instrument insider
Meeting the Challenge of Safety Issues in Ophthalmic Surgery
By Robert H. Osher, M.D.

The magnitude of blade injuries and the potential for devastating consequences is still not widely recognized by ophthalmic surgeons. This needs to change. The continuing problem of sharps injuries is long recognized as a risk for HIV, hepatitis B and C and other blood-borne diseases. The Centers for Disease Control and Prevention (CDC) estimates that between 600,000-800,000 needlesticks and other percutaneous injuries are sustained by healthcare workers annually.

When we consider the gravity of contracting HIV or hepatitis B or C due to a sharps injury, the importance of instrument safety takes on a much more serious tone. Consequently, as ophthalmic surgeons we must become disciplined about eliminating sharps injuries to ensure the safety of the patient and the entire surgical team.

BD Beaver Safety Knives

Prion Diseases

We are also confronting a new specter of lethal "prion diseases" known to be transmissible in ophthalmic procedures. Prions are normal proteins within cells. Naturally-occurring in most species, including humans, prions may help maintain proper neural functioning. But when a prion mutates into an abnormal, misfolded shape, it becomes infectious. Prion diseases are caused by spontaneous genetic mutations in a very small percentage of the population. However, in those patients, the damaged prion protein can live in lymphoid and other neurological tissue — like the eye, undetected but infectious — for decades before the onset of symptoms, followed by severe neurologic disease.

Prion diseases, like Creutzfeldt-Jakob disease (CJD) and the more rapid and lethal variant bovine spongiform encephalopathy (BSE) — more commonly known as mad cow disease, present unique problems.

Diseased prions are virtually immortal, and studies report that currently available sterilization techniques destroy the instrument before affecting the prion and its infectivity. Moreover, the disease's long-dormant period before symptoms appear — coupled with lack of a good diagnostic test, means every patient should be considered potentially infected — an entirely new kind of mindset.

Prions are concentrated in nerve cells, such as the retina and other eye tissue, the brain and spinal cord. The combination of these factors may pose a threat to ophthalmic surgical teams at risk of sharps injury and for patients who undergo procedures involving an instrument that may have been contaminated by an infected patient.

Safety Needs to be Taken Seriously

Sadly, despite the publicity given to the AIDS epidemic, most ophthalmologists are oblivious to the perils of an inadvertent blade injury. Even knowledgeable surgeons share an attitude of immortality, refusing to consider the possibility of contracting hepatitis or AIDS. From personal experience, I can testify that a health catastrophe can strike even a young healthy surgeon in excellent shape. While recently trained clinicians are more cognizant of universal precautions and may be more cautious than my generation, eye surgeons can become so engrossed in the actual procedure with emphasis on speed, that appropriate precautions may be compromised or overlooked.

Congress passed The Needlestick Safety and Prevention Act in 2000 to protect healthcare workers and patients from these emerging infectious agents. Consequently, the "Needlestick Safety and Prevention Law," which went into effect on or about August 2001, requires employers to (a) evaluate and implement the use of safer medical devices as they become available; (b) regularly update and implement their blood-borne pathogen exposure control plans; and (c) provide blood-borne pathogen training.

BD Beaver Safety Knife

Several years ago, Becton Dickinson (BD, Franklin Lakes, N.J.) introduced the BD Beaver Safety Knife, which includes a specially designed, integrated safety shield that protects the blade in procedure and handling. The surgical technician passes the shielded blade to the surgeon. The blade is then placed over the eye in focus under the microscope before the shield is retracted. The incision is made and immediately the shield is lowered before the knife is passed back to the scrub tech.

While I still design and use diamond knives as well as the exquisitely sharp Beaver Blades, the comfort level of my surgical team is higher when the shielded blades are used. Recently, BD added the 2.2-mm safety knife to its line for the surgeon who wishes to perform microcoaxial phacoemulsification, my current procedure of choice. I am confident that shielded blades will become the standard of care when performing cataract surgery in the future.

Robert H. Osher, M.D., is a professor in the Department of Ophthalmology, University of Cincinnati College of Medicine and medical director emeritus, Cincinnati Eye Institute. He can be e-mailed at rhosher@cincinnatieye.com.