Reprinted from Campolattaro BN, Olitsky MS, Rogers GL. Perioperative and postoperative use of antibiotics and steroids in strabismus surgery. J Pediatr Ophthalmol Strabismus. 2001;38(5):304-307.
Nelson: Once the diagnosis of strabismus is made, consent is given, the data are established, and it is clear the patient needs surgery, does your hospital require medical clearance and preoperative blood work?
Campolattaro: I perform the majority of my surgeries at the New York Eye and Ear Infirmary, which requires all patients 18 years of age or younger to undergo a physical examination within 1 week of surgery. Blood tests are not required except for pregnancy evaluations, when appropriate. All adults undergo serum work-up with complete blood-cell count and various other tests.
Olitsky: At the Children's Hospital of Buffalo, patients 18 years of age or younger do not receive blood work; they are seen by a nurse practitioner and the anesthesiologist just before surgery.
Rogers: Our patients do not require an evaluation before surgery. Any girl who is menstruating does get a pregnancy test. All patients are examined by a nurse practitioner and the anesthesiologist the morning they come in for surgery. The cardiologist also talks and listens to them. Patients with a preexisting condition, such as a heart murmur or a shunt in place, undergo prophylaxis before surgery, and we make certain we have clearance from the cardiologist before proceeding with surgery. Things are done minimally now, and it is proven to be medically efficacious to do it that way.
Nelson: What procedures are performed to assure that the right patient and the right eye are operated on?
Campolattaro: To ensure the correct eye is being operated on, if unilateral surgery is planned, an X is made with magic marker on that side of the patient's forehead prior to entering the operating room. All consent forms are reviewed by the head nurse, as well as by the patient, and dated for that day. Therefore, if the patient is unaware that bilateral surgery is to be performed, appropriate counseling can be done preoperatively.
Olitsky: Our checks are done verbally. The nurse checks the consent with the parents. And prior to making my first incision, I confirm which eye we are operating on.
Rogers: Usually, there is a board in the operating room with every procedure and patient's name, age, and what we are doing. I put my measurements up there so the surgical technician who is helping me knows exactly where I want the caliper set and we check them against the board.
Nelson: On the day of the surgery, prior to the patient entering the operating room, do you administer any topical or systemic medication?
Campolattaro: For pediatric cataract surgery, we routinely give cycloplegics with antibiotic and anti-inflammatory drops prior to the child's arrival in the operating room. For children with strabismus, we do that on an elective, not constant, basis. For example, children with chronic blepharoconjunctivitis would receive a preoperative regimen. But as a standard of care, topical medications are not given to children undergoing strabismus surgery.
Olitsky: Strabismus patients do not receive any preoperative medication, topical or systemic.
Rogers: If there is no indication for antibiotics, we do not use any.
Nelson: At the time the patient enters the operating room under anesthesia, do you administer any preoperative medication, topical or systemic?
Campolattaro: In 1991, at the New York Eye and Ear Infirmary, a large study was performed showing the efficacy of prophylaxis with povidone-iodine in preventing endophthalmitis. It was performed over 2 years and included thousands of patients. As a standard of care at the Eye and Ear Infirmary, all patients, including strabismus patients, undergo a preparation that includes half strength povidone-iodine through the conjunctival fornix for 4-5 minutes prior to its irrigation. In practice, the nurses do it as the first step in the prep, and then they prep the outside of the face. When they are finished, they go back and irrigate the conjunctival fornix.
Nelson: Do you give any other drops at that time?
Campolattaro: Only topical phenylephrine 2.5% solution for hemostasis.
Olitsky: Drops are usually given just as the child is put to sleep. I do not irrigate afterward.
Rogers: I had one case in which I helped a resident with a patient who had endophthalmitis. We used povidone after the child was intubated. During the prep, we put more povidone in the eye, let that dry, and then irrigated it. Then at the end of the case, we used it again.
Nelson: Do you administer phenylephrine at all?
Rogers: Yes.
Nelson: What do you do at the end of the surgical procedure? Do you administer any medications?
Campolattaro: Recently, we have been experimenting with various methods of topical and local anesthetic at the end of the procedure to minimize discomfort during the immediate postoperative period. We have used topical tetracaine and viscous lidocaine jelly. Both seem to be effective in reducing pain, and our recovery nurses believe it improves the recovery room stay with decreased morbidity. Patients also receive topical antibiotic steroid ointment at the end of the procedure. We currently use Tobradex (tobramycin-dexamethasone, Alcon Laboratories) exclusively.
Nelson: You use an antibiotic steroid as opposed to just an antibiotic at the end of the surgery?
Campolattaro: It has been our standard for many years.
Nelson: How do you decide between administering tetracaine or the lidocaine jelly?
Campolattaro: We have not performed any formal studies. We are currently using both, in a random fashion, to determine if our recovery nurses detect any significant difference.
Olitsky: At the end of surgery, I administer another drop of povidone-iodine and similarly a one-time dose of a broad-spectrum antibiotic such as a polysporin ointment.
Nelson: Why do you give the second drop of the iodine?
Olitsky: It comes under the category of "it can't hurt." If there has been any contamination, it could help in those cases and the same with the antibiotic. The child is asleep, and I do not see a reason not to.
Rogers: I use an antibiotic postoperatively. Sometimes the patient experiences irritation or dryness. The vehicle in the antibiotic makes the patient feel a little bit better and he or she will open his or her eyes. I usually use Maxitrol (neomycin-polymyxin-dexamethasone, Alcon Laboratories). I tell the parents to use it if they think the patient's eyes are irritated or if the eyes seem red, and to call me if the symptoms last.
Nelson: Do you tell the parents to use a specific amount each day?
Rogers: No, I do not have them use the antibiotic routinely. I have them use it only if the patient needs it.
Nelson: What are your instructions in terms of antibiotics or any kind of medication postoperatively?
Campolattaro: Perioperatively, we routinely administer one dose of intravenous antibiotic. We use a first-generation cephalosporin. Postoperatively, we recommend topical anesthetic steroid ointment on a twice-daily basis. The lubrication from the ointment decreases discomfort. Ice compresses are theoretically impractical for most children.
Nelson: Which antibiotic do you prescribe?
Campolattaro: I usually let the patient keep the Tobradex ointment tube that was given to him or her immediately postoperatively. We do not routinely use oral medications.
Olitsky: I only administer antibiotics once, just before the patient is taken out of anesthesia.
Nelson: Do you administer an antibiotic when you give the iodine?
Olitsky: At the end, so nothing goes home with them.
Nelson: Do you administer intravenous antibiotics?
Rogers: Unless intravenous antibiotics are indicated preoperatively with some medical condition, I do not administer them.
Nelson: When do you begin postoperative follow-up for the strabismus patient?
Campolattaro: I see the patient within 4 to 5 days postoperatively. All patients' families are instructed to contact me immediately if symptoms worsen after 48 hours. Children are a bit lethargic from general anesthesia for the first 24 hours, and swelling tends to be maximized at about 48 hours. Most patients' families tell me that by the third-postoperative day, the patient is "back to his or her old self." By the third day, if no significant improvement is noted and the parents speak to me, I will have them come in sooner than their scheduled appointment.
Nelson: What would be alarming signs or symptoms to a potential problem?
Campolattaro: I tell the parents that rare, but visually devastating, postoperative intraocular infections can be caused by either endogenous or exogenous factors. Therefore, I give them both local and systemic symptoms to look for in the patient. First, continued lethargy after the first 24 to 48 hours or other signs of systemic illness such as fever warrant attention. I often implore them to call me before they call their pediatrician in that regard. Second, worsening lid swelling or ocular injection are signs that they might need to call me about immediately.
Nelson: Do you call the parents the day after surgery, or do you routinely have them make the appointment in 4 to 5 days as long as there are no other complications?
Campolattaro: I usually call the night before surgery so the parents can ask all of their last minute questions without having to do that in the hectic pace of the operating room. At that time, I always instruct them to call me at any time during the immediate postoperative period. I do not routinely call them on the first postoperative night.
Nelson: What is your follow-up on your patients?
Olitsky: Well, it has changed because of medicolegal issues, not scientific issues. I typically see the patient within the first week because, like it or not, that is the standard of practice, not necessarily the standard of care.
Nelson: What do you tell the parents?
Olitsky: I tell them within the next day the child should be back to his or her usual self, and I want them to call me if there is any change for the worse (e.g. if the eye suddenly starts looking redder). After the first day, the child should be able to open both eyes and be comfortable. Any change from that, I want to know about.
Rogers: I usually see the child 1-week postoperatively. I do not routinely call the parents; however, I do leave my home phone number with them. At the time of surgery, they are given a pamphlet that talks about things that are expected postoperatively, and then I briefly go over the information with them right after the surgery. If there are any concerns at all, I want to hear from them.
Nelson: Is there anything that would make you change your typical postoperative management of the individual? Is there anything different about the surgery, the individual, or other complicating factors that would make you either see that patient earlier or do something different than you would normally do?
Campolattaro: The only time I demand patients to come in within 2 to 3 days postoperatively is if they are severely developmentally delayed. Sometimes I will be asked to perform combined surgery for children who need their tonsils out or need a myringotomy tube for chronic otitis. To save that patient a second anesthesia, I will perform elective strabismus surgery at that time. For those children, because they may not be able to address the concerns that I have as accurately as some other children may, I tend to see them earlier.
Olitsky: Some surgeons might use antibiotics, for instance, after a deep scleral pass or in a patient who is functionally monocular. However, that brings up the question if you are using it in this group of patients, why not use it in every patient? Therefore, I do not adjust my routine.
Rogers: One reason I do not have parents routinely use antibiotics after surgery is that it is difficult in younger children. They do not want to open their eyes, and it becomes a forceful situation on the part of the parent to get the drops in. This is one of the reasons why I stopped using postoperative antibiotics. I may alter that a bit with some of the older kids whom I know will put the drops in. I do use postoperative antibiotics on adults, only because of possible lid problems.
Nelson: When you see the patient on the first postoperative visit after strabismus surgery, do you routinely perform a slit-lamp examination?
Campolattaro: I routinely check initial ocular alignment, visual acuity, and look for severe lethargy or discomfort. If any indicating signs are present, I will perform a slit-lamp examination.
Nelson: If the patient is a preverbal child, does that affect your procedure?
Campolattaro: No. I will still assess the patient's fixation of following ability and ensure he or she has the same vision postoperatively as he or she did preoperatively.
Olitsky: I do not routinely perform a slit-lamp examination. Not much is going to be gathered on the examination that could not be gathered any earlier than having the parent call you if there appears to be a problem.
Rogers: I would perform a slit-lamp examination only if I suspected a problem. If the eye were redder, if the patient was photophobic, or if he or she was uncomfortable sitting with his or her eyes open, then I would start to look for further causes.