. When you clean the lids and periocualr skin be aware that the 10% solution will not reach the anterior segment. You can also observe the site effects if 5% is used and intensive apllicaton (by the syringe with brush cannula) is used and if afterwards no rinsing with NaCl or BSS follows. This can even occur after apllication of 5% as eye drops without clearing drops or solutions afterwards. Several of the colleages responded that they use povidone iodine at the end of surgery. I am a little bit hesitant to recommend this because small amounts of povidone iodine may than reach the anterior chamber and could cause endothelial damage. Intracameral cefuroxime seems to be the better solution.
because of epithelial irritations we made an attempt without 5% PVJodid and rinsing only with BSS Solution compared to 5% PVJodid some years ago. Never do surgery without using 5% PVJodid For 3 Minutes. You will see the difference in a short period of time. It is the gold standard clearly
I am using 10 % Povidone Iodine since last 18 years done around 200000 ocular surgeries so far. No serious side effect encountered.
My protocol as follows
1. One drops 10 % Povidone Iodine just after biometry one day before surgery.
2. One drops 10 % Povidone Iodine just after peribular block one day before surgery.
3. Eyelid margins and surround peri orbital skin cleaning with 10 % Povidone Iodine.
4. Instillation 10 % Povidone Iodine in cul de sac for 1 minute
5. Thoroughly washing of the cul de sac with BSS
6. At the end of surgery again gently painting of lid margins with 10 % Povidone Iodine.
Before intra ocular surgery and after prep of periocular with Povidone Iodine , I wash ocular surface in clouding-conjunctiva and fornices with 10 % Povidone Iodine.
I am using 5 % Povidone Iodine: it is very important. I think that it can contribute to post-op foreign body sensation.
My protocol
Some minutes before before entering the operating theater:
a) Eyelid margins and surround peri orbital skin cleaning with 5 % Povidone Iodine.
b) Instillation 5 % Povidone Iodine in cul de sac
Inside the operating theater, just before surgery:
a) Eyelid margins and surround peri orbital skin cleaning with 5 % Povidone Iodine in cul de sac for 3 minutes
b) Washing of the cul de sac with BSS
I use 5 % Povidone Iodine for all of my patients for washing ocular surface in clouding cornea , conjunctiva and fornices preoperative of beginning cataract surgery. ocular surface must completely washed and cleaned by BSS or ringer solution from residual Povidone Iodine. until now I had not significant complication for report.
I would like to add one point: In eyes with very recent anterior segment surgery Povidone Iodine should be applied very carfully. I always do it personally preoperatively. In the past I was asked for second opinion on unusual endothelial decompensation following complication management after cataract surgery. In all these cases PVP Iodine had been used and applied by assisting personal. I guess that either instable incision or mechanical impact (or both) during rinsing of the anterior segment may have led to penetration of PVP Iodine into the anterior chamber and destruction of the endothelial layer.
I use 5% Povidone Iodine (Pfizer) without any problems. Our day surgery also uses the same for cataract surgery. My only comment is that 5% povidine Iodine (Pfizer) is not sterile. Most others in our region are the same using non sterile povidone iodine. Is everyone else using non-sterile Povidone Iodine, or are they using sterile Povidone Iodine (Alcon)?
Dear Ernest, many thanks for your valuable comment. 5% Povidone Iodine (Pfizer) is not sterile . By my knowledge Povidone Iodine sterilization need micro filtration as like sterile Povidone Iodine by Alcon Co.