Postoperative infection following strabismus surgery is a rare but potentially visually devastating disorder. Endophthalmitis, with an estimated incidence of 1:3,500 to 1:85,000,1–4 can result in a complete loss of vision in the affected eye. Periocular infection, either cellulitis or subconjunctival abscess, following strabismus surgery is more common with a reported incidence of 1:1,000 to 1:1,900.1,5,6 The uncommon occurrence of postoperative infections after strabismus surgery has made it difficult to study the most effective means of prophylaxis. Native periocular bacterial flora has been implicated as a source for postoperative infections.7 Many prophylaxis methods aim to decrease exposure to periocular bacteria and the number of native bacterial colonies.
When an infection occurs, early detection is key. Young children are unable to report symptoms of infection, making early detection difficult.2 Scant information regarding timing of the first postoperative visit after strabismus surgery exists in the literature. This study was undertaken to characterize the practice patterns of pediatric ophthalmologists regarding their use of infection prophylaxis and timing of the first postoperative visit after strabismus surgery.
Patients and Methods
A ten-question multiple-choice, close-ended questionnaire was e-mailed to North American members of the American Association for Pediatric Ophthalmology and Strabismus listserv in April 2013 and May 2013. The organization e-mail list consisted of approximately 1,486 pediatric ophthalmologist members. The survey was sent to active and associate members, bringing the total number of members receiving the questionnaire to 867. Members were asked to complete the questionnaire (Table A, available in the online version of this article) regarding their management of infection prophylaxis before, during, and after strabismus surgery. Recipients were asked to access the questionnaire via a hyperlink ( www.surveymonkey.com) embedded in the e-mail invitation to participate. Internet protocol addresses and numerical labels assigned to computers participating in a computer network were deleted from data responses for anonymity. Surveys were excluded if any answers were omitted. The study was exempted from institutional review board review by the Wills Eye Hospital's institutional review board. “Povidone-iodine” was referred to as Betadine (Perdue Pharma, LP, Stamford, CT) in the questionnaire, but will be noted in this article as “povidone-iodine.”
Statistical analysis was mostly descriptive with survey responses summarized using frequencies and percentages. Univariable tests of association between prophylactic measures and surgeons reporting a prior episode of postoperative cellulitis or endophthalmitis were then performed using Fisher's exact test. A significance level of alpha = .05 was used for all tests. Analyses were performed in SAS software version 9.3 (SAS Institute, Inc., Cary, NC).
The questionnaire was sent to approximately 867 listserv members. A total of 395 (45.6%) members responded to the survey. Fifteen surveys were excluded for incomplete responses. The remaining 380 surveys were included in the data analysis (Table 1). Of the 380 surveys completed, 366 (96.3%) do not usually (defined as > 75% of the time) prescribe topical antibiotics to children (< 18 years old) for use before the day of surgery. Three hundred sixty-eight responders (96.8%) do not usually use intravenous antibiotics during pediatric strabismus surgery. Three hundred thirty-six (88.4%) instill 5% povidone-iodine solution in the eye as part of surgical preparation for strabismus surgery, but only 95 (25%) instill 5% povidone-iodine solution in the eye at the conclusion of strabismus surgery. One hundred twenty-three (32.4%) isolate the eyelashes with Tegaderm tape (3M, St. Paul, MN) or other adhesive drape. Fifteen (4%) soak sutures in 5% povidone-iodine solution or antibiotics before use in strabismus surgery. Three hundred forty-two (90%) instill topical antibiotics (with or without steroids) at the end of strabismus surgery. Three hundred twenty-five (85.5%) prescribe a course of antibiotics for use after strabismus surgery. Of those 325, 289 (76.1%) prescribe topical antibiotics with a steroid, 24 (6.3%) prescribe topical antibiotics only, 5 (1.3%) prescribe oral antibiotics, and 7 (1.8%) prescribe a topical antibiotic, depending on the age of the patient.
Survey Responses (N = 380)
Eighty (21.1%) routinely see patients for the first postoperative visit on day 1, 65 (17.1%) on day 2 to 3, 69 (18.2%) on day 4 to 5, 107 (28.2%) on day 6 to 7, and 59 (15.5%) on day 8 or after. One hundred sixty-nine (44.5%) reported having a patient in the past who experienced a postoperative infection following strabismus surgery. Of the 169 who reported a previous postoperative infection, 22 (5.8%) reported only orbital cellulitis, 21 (5.5%) reported only endophthalmitis, and 107 (28.2%) reported only preseptal cellulitis. Nineteen responders (5%) reported more than one type of postoperative infection.
Univariable analysis was performed to find a significant association between those who reported a previous postoperative infection and the institution of a particular infection prophylaxis strategy (Table 2). Of the 12 responders who usually use intravenous antibiotics during strabismus surgery, 11 (91.7%) reported a previous postoperative infection compared with 158 (42.9%) who do not routinely use intravenous antibiotics during surgery who reported a previous postoperative infection (P = .002). Of the 123 responders who usually use Tegaderm tape or other adhesive drape to isolate the eyelashes, 64 (52%) reported a previous postoperative infection complication. Of the 257 responders who do not routinely use Tegaderm tape or other adhesive drape to isolate the eyelashes, 105 (40.9%) reported a previous postoperative infection complication (P = .047).
Association With Prior Infection Complications
Although postoperative infection following strabismus surgery is uncommon, it can be potentially devastating.2 Recchia et al.2 reported six patients treated for endophthalmitis after strabismus surgery. The final visual acuity in all six eyes was no light perception, and three of those eyes were enucleated. Strabismus surgeons use multiple infection prophylaxis methods. In the current study, most pediatric ophthalmologists reported instilling 5% povidone-iodine solution during surgical preparation, which has been shown to decrease the incidence of endophthalmitis following cataract surgery.8 Koederitz et al.9 found that a single dose of 5% povidone-iodine administered at the completion of routine strabismus surgery through a fornix incision had the same infection and complication rate as a postoperative 1-week course of a topical antibiotic/steroid. This study also suggests that there may be some prophylactic benefit of a postoperative antibiotic and/or steroid course in patients undergoing reoperations or limbal incisions.
Most responding pediatric ophthalmologists in our survey do not use a 5% povidone-iodine solution at the conclusion of surgery, instead preferring topical antibiotics with or without steroids at the conclusion of surgery, and often prescribe a 1-week course of a topical antibiotic/steroid. Although this is a common practice, Ing10 suggested that it may not provide significant infection prophylaxis. A recent study11 found that the contamination rates of the conjunctival incisions and sutures were significantly decreased by a second application of povidone-iodine after eyelid speculum placement in patients undergoing strabismus surgery. Rosetto et al.12 found that the instillation of povidone-iodine at the end of adjustable suture strabismus surgery had the same colonization rate of the sutures as no instillation. Most responders did not prescribe a course of preoperative topical antibiotics. A short preoperative regimen of topical antibiotics decreased the number of eyelid and conjunctival bacteria when studied in patients undergoing cataract surgery.8 Factors that may prevent the common use of preoperative antibiotics by pediatric ophthalmologists before strabismus surgery include cost, difficulty of medication administration in the pediatric population,13 and the low incidence of endophthalmitis.
Intravenous antibiotic administration before surgery as a means of surgical site infection prophylaxis has been reported to be most beneficial when given within 2 hours before surgery.14 A more recent study in 2013 examining perioperative intravenous antibiotic administration for patients undergoing hip or knee arthroplasty, colorectal surgical procedures, arterial vascular surgical procedures, and hysterectomy found that timing may not be as significant as once thought.15 Strabismus surgery is not currently on the list of procedures recommended to have prophylactic intravenous antibiotics at the time of surgery16; however, some responders (3.2%) in our study routinely administer intravenous antibiotics at the time of surgery.
Intraoperative suture and needle contamination is a possible cause of postoperative infection.17,18 Approximately 54% of either sutures or needles are culture positive after strabismus surgery.19 Although most do not contain enough colony-forming units to sustain infection, a small percentage do carry a high contaminant load and possibly a predisposition for postoperative infection.19 Soaking sutures in povidone-iodine prior to use in strabismus surgery is not a commonly used prophylactic method. Eustis and Rhodes20 found that antibiotic/steroid-coated sutures soaked in antiseptic had a significant reduction in bacterial growth when cultured after surgery in comparison to uncoated or unsoaked sutures. Whether this causes a clinically significant decrease in postoperative infection is unknown. A distinction was not made in the questionnaire between adjustable and non-adjustable sutures.
Most study responders do not routinely apply Tegaderm tape or other adhesive drape to isolate the eyelids or eyelashes. Because these tissues are a potential source of infection, Tegaderm tape or other adhesive drape theoretically could help provide a more sterile surgical field. Rogers et al.17 studied contamination rates of surgical needles and suture materials during strabismus surgery. They found no difference in contamination rates when comparing techniques that isolate the eyelashes versus those that do not. However, this study used a blade speculum instead of Tegaderm tape for isolation, which provided partial isolation. It is possible that responders who routinely apply adhesive drapes during surgery do so for reasons other than infection prevention.
There does not appear to be a prevailing practice pattern regarding the timing of the first postoperative visit among our responders. It has previously been reported that 96% of strabismus surgeons see patients for their first postoperative visit at some point within the first week.21 This was slightly higher than our findings of 85% of surgeons. There is a large amount of variability in the timing of the first postoperative visit during the first week. Our survey found that 56% of surgeons who responded routinely saw patients within the first 5 days after surgery when the signs and symptoms of postoperative endophthalmitis following strabismus surgery will most likely first appear.2 Presenting signs and symptoms include lethargy, fever, anorexia, head-ache, asymmetric erythema, asymmetric eyelid swelling, intraocular inflammation, hypopyon, and photophobia.2 Patients did not present with all signs or symptoms.2 This study addressed the timing of the first postoperative office visit and did not explore other forms of communication, such as phone calls or photo sharing.
Although the reported incidence of postoperative infections is low, 45% of our survey responders reported previous experience with postoperative cellulitis or endophthalmitis. The responders who previously reported experiences with postoperative infections were more likely to use intraoperative intravenous antibiotics and Tegaderm tape or other adhesive drape to isolate the eyelids and eyelashes. It is possible that previous experience with postoperative cellulitis or endophthalmitis may lead to the adoption of more aggressive infection prophylaxis measures as a result.
Limitations of our study include its self-reported methodology. In addition, the study was not designed to determine whether an association exists between a particular infection prophylaxis measure and incidence of postoperative infection. We also did not determine if the same ophthalmologist used multiple prophylaxis techniques or considered the number of years in practice to calculate infection rates. It is possible that the study title led to a skewed response, because responders may have been more or less likely to respond based on previous infection experiences.
A common practice pattern appears to exist among practicing pediatric ophthalmologists regarding the use of 5% povidone-iodine solution in sterile surgical preparation, application of topical antibiotics at the end of surgery, and a postoperative regimen of antibiotics, with or without steroid. Although the literature supports the use of 5% povidone-iodine in sterile surgical technique,7,8 some studies question the benefit of postoperative topical antibiotic administration.9,10 Interestingly, among the uncommon prophylaxis measures such as isolation of eyelids and eyelashes with Tegaderm tape or other adhesive drape, soaking sutures in povidone-iodine, and postoperative instillation of povidone-iodine, the literature suggests that some of these methods are successful in decreasing contamination, deserving further study and consideration.9,12,18–21 There does not appear to be a prevailing common practice pattern regarding the timing of the first postoperative visit, which is consistent with previous findings.
- Ing MR. Infection following strabismus surgery. Ophthalmic Surg. 1991;22(1):41–43.2014110
- Recchia FM, Baumal CR, Sivalingam A, et al. Endophthalmitis after pediatric strabismus surgery. Arch Ophthalmol. 2000;118(7):939–944.10900107
- Walton RC, Cohen AS. Staphylococcus epidermidis endophthalmitis following strabismus surgery. J AAPOS. 2004;8(6):592–593. doi:10.1016/j.jaapos.2004.08.006 [CrossRef]15616511
- Simon JW, Lininger LL, Scheraga JL. Recognized sclera perforation during eye muscle surgery: incidence and sequelae. J Pediatr Ophthalmol Strabismus. 1992;29(5):273–275.1432512
- Locatcher-Khorazo D, Seegal BC, Gutierrez EH. Postoperative infections of the eye. In: Locatcher-Khorazo D, Seegal BC, eds. Microbiology of the Eye. St. Louis, MO: CV Mosby; 1972:80–82.
- Kivlin JD, Wilson ME Jr, The Periocular Infection Study Group. Periocular infection after strabismus surgery. J Pediatr Ophthalmol Strabismus. 1995;32(1):42–49.7752033
- Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98(5):639–649. doi:10.1016/S0161-6420(91)32239-5 [CrossRef]2062496
- Liesegang TJ. Use of antimicrobials to prevent postoperative infection in patients with cataracts. Curr Opin Ophthalmol. 2001;12:68–74. doi:10.1097/00055735-200102000-00012 [CrossRef]11150084
- Koederitz NM, Neely DE, Plager DA, et al. Postoperative povidone-iodine prophylaxis in strabismus surgery. J AAPOS. 2008;12(4):396–400. doi:10.1016/j.jaapos.2007.10.005 [CrossRef]
- Ing MR. Infection following strabismus surgery. J Ophthalmic Nurs Technol. 1991;10(5):211–214.1942102
- Benson CE, Rogers KL, Suh DW. Dual application versus single application of povidone-iodine in reducing surgical site contamination during strabismus surgery. J AAPOS. 2014;18(4):347–350. doi:10.1016/j.jaapos.2014.02.014 [CrossRef]25173897
- Rosetto JD, Suwannaraj S, Cavuoto KM, et al. Evaluation of postoperative povidone-iodine in adjustable suture strabismus surgery to reduce suture colonization: a randomized clinical trial. JAMA Ophthalmol. 2016;134(10):1151–1155. doi:10.1001/jamaophthalmol.2016.2926 [CrossRef]
- Sujuan JL, Handa S, Perera C, Chia A. The psychological impact of eyedrops administration in children. J AAPOS. 2015;19(4):338–343. doi:10.1016/j.jaapos.2015.05.010 [CrossRef]26296784
- Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281–286. doi:10.1056/NEJM199201303260501 [CrossRef]1728731
- Hawn MT, Richman JS, Vick CC, et al. Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg. 2013;148(7):649–657. doi:10.1001/jamasurg.2013.134 [CrossRef]23552769
- Bratzler DW, Dellinger EP, Olsen KM, et al. American Society of Health-System Pharmacists; Infections Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70(3):195–283. doi:10.2146/ajhp120568 [CrossRef]23327981
- Rogers DL, Chheda L, Ford C, et al. The effect of surgical preparation technique on the bacterial load of surgical needles and suture material used during strabismus surgery. J AAPOS. 2011;15(3):230–233. doi:10.1016/j.jaapos.2011.03.005 [CrossRef]21665501
- Olitsky SE, Vilardo M, Awner S, Reynolds JD. Needle sterility during strabismus surgery. J AAPOS. 1998;2(3):152–152. doi:10.1016/S1091-8531(98)90006-4 [CrossRef]
- Carothers TS, Coats DK, McCreery KM, et al. Quantification of incidental needle and suture contamination during strabismus surgery. Binocul Vis Strabismus Q. 2003;18(2):75–79.12765540
- Eustis HS, Rhodes A. Suture contamination in strabismus surgery. J Pediatr Ophthalmol Strabismus. 2012;49(4):206–209. doi:10.3928/01913913-20110920-01 [CrossRef]22909077
- Olitsky SE, Awner S, Reynolds JD. Perioperative care of the strabismus patient. J Pediatr Ophthalmol Strabismus. 1997;34(2):126–128.9083962
Survey Responses (N = 380)
|1. Preoperative topical antibiotics||14 (3.7%)||366 (96.3%)|
|2. Intraoperative intravenous antibiotics||12 (3.2%)||368 (96.8%)|
|3. 5% Betadine surgical preparation||336 (88.4%)||44 (11.6%)|
|4. Tegaderm tape over eyelashes||123 (32.4%)||257 (67.6%)|
|5. Soak sutures in povidone-iodine||15 (4.0%)||365 (96.1%)|
|6. 5% Betadine at surgery completion||95 (25.0%)||285 (75.0%)|
|7. Apply postoperative antibiotics||342 (90.0%)||38 (10.0%)|
|8. Course of antibiotics after surgery||325 (85.5%)||55 (14.5%)|
| Oral||5 (1.3%)|
| Topical||24 (6.3%)|
| Topical with steroid||289 (76.1%)|
| Topical but depends on age||7 (1.8%)|
|9. Timing of first postoperative visit|
| Day 1||80 (21.1%)|
| Day 2 to 3||65 (17.1%)|
| Day 4 to 5||69 (18.2%)|
| Day 6 to 7||107 (28.2%)|
| Day 8+||59 (15.5%)|
|10. Postoperative infection||169 (44.5%)||211 (55.5%)|
| Orbital cellulitis only||22 (5.8%)|
| Endophthalmitis only||21 (5.5%)|
| Preseptal cellulitis only||107 (28.2%)|
| Any combination||19 (5.0%)|
Association With Prior Infection Complicationsa
|Question||No (n = 211)||Yes (n = 169)||P|
|1. Do you usually (≥ 75% of the time) prescribe topical antibiotics for children (≤ 18 years old) before the day of strabismus surgery?||.414|
| No||205 (56.0%)||161 (44.0%)|
| Yes||6 (42.9%)||8 (57.1%)|
|2. Do you usually use intravenous antibiotics during pediatric strabismus surgery?||.002|
| No||210 (57.1%)||158 (42.9%)|
| Yes||1 (8.3%)||11 (91.7%)|
|3. Do you usually instill 5% Betadine in the eye as part of sterile surgical preparation for strabismus surgery?||.425|
| No||27 (61.4%)||17 (38.6%)|
| Yes||184 (54.8%)||152 (45.2%)|
|4. Do you usually use Tegaderm tape or other adhesive drape to isolate eyelashes during surgery?||.||.047|
| No||152 (59.1%)||105 (40.9%)|
| Yes||59 (48.0%)||64 (52.0%)|
|5. Do you usually soak sutures in Betadine or antibiotics before use in strabismus surgery?||.110|
| No||206 (56.4%)||159 (43.6%)|
| Yes||5 (33.3%)||10 (66.7%)|
|6. Do you usually instill 5% Betadine at the end of strabismus surgery?||.074|
| No||166 (58.3%)||119 (41.8%)|
| Yes||45 (47.4%)||50 (52.6%)|
|7. Do you usually instill topical antibiotic (either with or without steroids) at the end of strabismus surgery?||.864|
| No||22 (57.9%)||16 (42.1%)|
| Yes||189 (55.3%)||153 (44.7%)|
|8. Do you usually prescribe a course of antibiotics for children to use after strabismus surgery?||.158|
| No||33 (60.0%)||22 (40.0%)|
| Oral antibiotics||2 (40.0%)||3 (60.0%)|
| Topical antibiotics||9 (37.5%)||15 (62.5%)|
| Topical antibiotics with steroid||161 (55.7%)||128 (44.3%)|
| Topical but depends on age||6 (85.7%)||1 (14.3%)|
|9. How many days postoperatively do you routinely examine children for the first post-operative visit following strabismus surgery?||.110|
| Day 1||49 (61.3%)||31 (38.8%)|
| Day 2 to 3||31 (47.7%)||34 (52.3%)|
| Day 4 to 5||34 (49.3%)||35 (50.7%)|
| Day 6 to 7||68 (63.6%)||39 (36.5%)|
| Day 8+||29 (49.2%)||30 (50.9%)|
|1. Do you usually (≥ 75% of the time) prescribe topical antibiotics for children (≤ 18 years old) before the day of strabismus surgery?|
|2. Do you usually use IV antibiotics during pediatric strabismus surgery?|
|3. Do you usually instill 5% Betadine in the eye as part of sterile surgical preparation for strabismus surgery?|
|4. Do you usually apply Tegaderm tape or other adhesive drape to isolate eyelashes during surgery?|
|5. Do you usually soak sutures in Betadine or antibiotics before use in strabismus surgery?|
|6. Do you usually instill 5% Betadine at the end of strabismus surgery?|
|7. Do you usually instill topical antibiotic (with or without steroids) at the end of strabismus surgery?|
|8. Do you usually prescribe a course of antibiotics for children to use after strabismus surgery?|
| Topical antibiotics|
| Topical antibiotics with steroid|
| Oral antibiotics|
| Topical but depends on age|
|9. How many days postoperatively do you routinely examine children for the first postoperative visit following strabismus surgery?|
| Day 1|
| Day 2–3|
| Day 4–5|
| Day 6–7|
| Day 8+|
|10. Have you ever had a case of postoperative endophthalmitis, preseptal cellulitis, or orbital cellulitis following strabismus surgery?|
| Orbital cellulitis|
| Preseptal cellulitis|