Surgical Drapes Research Articles

Errors in visual estimation of flexion contractures during total knee arthroplasty

To quantify and reduce the errors in visual estimation of knee flexion contractures during total knee arthroplasty (TKA). This study was divided into two parts: Quantification of error and reduction of error. To quantify error, 3 orthopedic surgeons visually estimated preoperative knee flexion contractures from lateral digital images of 23 patients prior to and after surgical draping. A repeated-measure analysis of variance was used to compare the estimated angles prior to and following the placement of the surgical drapes with the true knee angle measured with a long-arm goniometer. In an effort to reduce the error of visual estimation, a dual set of inclinometers was developed to improve intra-operative measurement of knee flexion contracture during TKA. A single surgeon performed 6 knee extension measurements with the device during 146 consecutive TKA cases. Three measurements were taken with the desired tibial liner trial thickness, and 3 were taken with a trial that was 2 mm thicker. An intraclass correlation coefficient (ICC) was calculated to assess the test-retest reliability for the 3 measurements taken with the desired liner thickness, and a paired t test was used to determine if the knee extension measurements differed when a thicker tibial trial liner was placed. The surgeons significantly overestimated flexion contractures in 23 TKAs prior to draping and significantly underestimated the contractures after draping (actual knee angle = 6.1° ± 6.4°, pre-drape estimate = 6.9° ± 6.8°, post-drape estimate = 4.3° ± 6.1°, P = 0.003). Following the development and application of the measurement devices, the measurements were highly reliable (ICC = 0.98), and the device indicated that 2.7° ± 2.2° of knee extension was lost with the insertion of a 2 mm thicker tibial liner. The device failed to detect a difference in knee extension angle with the insertion of the 2 mm thicker liner in 9/146 cases (6.2%). We determined the amount of error associated with visual estimation of knee flexion contractures, and developed a simple, reliable device and method to improve feedback related to sagittal alignment during TKA.

A simple technique to aid intraoperative identification of the tibial mechanical axis during total knee replacement

BACKGROUND Successful total knee replacement (TKR) requires accurate component placement and coronal plane malalignment of greater than 3o varus/valgus from the mechanical axis has been shown to predispose to early failure.1–3 An extramedullary alignment jig is most commonly used to identify the mechanical axis. The distal end of the jig should be centred over the ankle mortise, which can be difficult to assess when the leg is covered by surgical drapes, particularly in obese patients.

288 DEVELOPMENT OF AN EXPERIMENTAL MODEL FOR ANOSMIA FOR CELL THERAPY PURPOSES

The olfactory sense is most important for social and environmental interaction, contributing to the quality of life. Its dysfunction, called anosmia, is followed by severe social problems. Anatomically, this is associated with changes in the nasal epithelium and the central and peripheral nervous system. Anosmia can be caused by infection, trauma, and cancer. Along with other olfactory disorders, anosmia occurs in ~50% of the population between 65 and 80 years of age and 75% of the population above 80 years of age. Because of the dramatic effect of such diseases, we aim to develop an experimental model of anosmia in rats as well as to culture stem cells that may be used for future cell therapy purposes. We used 15 adult Wistar rats (60 days). As a first step of our project, the animals were submitted to an experimental surgery to ablate the olfactory bulb (OB). The ocular bulb was used as reference to localizate transfrontal craniotomy. The surgical time for this procedure ranged from 40 to 50 min. The olfactory bulb has an elliptical shape and consists of soft tissue, almost gelatinous, which breaks up easily when manipulated or restrained by surgical instruments. Therefore, we chose to aspirate the tissue, using a urethral probe coupled to an aspirator. Removal of the OB resulted in bilateral cavities, elongated, situated between the cribriform plate of the ethmoid bone and brain. The postoperative period passed without major incidents. The skin suture was removed between 7 and 10 days after surgery. The animals were clinically evaluated each day for a period of 60 days. No animal showed signs of pain or discomfort, apathy, loss of appetite, or hypersensitivity in the surgical wound. However, the consumption of food and water was increased. Some animals lost their feeding selectivity, eating pieces of paper, shavings, and surgical drapes used to line the cages. In addition, we observed behavioural changes such as excitability and aggressiveness. Tests of revulsion at the smell of cats and perception of pungent odor demonstrated the lack of odor perception, consequently regarded as signs of anosmia. We conclude that the surgical technique used was effective and easy to perform in order to establish an experimental model for anosmia in rats. As a next step, potential stem cells derived from the olfactory epithelium were successfully isolated. A characterisation of these cells is currently under way, as well as preclinical tests to reveal the recovery of olfactory functions after cell therapy.

A Sterile-Freehand Reduction Technique for Corrective Osteotomy of Fixed Cervical Kyphosis

A technical note and a retrospective review of cervical osteotomy using an innovative reduction technique. To present the clinical and radiological outcomes and effectiveness of the sterile-freehand reduction technique for cervical osteotomy. SUMMARY OF BACKGROUD DATA: For a successful osteotomy, controlled reduction of deformity after complete release of bony deformity is the most critical step. Conventional "unscrubbed-scrubbed" manual reduction techniques necessitate multiple releases and retightening of the clamp and are inconvenient for the surgeon to control the force and monitor the surgical field closely. A total of 7 consecutive patients (5 male and 2 female; mean age, 52.6 yr) who underwent corrective osteotomy of the fixed cervical kyphosis by a single surgeon were enrolled. Radiographically, C2-C7 sagittal and coronal angle, and the chin-brow vertical angle were measured. In the prone position, the entire head and the Gardner-Wells tong were included in the surgical field, and a sterile rope was connected to a weight through a hole made in the surgical drape. After complete release of bony element and fixation of the caudal part of osteotomy with a prebent lordotic rod, the operator held the tong with right hand and gradually reduced the deformity to place the rod within the screw heads on the cranial part of osteotomy under close visual observation, with the support of the caudal part with left hand. RESULTS.: The type of osteotomy performed was pedicle-subtraction osteotomy in 5 cases and anterior-release-posterior osteotomy in 2 cases. The mean correction angle was 39.7° (28°-63°) on the sagittal plane and 9.3° (0°-16°) on the coronal plane. The mean correction of the chin-brow vertical angle was 37.1° (18°-61°). There was no neurovascular complication. Using the sterile-freehand reduction technique, the operator can obtain a safe, controlled reduction with close monitoring of the surgical field. The technique is potentially a simple and effective method to provide stable, 3-dimensional reduction for corrective osteotomies of the cervical spine.

Prevention methodologies against infection after total joint arthroplasty

Surgical site infections after lower extremity total joint arthroplasty procedures remain a substantial economic burden to the patient, the treating institution, and the healthcare system. The complexity of these surgical procedures creates the potential for various patient-related or surgery-related risk factors for infection. Although there is much literature regarding the use of many preventative methods, a consensus regarding the true efficacy and application of such practices generally is not available. In this review, we evaluated selected preventative measures including: the Centers for Disease Control and Prevention recommendations, skin preparation techniques, surgical draping techniques, operative dress, operating room ventilation, hair removal techniques, as well as operating room traffic control. Our literature review consisted of searching PubMed, EMBASE, Ovid, and other relevant orthopaedic journal databases. Preference was given to randomized-controlled trials, data from national registries, and meta-analyses within the past 5 years written in the English language. After reviewing the available literature, we present the authors’ current preferred infection prevention methodology and protocol.

Clear Surgical Drapes

Clear Surgical Drapes

Potential contamination of the surgical site caused by leakage from an interscalene catheter with the patient in a seated position: a case report

Continuous catheterized nerve blockade has been used for many years to provide effective analgesia postoperatively. We report a potential complication of interscalene nerve block performed with the traditional catheter-through-needle insertion technique. Specifically, leakage from the catheter insertion site posed a risk of contamination to the sterile surgical field. We also describe an alternative catheter design to overcome this leakage problem. We present a case of leakage from the catheter insertion site during the course of an interscalene nerve block with the patient in a beach chair position for shoulder arthroplasty. Using the traditional catheter-through-needle technique, an 18G 100-mm Tuohy needle was inserted between the C6 and C7 roots under ultrasound guidance. After confirming the needle tip position, 20mL of local anesthetic (1% ropivacaine and 0.25% bupivacaine 1:1) were injected. A 20G catheter was then threaded through the Tuohy needle and carefully secured with tape and dressing. In the operating room, leakage from the catheter insertion site started to disturb the adhesives of the surgical drapes and threatened the sterility of the surgical field. The catheter was removed prior to surgery upon the surgeon's request. Upon completion of the operation, a catheter was reinserted using an alternative catheter-over-needle method. Postoperatively, no leakage was seen at or around the catheter entry site. This case report serves as a reminder that leakage from the catheter entry site remains a troublesome and hazardous issue during continuous peripheral nerve block. Leakage from the catheter insertion site often occurs due to the loose fit of the catheter in the larger diameter hole left by the Tuohy needle. We have also shown the successful use of an alternative catheter-over-needle design to minimize the risk of leakage from the catheter entry site. This technique resulted in being particularly vital for shoulder surgery with the patient in the beach chair position.

Skin Avulsion Injuries with Use of Adhesive Surgical Drapes

Iodophor-impregnated adhesive drapes are commonly used to reduce the incidence of surgical site infections (SSI).While proper and discretionary use of drapes can provide significant benefit, there are potential risks. We present two cases of degloving injuries sustained from use of these drapes during total knee arthroplasty. The patients, deemed high risk for potential skin avulsion injuries, received standard wound care and close follow-up which resulted in healing of the lesions at 6-week follow-up.

A survey of surgical draping practices in small‐animal practice in the UK

Veterinary practices in the United Kingdom were surveyed to compare their surgical draping practices with Royal College of Veterinary Surgeons (RCVS) accreditation tier and other surgery-related factors. Using descriptive statistics and logistic or ordinal regression analysis (where appropriate), the relationships between draping material and accreditation tier and other surgery-related factors were assessed. Procedures were categorised as short or long. Two hundred and sixty-nine surveys were completed. Reusable drapes were used in 66 per cent of practices. Antibiotics were administered routinely in 38 per cent of short and 93 per cent of long procedures. Practices accredited as a Veterinary Hospital (VH) were 6.3-7.2 (short and long surgeries, respectively) times more likely to use disposable drapes, when compared with non-accredited practices. Use of dedicated surgical attire, draping the whole animal/table, and routine antibiotic usage were also positively correlated with disposable drape usage. Fifty-one per cent of practices rated infection rate as most important when choosing drape material. 'Best practice' techniques are associated with lower importance given to infection rate, and higher importance given to financial cost, when choosing drape material. Disposable drape use correlates with RCVS accreditation and with other aspects of surgical technique. Importance ratings awarded correlate with best practice procedures. Clinical relevance 'Best practice' draping procedures, that are not governed by RCVS accreditation scheme, are also more frequently performed in accredited VHs.

Surgical Access Warming Blanket to Prevent Hypothermia After Hip Arthroscopy

Surgical Access Warming Blanket to Prevent Hypothermia After Hip Arthroscopy

Antibacterial finishing reduces hospital textiles contamination. An experimental study

Introduction and methods Contaminated dressings are particularly suitable for growth of microorganisms and a well-known source of bacterial spreading in the hospital environment. This study evaluates the bacterial contamination of white coats and surgical gowns and drapes treated with a novel antibacterial finishing technology of hospital textiles. Bacterial contamination rates of untreated white coats and surgical gowns and drapes were compared to treated textiles. In vitro determination of antibacterial activity against reference bacterial strains and clinical isolates was performed according to the European guideline EN ISO 20645. Efficacy of the treatment was verified in clinical setting by comparing the amount of bacteria isolated from treated and untreated textiles used for clinical and surgical activities.

Effectiveness of a Radiofrequency Detection System as an Adjunct to Manual Counting Protocols for Tracking Surgical Sponges: A Prospective Trial of 2,285 Patients

Despite rigorous manual counting protocols and the classification of retained surgical items (RSIs) as potential "never events," RSIs continue to occur in approximately 1 per 1,000 to 18,000 operations. This study's goals were to evaluate the incorporation of a radiofrequency detection system (RFDS) into existing laparotomy sponge- and Raytec-counting protocols for the detection of RSIs and define associated risk factors. All patients undergoing surgery at the University of North Carolina Hospitals from September 2009 to August 2010 were enrolled consecutively. The performance of an RFDS-incorporated accounting protocol for detecting RSIs was prospectively evaluated. Several operative metrics were recorded to identify risk factors for miscounts. A total of 2,285 patients were enrolled. One near miss was detected by the RFDS. Thirty-five miscounts occurred, for a rate of 1.53%. The ultimate locations of miscounted items were surgical site (n = 11), within operative suite (n = 10), surgical drapes (n = 2), and emergency protocol deviations (n = 12). Perioperative variables associated with miscounts were higher estimated volume of blood lost, longer operations, higher number of laparotomy sponges used, open surgical approach, "after hours" operations, change of surgical team during operation, weekend or holiday operations, unanticipated changes in operative plan during surgery, and emergency operations. Body mass index was not associated with miscounts. Surveys completed by participating surgical staff suggested high confidence in the RFDS for prevention of RSIs. The incorporation of the RFDS assisted in the resolution of a near-miss event (1 of 2,285) not detected by manual counting protocols and assisted in the resolution of 35 surgical-sponge miscounts. No known RSIs occurred during the study period. Risk factors for miscounts were identified and can help identify at-risk surgical populations.

Comparison of Two Preoperative Skin Antiseptic Preparations and Resultant Surgical Incise Drape Adhesion to Skin in Healthy Volunteers

Adhesion of incise drapes is important at the wound edge, where the skin and drapes are contiguous with the wound. Separation of incise drapes from the skin has been reported to be associated with a sixfold increase in the infection rate compared with surgical procedures in which the drape did not lift off. The present study sought to determine whether the choice of preoperative skin preparation affects the adhesion of various incise drapes. Following randomization, the backs of twenty-two healthy volunteers were prepared with two skin preparations, 3M DuraPrep Surgical Solution Patient Preoperative Skin Preparation or ChloraPrep with Tint (Scrub Teal) Patient Preoperative Skin Preparation, according to the label directions. Sample strips (12.7 × 76.2 mm) of three different drapes were applied to the prepared areas and were covered with gauze soaked with saline solution for thirty minutes to simulate a fluid challenge. Drape samples were mechanically removed with use of a peel tester based on an international standard for testing peel adhesion of pressure-sensitive tape. Adverse events were monitored and the skin condition was observed. The primary outcome was drape adhesion, measured as the peel strength in units of gram-force. Outcomes were assessed according to drape type and skin preparation with use of mixed-model analysis of variance. Skin prepared with DuraPrep solution had significantly greater drape adhesion (mean peel strength, 181 gf) compared with skin prepared with ChloraPrep (79 gf, p < 0.001). Although maintaining good adhesion is important, an incise drape that has excessive adhesion may cause skin irritation. Regardless of the skin preparation used, the skin reaction at the application site ranged from none to moderate erythema, and in no instance constituted an adverse event that required treatment. The data suggest that the type of skin preparation affects drape adhesion. For surgical procedures in which incise drapes are used, choosing a skin preparation that enhances drape adhesion may minimize drape lifting and the potential for wound contamination.

Influence of Rescrubbing Before Laparotomy Closure on Abdominal Wound Infection After Colorectal Cancer Surgery

To test the hypothesis that strict asepsis in closing wounds following laparotomy reduces the risk for surgical wound infection in elective colorectal cancer surgery. Multicenter randomized clinical trial conducted from June 1, 2009, through June 1, 2010. Colorectal surgery units of 9 Spanish hospitals. A total of 969 patients who underwent elective colorectal cancer surgery were eligible for randomization. In closing the laparotomy wound, the patients were randomized to 2 groups: conventional (n=516) and new operation (n=453). In the conventional group, a new set of instruments was used, surgical staff changed their gloves, and the surgical drapes surrounding the laparotomy were covered by a new set of drapes. The new operation group involved removing all drapes, the surgical staff scrubbed again, and a new set of drapes and instruments was used. Incisional (superficial and deep) surgical site infection 30 days after the operation and risk factors for postoperative wound infections. A total of 146 incisional surgical site infections (15.1%) were diagnosed. Of these, 96 (9.9%) were superficial and 50 (5.1%) were deep infections. On an intent-to-treat basis, significant differences were found between both groups (66 [12.8%] in the conventional group vs 80 [17.7%] in the new operation group [P=.04]). This study does not support the use of rescrubbing to reduce the incidence of incisional surgical site infection. isrctn.org Identifier: ISRCTN19463413

Incêndio no centro cirúrgico

JUSTIFICATIVA E OBJETIVOS: A existencia de um ambiente rico em oxigenio, material combustivel em abundância e a utilizacao de aparelhos capazes de fornecerem ignicao transformam a sala cirurgica em um ambiente de risco para a ocorrencia de incendios. Apesar de rara, trata-se de uma complicacao potencialmente grave e na maioria das vezes evitavel. Relatamos um caso de incendio no campo cirurgico durante uma cirurgia de blefaroplastia em que foi suplementado oxigenio por meio de cateter nasal. RELATO DO CASO: Paciente de 52 anos, sexo feminino, sem comorbidades, admitida para realizacao de blefaroplastia bilateral. Apos monitorizacao e venoclise, procedeu-se a sedacao endovenosa com oferta de oxigenio suplementar por meio de cateter tipo oculos, com fluxo de 4 L.min-1, seguida de anestesia local das palpebras. Durante o ato cirurgico, a utilizacao do bisturi eletrico ocasionou combustao dos campos cirurgicos e queimaduras na face da paciente. CONCLUSOES: O anestesiologista desempenha papel fundamental na prevencao de incendio na sala cirurgica, reconhecendo possiveis fontes de ignicao e administrando de forma racional o oxigenio, principalmente com sistemas abertos. O primeiro passo para a prevencao deve ser a lembranca constante da possibilidade de incendio.

Flammability of topical preparations and surgical dressings in cutaneous and laser surgery: A controlled simulation study

Surgical fires are a rare, but serious complication of dermatologic procedures involving electrosurgical and laser devices. Given the lack of data regarding basic fire safety principles, many dermatologists remain unaware of this potential risk. We evaluated the flammability of topical preparations and surgical drapes commonly encountered in the immediate operative field during cutaneous and laser surgery. Surgical dressings, drapes, and pork belly skin were examined for fire risk upon exposure to isopropyl alcohol, chlorhexidine gluconate, and aluminum chloride under dry, saturated, and damp conditions. Both electrosurgery and a carbon-dioxide laser were used as ignition sources. At least some char was observed in 86 of 126 simulated conditions (68%). Flames occurred in 2 test conditions: dry underpad drapes and cotton balls exposed to the carbon-dioxide laser. In general, drapes and dressings dampened or saturated with isopropyl alcohol failed to ignite with electrofulguration or electrodessication, although sparks and moderate char developed on pork belly skin and the underpad drape. Materials dampened or saturated with chlorhexidine gluconate, which contains isopropyl alcohol, generated less smoke and char compared with materials exposed to aluminum chloride, which does not contain alcohol. Future studies may assess the flammability of materials in the setting of oxygen supplementation. In common cutaneous surgical environments, electrosurgery or ablative laser may lead to char and rarely to fire. Char may be seen in up to two thirds of simulated conditions, and in a minute proportion of conditions, fire is observed.

Fire in the Surgical Center

Background and objectivesThere are several factors in operating rooms that increase the risk of fire. Besides being an oxygen-enriched environment, it contains combustible materials and equipment with available ignition sources. Although fires in operating rooms are a relatively rare event, the consequences are potentially serious and mostly avoidable. We present a case report of a fire occurring in the surgical drape during a blepharoplasty in which oxygen was supplemented by nasal catheter. Case ReportFemale patient, 52-years old, without comorbidities, admitted to hospital for a bilateral blepharoplasty. After monitoring and venoclysis, the patient underwent intravenous sedation and additional oxygen given via spectacle-type catheter at a flow rate of4 L.min−1, followed by local anesthesia in the eyelids. During surgery, the use of electric scalpel provoked combustion in the surgical drapes and burns on the patient's face. ConclusionsAnesthesiologists play an important role preventing fire in operating rooms, as they can recognize possible ignition sources and rationally administer the oxygen, especially in open systems. The first step toward prevention is to be constantly aware of potential fire.

A Comparison of Reusable and Disposable Perioperative Textiles

Contemporary comparisons of reusable and single-use perioperative textiles (surgical gowns and drapes) reflect major changes in the technologies to produce and reuse these products. Reusable and disposable gowns and drapes meet new standards for medical workers and patient protection, use synthetic lightweight fabrics, and are competitively priced. In multiple science-based life cycle environmental studies, reusable surgical gowns and drapes demonstrate substantial sustainability benefits over the same disposable product in natural resource energy (200%-300%), water (250%-330%), carbon footprint (200%-300%), volatile organics, solid wastes (750%), and instrument recovery. Because all other factors (cost, protection, and comfort) are reasonably similar, the environmental benefits of reusable surgical gowns and drapes to health care sustainability programs are important for this industry. Thus, it is no longer valid to indicate that reusables are better in some environmental impacts and disposables are better in other environmental impacts. It is also important to recognize that large-scale studies of comfort, protection, or economics have not been actively pursued in the last 5 to 10 years, and thus the factors to improve both reusables and disposable systems are difficult to assess. In addition, the comparison related to jobs is not well studied, but may further support reusables. In summary, currently available perioperative textiles are similar in comfort, safety, and cost, but reusable textiles offer substantial opportunities for nurses, physicians, and hospitals to reduce environmental footprints when selected over disposable alternatives. Evidenced-based comparison of environmental factors supports the conclusion that reusable gowns and drapes offer important sustainability improvements. The benefit of reusable systems may be similar for other reusables in anesthesia, such as laryngeal mask airways or suction canisters, but life cycle studies are needed to substantiate these benefits.

Identification of foreign bodies on the ocular surface after uneventful intravitreal injections

Editor, Intravitreal injections with anti-Vvascular endothelial growth factor (VEGF) for various retinal diseases have become very common intraocular procedures worldwide. Known but rare complications to intravitreal injections are endophthalmitis, uveitis, an increase in intraocular pressure, retinal detachment and retinal tear (Day et al. 2011; Meyer et al. 2011). In addition, approximately 10% of the patients experience a self-limiting postinjection discomfort (Rodrigues et al. 2011). Although this surface discomfort is not sight threatening, it may affect the willingness of the patients to continue the treatment, in particular because of its repetitive nature. Here, we describe a potential cause of discomfort owing to foreign bodies after intravitreal injections of 0.05 ml ranibizumab (Lucentis; Genentech, South San Francisco, CA, USA), because we found small plastic particles on the ocular surface of patients during four procedures. All procedures were performed on different patients, at different dates and by different surgeons. To our knowledge, this has not been reported earlier. All patients had previously received uncomplicated intravitreal injections and they had all been done in the same manner. Injections are at our department routinely given under sterile conditions in an operating room with the patient in supine position without the use of a surgical microscope. Disinfection of the eyelids was carried out with topical 5% povidone-iodine and topical anaesthesia (0.5% tetracaine and 0.4% oxybuprocain). Handling and preparation of the 0.05 ml ranibizumab was performed under sterile conditions and according to the manufactures instructions. The medication was used before the expiration date. We used the package supplied 1-ml syringe, 18-gauge filter-needle [BD – BD Blunt Fill Needle - Filter 18G 1½ 1.2 × 40 mm (5 mikr.m.) REF305211] and the 30-gauge injection needle (BD Microlance 30G 0.3 × 13 mm REF 304000). 0.05 ml of ranibizumab was sucked up from the capped vial into the filter-needle (18G). The filter-needle was then exchanged with the injection needle (30G), which was attached on to the syringe. A sterile 40 × 40 centimetre surgical drape with a prefabricated ocular opening was placed over the eye, and an eye speculum was used to fixate the lashes. During the intravitreal injections, small plastic foreign bodies on the ocular surface were immediately observed after the intravitreal injection was completed, but before the eye speculum was removed. The foreign bodies were flat, transparent, purple in colour and with varying shape and a maximum size of 1 × 0.5 mm (Fig. 1A). The foreign bodies were removed from the limbus area and inferior fornix using a cotton tip (Fig. 1A). After removal of the particles, the procedure was completed with removal of the eye speculum and surgical drape, without further complications. No postinjection discomfort was reported. Cotton tip with the plastic particles (arrows) removed from the ocular surface (A). Superficial defect (arrow) in the plastic of 18-gauge filter-needle (B). The plastic foreign bodies, probably originated from the surface of plastic part of the filter-needle, were small, and superficial defects were found (Fig. 1B). These defects might have been caused by the manual attachment and removal of syringe from the filter-needle during preparation of the 0.05 ml ranibizumab. The particles may have been transferred to the ocular surface by sticking to the sterile surgical gloves. This is not the first time that plastic particles have been reported to shed from syringes (Cant et al. 1988) and silicone oil microdroplets originating from syringes have been reported intraocularly after anti-VEGF treatment (Kocabora et al. 2010). If the particles had not been removed they had most likely caused foreign body sensation and might have lead to infection or corneal epithelial damage. We suggest that care should be taken to observe for potential foreign bodies even though the intravitreal injection is given under sterile condition, and patients with continuous ocular discomfort after intravitreal injections should be evaluated for possible foreign bodies.

Radiation Exposure—Do Urologists Take it Seriously in Turkey?

A questionnaire was administered to urologists to evaluate attitudes and behaviors about protection from radiation exposure during fluoroscopy guided endourological procedures. The questionnaire was e-mailed to 1,482 urologists, including urology residents, specialists and urologists holding all levels of academic degrees, between May and June 2011. The questionnaire administered to study participants was composed of demographic questions, and questions on radiation exposure frequency, and the use of dosimeters and flexible protective clothes. If a respondent reported not using dosimeters or protective clothes, additional questions asked for the reason. Of the 1,482 questionnaires 394 (26.58%) were returned, of which 363 had completed answers. A total of 307 physicians (84.58%) were exposed to ionizing radiation, of whom 79.61% stated that they perform percutaneous nephrolithotomy at the clinic. Fluoroscopy guidance was the initial choice of 96.19% of urologists during percutaneous nephrolithotomy. Despite the common use of lead aprons (75.24%) most urologists did not use dosimeters (73.94%), eyeglasses (76.95%) or gloves (66.67%) while 46.44% always used thyroid shields during fluoroscopy. When asked why they did not use protective clothing, the most common answers were that protective clothes are not ergonomic and not practical. Results clearly highlight the lack of use of ionizing radiation protection devices and dosimeters during commonly performed fluoroscopy guided endourological procedures among urologists in Turkey.