Perioperative antibiotic prophylaxis during phaco-emulsification and intraocular lens implantation: national survey of smaller eye units in England.

PURPOSE: To evaluate the commonest routinely used perioperative antibiotic, the preferred route of administration and the choice of antibiotic in 'penicillin allergy' by consultant ophthalmic surgeons in England. METHODS: A postal survey was conducted, between December 2008 and April 2009, among consultant ophthalmic surgeons working in smaller National Health Service Ophthalmic departments in England. Smaller units were defined by having a maximum of eight consultant surgeons and tend to be based in district general hospitals. The questionnaires were sent to all consultant ophthalmic surgeons irrespective of special interests. The three questions asked were: (i) Which antibiotic(s) do you use routinely for phaco-emulsification and intraocular lens implantation? (ii) What is your usual route of administration? and (iii) Which antibiotic(s) do you use when the patient states that they have 'penicillin allergy'? RESULTS: The questionnaire was sent to 401 consultant ophthalmic surgeons and 262 consultants (65.34%) replied. Further analysis showed, 44.7% used only intracameral cefuroxime, 31.7% used only subconjunctival cefuroxime, 2.3% used only subconjunctival gentamicin, 6.9% used subconjunctival gentamicin or cefuroxime, 0.4% used subconjunctival cefotaxime, 0.4% used subconjunctival ceftazidime and 0.8% used no antibiotic prophylaxis. One hundred and three (37%) used cefuroxime in patients allergic to penicillin and 47% switched to gentamicin in this situation. CONCLUSION: Routine phaco-emulsification and intraocular lens implantation is the commonest elective surgical procedure undertaken in the National Health Service and yet there is a wide variation in the use of prophylactic antibiotics in patients with or without 'penicillin allergy' despite The European Society of Cataract and Refractive Surgeons recommendations in 2007. Less than half of the surgeons working in smaller ophthalmic units routinely used intracameral cefuroxime and in 'penicillin allergy' only one-third used cefuroxime. This survey highlights the reluctance of using cefuroxime in patients allergic to penicillin despite evidence to the contrary.

An oculoplastic use for the temporalis muscle flap.

PURPOSE: To report a novel method of repairing a large periorbital defect with exposed bone, using a pedicled temporalis muscle flap and split thickness skin graft. METHODS: Interventional case note review with clinical photographs, computerised tomography (CT) imaging, intra-operative photographs and histology. RESULTS: A 77-year-old man presented with an extensive neglected ulcerating lesion extending from the left lateral canthus to the tragus of the left ear. An incisional biopsy of the 15 cm lesion confirmed the clinical diagnosis of an invasive squamous cell carcinoma. A CT scan demonstrated the tumour depth and there were no infra-temporal fossa or intra-orbital extensions or associated lymphadenopathy. A wide surgical excision was performed which resulted perioperatively in a large area of exposed zygomatic and temporal bone. A pedicled temporalis muscle flap was rotated to cover the exposed bone and therefore allow placement of a split thickness skin graft. At 3 months' follow-up the graft is viable and the surgical rehabilitative result is satisfactory. CONCLUSIONS: A pedicled temporalis muscle flap and split thickness skin graft is a good one-stage reconstruction technique when faced with a large area of exposed bone. The temporalis muscle provides a suitable recipient site for a split skin graft and enhances its chances of survival. This technique, to our knowledge, had not previously been reported in the literature.

Periocular necrotising fasciitis--a case report.

PURPOSE: To document the step-by-step reconstructive surgical rehabilitation, over a 12-month period, of a patient with severe periocular necrotising fasciitis. METHODS: This is a retrospective interventional case note review of a 68-year-old man who developed necrotising fasciitis a few days after an insect bite. He had severe facial cellulitis with subsequent necrosis of all four eyelids despite broad spectrum antibiotics. RESULTS: The initial management included performing a wide surgical debridement, with the removal of infected and necrotic tissue extending bilaterally from the forehead to the mouth. Split skin grafts were used to cover the extensive tissue defects. Subsequent horizontal eyelid shortening and full-thickness skin was required to correct severe cicatricial ectropions, eyelid displacement and improve lagophthalmos. CONCLUSIONS: Necrotising fasciitis is an acute fulminant infection of the subcutaneous fat and deep fascia. The initial appearance may look like cellulitis but necrosis quickly follows. Facial disease with extensive periocular involvement represents a significant management challenge.