Protocols involved in training allied ophthalmic personnel and setting up ocular microbiology laboratories in peripheral centers

Arpan Gandhi; Shalinder Sabharwal

doi:10.4103/jcor.jcor_235_20

OPINION CATEGORY

Year : 2022 | Volume : 10 | Issue : 1 | Page : 50-52

Protocols involved in training allied ophthalmic personnel and setting up ocular microbiology laboratories in peripheral centers

Arpan Gandhi¹, Shalinder Sabharwal²
¹ Laboratory Services, Dr. Shroff's Charity Eye Hospital, New Delhi, India
² Departments of Community Ophthalmology, Dr. Shroff's Charity Eye Hospital, New Delhi, India

Date of Submission	21-Oct-2020
Date of Decision	29-Apr-2021
Date of Acceptance	07-Jun-2021
Date of Web Publication	3-Feb-2022

Correspondence Address:
Arpan Gandhi
Department of Laboratory Services, Dr. Shroff's Charity Eye Hospital, 5027 Kedar Nath Road, Daryaganj, New Delhi - 110 002
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcor.jcor_235_20

Abstract

One of the most important causes of corneal blindness in our country is infective keratitis (IK). IK blinds at least 1.5 million eyes every year in the world; and its projected that India alone will have 0.6 million people blind due to IK by 2020. From studies describing it as a 'silent epidemic', to others referring to it as an 'ophthalmic emergency', IK is a problem which can not be ignored in a world of growing antibiotic resistance. The detailed protocols involved in setting the Ocular Microbiology set up and training staff would involve the core requirement in combating IK is to have targeted treatment specific to the causative microorganisms. This is possible when corneal scraping and microbiology work up is done for all patients presenting with IK. All eye hospitals and ophthalmologists should set up protocols for integrating microbiology services in their practice.We have been following the below training method and trained over 50 people from secondary centers, ophthalmic clinics and institutes . Before we thought of going ahead with this we had the consent and the ownership of the management to do so and they felt it was the need of the hour for such training protocols to be defined and implemented.We categorized the process into Capacity building,Infrastructure and Implementation and quality monitoring. The training also included Antibiotic Sensitivity .The process and reporting both were explained in detail. Also on how it was clinically relevant was explained.

Keywords: Nystagmus, prisms, strabismus

How to cite this article:
Gandhi A, Sabharwal S. Protocols involved in training allied ophthalmic personnel and setting up ocular microbiology laboratories in peripheral centers. J Clin Ophthalmol Res 2022;10:50-2

How to cite this URL:
Gandhi A, Sabharwal S. Protocols involved in training allied ophthalmic personnel and setting up ocular microbiology laboratories in peripheral centers. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Jun 2];10:50-2. Available from: https://www.jcor.in/text.asp?2022/10/1/50/337191

According to 2010 World Health Organization data, 4.9 million people suffer from bilateral corneal blindness globally,^[1],[2] and these numbers are as high as 23 million if we consider unilateral corneal blindness.^[3] By some estimates, 98% of corneal blindness exists outside the developed world.^[4] In India, corneal blindness has been projected to grow from 0.66% (2001) to 0.84% (2020), largely unilateral cases.^[3] These are expected to reach 10 million by the year 2020.^[3],[5] A recent national survey has attributed 7.4% of total blindness in Indians above the age of 50 years, second only to cataract.^[6]

One of the most important causes of corneal blindness in our country is infective keratitis (IK). IK blinds at least 1.5 million eyes every year in the world; and its projected that India alone will have 0.6 million people blind due to IK by 2020. From studies describing it as a “silent epidemic,” to others referring to it as an “ophthalmic emergency,” IK is a problem which can not be ignored in a world of growing antibiotic resistance.

The detailed protocols involved in setting the Ocular Microbiology set up and training staff would involve the core requirement in combating IK is to have targeted treatment specific to the causative microorganisms. This is possible when corneal scraping and microbiology workup is done for all patients presenting with IK. All eye hospitals and ophthalmologists should set up protocols for integrating microbiology services in their practice. We have been following the below training method and trained over 50 people from secondary centers, ophthalmic clinics, and institutes. Before we thought of going ahead with this we had the consent and the ownership of the management to do so and they felt it was the need of the hour for such training protocols to be defined and implemented. We categorized the process into capacity building, Infrastructure and Implementation, and quality monitoring.

Training Duration

We decided to impart microbiology training in small, structured courses of 2–4 weeks duration. The training course was designed to make the trainees independent in performing basic laboratory work and enhance their skill. A lot of hospital work and responsibility is shared by Allied Opthalmic Personnel and Optometrists, where they contribute to the daily working of the hospital and patient management. Many hospitals, would benefit in a, train young girls to become laboratory.

The training protocols and components were to Stress on Detailed Sterilisation protocols and Operation Room surveillance protocols.

How to take samples from the operation room, what samples are to be taken, and the frequency of culture samples from the operation room. These are explained in detail and all documentation, protocols, and reports are also shared. Corrective action and hospital infection control protocols are explained in detail during the training this along with slide staining was dealt with in great depth.

Maintaining a Record

A detailed log of patients with their registration number, disease, and diagnosis should be maintained. This will not only be helpful in making records available for tests which were done earlier, but also help in medico-legal or audit situations. In hospitals, which are equipped with an Electronic Medical Record (EMR), it is a good practice to incorporate a laboratory module in the EMR.

Indepth Idea of Budgeting

Was decided to include all the Human Resource Costs, Infrastructure, and Equipment, consumable. Explained the process of procurement and budgeting so that they can start the planning and execution in a structured way. A total estimated budget of around 120,000–140,000 rupees should be set aside. The main cost is for the microscope (around 30,000–40,000 rupees), Incubator costing 20000–25000 rupees and for the fridge (around 50,000 rupees) Gram's stain is estimated at 20 rupees/test and Giemsa stain and potassium hydroxide (KOH) preparation at 10-rupees/test. Blood Agar and Chocolate Agar usually costs 35-rupees/test and Sabouraud dextrose agar (SDA) costs 20 rupees/test. Additional costs of normal saline (15 rupees/100 ml), slide box of 50 slides (1000 rupees/box) and marking pen (60 rupees) should also be considered. Running cost of electricity and water supply is additional. These are all estimated costs and may have demographic variations. o the cost per patient would be 80–100 per patient culture versus 150–300 rs courier charge per patient sample to the main center. Secondary centers like ours get 5–10 ulcer patients every week so the saving of 200–300 rs per patient samples is evident as well as an early diagnosis and an early appropriate treatment protocol saves them from progressing to getting therapeutic keratoplasties.

Navigating Challenges

It is always a challenge to start a new procedure or practice. Getting trained and also sensitizing the staff and changing mindsets can be difficult initially. Fuerthermore, motivating patients to undergo an additional procedure in terms of scraping may be challenging. Maintaining inventory and paperwork also requires time and dedication. Building collaborations: With time, once the trainee is comfortable in laboratory diagnosis and treatment, he can collaborate with other eye hospitals, which could send their samples for review. Also, for diagnostic dilemmas, arrangement to send the sample to other national laboratories (like we get from all over to our hospital) should be made. Finally, data collection and sharing could be used for any future research projects that may be worth sharing with the ophthalmic fraternity. Even though numbers of existing corneal blindness are daunting, we must not forget that 80% of corneal blindness is preventable.^[4] Lot of work is being done in medical care and infrastructure, including successful eye bank development efforts and evolving techniques.

The process to be used for setting it up would be based on Infrastructure models and detailing was explained.

Identifying a Room

Preferably near the consultation room for ease of movement during a busy clinic. The room should be well lit, should have running tap water with a sink dedicated to staining procedures. A tabletop with washable surfaces and enough space to both stain the slides and later do bench work should be available. The room must follow all waste disposal guidelines and safety protocols as laid down by the hospital.

Microscope

A binocular compound table-mounted microscope with good lenses and illumination system is mandatory. It should be from a standard company with provision for an annual maintenance check for at least 3 years. Presently these are easily available in markets and even online.

Consumables

For daily laboratory work with an inventory system is required. This includes slide boxes, Cover Slips, Gram's Crystal violet and Gram's Iodine (HiMedia Laboratories), Giemsa stains. Gram decolourizer (95% ethyl alcohol) and 0.5% safranin are also required. Other stains like Zeil Nelson Stain can also be procured. KOH preparation for quick fungal testing is also important to have. Culture media-blood agar, chocolate agar, SDA are a must. Additional Media like Lowenstein Jensen media. It is important to track expiry dates of these media and order as per requirement. Culture swabs, culture sterile bottles, distilled water and marking pens are other essentials. The training also included Antibiotic Sensitivity. The process and reporting both were explained in detail. Also on how it was clinically relevant was explained.

So we recommend in this communication the challenges and below-mentioned recommendations.

The Need to be Building Collaborations

With time, once the ophthalmologist is comfortable in laboratory diagnosis and treatment, he can collaborate with other eye hospitals, which could send their samples for review. Also, for diagnostic dilemmas, arrangement to send the sample to other national laboratories (like we get from all over to our hospital) should be made. Lastly, data collection and sharing could be used for any future research projects that may be worth sharing with the ophthalmic fraternity.

Digital/TeleMicrobiology

We realized with the covid situation and the extreme ease with which the younger generation took to digital initiatives it would be a great idea to use it to share pics and this was also discussed with them. In fact great ideas to share this came up from them which we incorporated.

Stained Slides, reference material, and Standard operating procedure's were shared with them to use in their setups as well as reference material was shared.

Also as Part Resident/Fellow Training for Ophthalmologists and Optometrists

It was realized the importance to impart microbiology training to post-graduate residents and fellows during their training period. Small, structured courses of 2-4-week duration should be incorporated in the training curriculums. Such courses make the ophthalmologist independent in performing basic laboratory work and enhance their skill. Laboratory rotations are mandatory for postgraduates and fellows under training at our institute, and we encourage other training centers to also incorporate similar courses.

Advantages

The training and implementation would ensure reducing the Cost borne by the patient as well as help in Cost minimization and reducing the recurrent costs for the organization.

Even though numbers of existing corneal blindness is daunting, we must not forget that 80% of corneal blindness is preventable.^[4] Lot of work is being done in medical care and infrastructure, including successful eye bank development efforts and evolving techniques in corneal transplantation. However, more emphasis needs to be given to preventative care to address corneal blindness, which can be done through proper management of cases in the clinics. We hope that this paper will not only help general ophthalmologists but also institutes to set up laboratory services in their secondary centers for better uptake of services. This, when combined with tele microbiology could improve eye care services in areas of need, where a trained Allied personal could help the resident ophthalmologist with scraping and images could be relayed to the main center. Such simple steps and innovations could help us tackle corneal blindness in years to come in more systematic fashion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2.	Dandona R, Dandona L. Corneal blindness in a southern Indian population: Need for health promotion strategies. Br J Ophthalmol 2003;87:133-41.
3.	Oliva MS, Schottman T, Gulati M. Turning the tide of corneal blindness. Indian J Ophthalmol 2012;60:423-7. [Full text]
4.	National Programme for the Control of Blindness. Report of National Programme for Control of Blindness, India and World Health Organisation; 1986-89National Program for Control of Blindness and Visual Impairment. Available from: https://npcbvi.gov.in/writeReadData/mainlinkFile/File341.pdf. [Last accessed on 2020 Jun 04].
5.	Whitcher JP, Srinivasan M. Corneal ulceration in the developing world–A silent epidemic. Br J Ophthalmol 1997;81:622-3.
6.	Srinivasan M, Gonzales CA, George C, Cevallos V, Mascarenhas JM, Asokan B, et al. Epidemiology and aetiological diagnosis of corneal ulceration in Madurai, south India. Br J Ophthalmol 1997;81:965-71.