Response to comments on: All India Ophthalmological Society (AIOS) task force guidelines to prevent intraocular infections

Dear Editor,

We would like to thank the authors[1] for showing interest in our manuscript by the All India Ophthalmology Society (AIOS) task force featuring guidelines for prevention of intraocular infections after surgical interventions.[2] The authors mainly address two issues which rightly need further discussion and introspection, which are (1) the issue of limiting the number of patients undergoing cataract surgery in one operating room per surgeon, maximizing the use of disposables, and optional use of intracameral antibiotics based on surgeon discretion and (2) patient features including control of blood glucose levels/diabetes.[1,2]

The authors quote the manuscript from Aravind Eye Care system, which has a clinical registry covering over 2 million cataract surgeries in India with similar rates of postoperative endophthalmitis compared to the US Intelligent Research in Sight (IRIS) registry.[3] As also quoted by the authors, there is a great variability of eye care setups in India, and Aravind is a large tertiary care institution that can possibly handle large-volume cataract surgeries due to the infrastructure and resources of the facility. The AIOS task force believed that the number of 25 eyes per surgeon in a 4-h session should be a reasonably high number of surgeries that can be accommodated in a majority of eye hospitals in India, without undue restrictions on the facility. Though this empiric number was reached based on a consensus discussion among the task force members who belonged to various parts of India, taking into consideration regional differences and the level of expertise available (even though no published data on this is available in the Indian database), individual ophthalmologists or institutions can exercise their judgment on the number of surgeries per session based on the surgeon’s skills and the institutional protocols based on the support infrastructure and human resources. While the guidelines by the AIOS are named as such since they provide basic knowledge for conducting surgeries while minimizing infections, we would like to reiterate and quell the authors’ concern that these are not legally binding or mandatory, since guidelines are known to evolve as science advances.[2]

Regarding the use of disposable accessories in the operating room, the guidelines do not make it mandatory. Our manuscript already mentions, “it is imperative for every surgeon in individual practice or for groups in group practice or hospitals to have their standard operating procedures (SOP) incorporating standard guidelines, customized to their prevailing situations.”[2] The individual practitioner and institutes can develop their own standard operating protocol based on their assessment of environmental factors and frame guidelines for reuse, indicating the number of times of reuse and the cleaning/sterilization protocol.

The burden of diabetes is increasing rapidly in India, and several patients may not have regular care with a physician/endocrinologist. Patients may be consulting with the general physician just before the cataract surgery at the time of pre-anesthesia testing. Therefore, the practicing ophthalmologists in the country are often faced with the challenge of balancing the following two: cataract-related blindness and systemic management of diabetes. While we agree that there are no published data from India about the optimum blood glucose levels before surgery, the AIOS task force has been lenient in recommending the criteria (such as fasting blood sugar of ≥140 mg/dL, random blood sugar of ≥200 mg/dL, and blood pressure of ≥160/95 mmHg). In general, such patients may not be taken up for any elective surgery by universal practice guidelines.[4,5] Similar results were published by a survey of ophthalmologists in Singapore.[6] However, the AIOS guidelines also state that if the patient is medically cleared by physician/anesthetist, the surgeon may proceed with the cataract surgery.[2]

We sincerely hope that this reply clarifies some of the concerns raised by the authors. The AIOS task force intends to lead studies in the future that provide scientific evidence to modify/add or delete statements from the published guidelines.[2] We further re-emphasize that the published guidelines serve as empiric considerations rather than as requirements.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.