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Letters to the Editor Safe surgery checklist for cataract surgery in ophthalmic day centres in India Sir, Surgery is the only method to alleviate disability in several common conditions. However, unsafe surgery can lead to morbidity and mortality. In industrialised countries, nearly half of all adverse events in hospitalised patients are related to surgery and at least half of them are considered preventable. In 2008, the World Health Organisation (WHO) created the implementation manual for the WHO surgical safety checklist. The checklist was intended to be universally applicable with adaptations to fit specific disciplines.[1] It is administered at three critical junctures: before induction of anaesthesia, before skin incision, and before patient leaves the operating room. It was adapted for eye surgeries by The Royal College of Ophthalmologists, UK, in 2010 and the American Academy of Ophthalmology in 2012.[2,3] In a survey conducted with the members of the Royal College of Ophthalmologists, 94% of respondents considered that a preoperative checklist added value to cataract surgery. However, the participants in the study also recommended inclusion of blood glucose level check from the list.
Primary health care in the Western countries involves a structured health care with general practitioners and nurse practitioners. A majority of patients are well informed about control of comorbidities. Studies show that more than half of the diabetic patients have poor glycaemic control, uncontrolled hypertension, and dyslipidaemia; which are associated with high morbidity and mortality in the operation theatres. Their high prevalence of risk factors, such as hypertension, diabetes mellitus, renal insufficiency, chronic heart failure and chronic obstructive pulmonary disease, increases the incidence of perioperative myocardial ischaemia to as high as 31%. The mortality rate within 90 days of cataract surgery is 7.1/1000 patients.[4] Rather than mortality; negligent surgery, biometry error or wrong intraocular lens implantation are the main reasons for claims in the NHS. These can be prevented with proper planning of surgery and a checklist, ensures it. The Indian population also reflects a prevalence of hypertension in 57.4% (32% known) and controlled diabetes only in 28.8%. However, the structure of Indian healthcare is unorganised. Hence, the ophthalmologist has to ensure that blood pressure and sugar levels are controlled by the physician before the surgery. Hence, a checklist in Western scenario has to be adapted to Indian healthcare. H V Desai Eye Hospital, providing comprehensive and high volume eye surgery in Pune, has created its own checklist, for eye surgeries keeping in mind local needs.[5] Our checklists
Table 1: Safe surgery checklist for ophthalmic day centres Before anaesthesia
Before incision
Before leaving OT
Patient Identity Procedure Site Any allergy Consent
All team members Introduce with role Surgeon, anaesthetist and nurse Orally confirm patient, site, and procedure
Nurse and surgeon Orally confirm with team: Name of procedure performed Any equipment issues Nurse Instrument, sponge, sharp, suture count correct IOL labelled
Nurse Medical assessment Investigations: Blood sugar, urine, ECG, BP, serum creatinine Pre-anaesthetic evaluation/physician opinion Is the site marked Is IOL calculation/toric lens chart available BP under 140/90 mmHg RBS (if diabetic): 200 mg/dL Duration of starving Consent taken Any concerns Anaesthetist Anaesthesia machine and emergency medication check Are pulse oximeter and ECG monitors connected Does the patient have difficult airway/ aspiration risk If yes, are the equipment/assistance available Is BP under 140/90 mmHg?
Nursing team orally confirm Sterility indicator results, expiry of pack Equipment issues Any allergy Any concerns Anaesthetist BP: 140/90 mmHg Any patient‑specific concerns
Surgeon, anaesthetist and nurse Any variation in standard recovery and management of the patient
Surgeon Topical/peribulbar/subtenon anaesthesia Anticipated critical events Operative duration Vitrectomy Any specific instrument/equipment needed
Patient label/name with date of birth UHID Date of surgery: _____
BP: Blood pressure, ECG: Electrocardiography, RBS: Random blood sugar, UHID: Universal Healthcare Identifier, IOL: Intraocular lens, OT: Operation theatre
© 2017 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
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different from those at tertiary care hospitals, is suited to ophthalmic day centres in reducing errors [Table 1]. It is more comprehensive. Our proposal is important as it is mandatory for hospitals to have at least entry level NABH accreditation to be eligible for reimbursement by insurance companies. The checklist not only prevents errors but also helps in avoiding violence against doctors. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Srinivas V Hirekatur, Sindhu H Manjunath1 Ophthalmologist and Medical Director, Aditya Netralaya, Bengaluru, 1Medical Student, Kasturba Medical College, Manipal, Karnataka, India Correspondence to: Dr. Srinivas V Hirekatur, Aditya Netralaya, 244, 7th Cross, 6th Block, 3rd Phase, Banashankari 3rd Stage, Bengaluru ‑ 560 085, Karnataka, India. E‑mail:
[email protected]
References 1. World Alliance for Patient Safety. WHO Guidelines for Safe Surgery. Geneva: World Health Organization; 2008. 2. Kelly SP, Steeples LR, Smith R, Azuara‑Blanco A. Surgical checklist for cataract surgery: Progress with the initiative by the Royal
Comment on: Visual function of children with visual and other disabilities in Oman: A case series Sir, I read with interest the article titled, “visual function of children with visual and other disabilities in Oman: A case series” by Gogri et al.[1] The authors have not defined what they mean by visual function. It is already well accepted in literature that vision is not only just “visual acuity” but also how a person interprets his surroundings.[2] Visual function not only involves neurophthalmological assessment such as strabismus, nystagmus, and saccades but also higher visual function assessments such as visual field, visual attention, visual search, visual task performance, and visual recognition and orientation.[3] This information seems to be missing in the article. The article is a bit confusing as the topic is on visual function in children with special needs, but the article is mainly emphasizing on refractive error and low vision aids. In the abstract, the authors have mentioned that this paper presents the different methods of assessing visual function, outcomes and interventions. However, there is no mention of the outcomes of the interventions carried out except to state in the methodology section that glasses and low vision were prescribed and outcomes discussed with institution in‑charge and timely follow‑up recommended. In the result section of the article, the age group mentioned is 3–8 years (mean age
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College of Ophthalmologists to improve patient safety. Eye (Lond) 2013;27:878‑82. 3. Available from: https://www.aao.org/patient‑safety‑statement/ ophthalmic‑surgical‑task‑force‑surgery‑checklist‑2. [Last accessed on 2016 Nov 06]. 4. Available from: https://www.aao.org/Assets/0985ab39‑20ce ‑4779‑9322‑e718972edd86/635711977904770000/anesthesia‑ management‑of‑ophthalmic‑surgery‑in‑geriatric‑patients‑pdf. [Last accessed on 2017 Mar 05]. 5. Available from: http://www.safesurg.org/uploads/1/0/9/0/1090835/ eyehospitalchecklist.pdf. [Last accessed on 2016 Nov 06]. This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/ijo.IJO_194_17 PMID: ***
Cite this article as: Hirekatur SV, Manjunath SH. Safe surgery checklist for cataract surgery in ophthalmic day centres in India. Indian J Ophthalmol 2017;65:639-40. © 2017 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
8.7 years), however, in the abstract, the age group studied is 3–18 years. Likewise, the numbers in Group 4 need some clarification. Assessing visual function in children with other disabilities like cerebral palsy cannot be limited to the tests mentioned in this article as many of these children can have a cerebral visual impairment (CVI). CVI is emerging as the commonest cause of visual impairment in children both in the first and third world countries.[4] This condition due to its varied clinical presentation often goes unnoticed.[5] To assess CVI, it is important for pediatric ophthalmologist and optometrist to undergo specialized training. A proper assessment and management can give a much fuller life to these children. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Swetha Sara Philip Department of Ophthalmology, The Cerebral Visual Impairment Clinic, Christian Medical College and Hospital, Vellore, Tamil Nadu, India Correspondence to: Dr. Swetha Sara Philip, Department of Ophthalmology, The Cerebral Visual Impairment Clinic, Christian Medical College, Vellore ‑ 632 001, Tamil Nadu, India. E‑mail:
[email protected] 