Elsevier

World Neurosurgery

Volume 96, December 2016, Pages 610.e1-610.e4
World Neurosurgery

Case Report
Corneal Injury from Presurgical Chlorhexidine Skin Preparation

https://doi.org/10.1016/j.wneu.2016.09.035Get rights and content

Background

Chlorhexidine skin preparation has been shown to provide highly effective antimicrobial presurgical skin cleansing. However, there is a significant risk of ocular toxicity when it is used in periocular areas.

Case Description

We describe 2 cases of significant corneal damage resulting from 4% chlorhexidine gluconate preoperative skin cleanser, despite the use of protective occlusive dressing over the eyes. Because of the potential for severe corneal toxicity resulting from use of chlorhexidine, alternative agents such as 10% povidone-iodine should be considered for skin preparation near periocular areas whenever possible.

Conclusions

If chlorhexidine gluconate must be employed near periocular areas, great care must be exercised to avoid contact with the eyes, and additional protective measures (e.g., absorbent eye pads along with tightly occlusive dressings) must be used whenever possible.

Introduction

The benefits of preoperative use of chlorhexidine skin scrub for decreasing the incidence of surgical site infection have been shown in a large randomized controlled trial1 as well as a review and meta-analysis of the literature.2 However, if chlorhexidine inadvertently comes into contact with the ocular surface, progressive corneal damage can occur in a dose-dependent fashion.3, 4 At lower concentrations, chlorhexidine can cause toxic effects on the epithelial layers of the cornea and conjunctiva, which can cause transient epithelial disruption and abrasion. Typically, full recovery without lasting visual sequelae is possible.3 However, at higher concentrations, irreversible injury occurs to the corneal endothelial monolayer, which in humans lacks the ability to regenerate.3, 4 With sufficient loss of endothelial cells, corneal edema ensues, and the cornea loses its transparency; the resultant visual loss can be severe. Although lesser degrees of corneal endothelial injury may heal over a period of weeks to months, severe corneal endothelial injury results in irreversible corneal edema and accompanying visual loss that can be treated only by corneal transplantation.

There have been several reports of ocular toxicity occurring as a result of inadvertent exposure of the cornea to chlorhexidine applied to the skin as preparation for nonocular surgery. Phinney et al.5 described a series of patients undergoing nonocular surgery who had ocular exposure to Hibiclens (Mölnlycke Health Care, Norcross, Georgia, USA) (4% chlorhexidine gluconate, 4% isopropyl alcohol, purified water) during preoperative skin cleaning. All patients experienced corneal abrasion and corneal edema with reduction in visual acuity. In 2 patients, the corneal edema did not respond to treatment with corticosteroid eye drops, and the patients ultimately required corneal transplantation. Hamed et al.6 described a case of a pediatric patient who underwent Hibiclens skin preparation immediately before a craniotomy procedure; by the end of the case, the cornea was found to be completely opacified on the operative side with a complete corneal abrasion. Liu et al.7 recently described a case of a patient who underwent resection of gingival cancer with inadvertent ocular exposure to chlorhexidine skin preparation, which led to persistent corneal edema that eventually required corneal transplantation. We report 2 neurosurgical patients who experienced severe corneal toxicity and visual loss as a result of presumed inadvertent topical ocular exposure to the chlorhexidine skin preparation.

Section snippets

Case 1

A 61-year-old man with previously normal vision presented for ophthalmologic evaluation 1 day after undergoing an uncomplicated posterior cervical laminectomy, decompression, and arthrodesis with autograft from C3-7. The patient had been in the prone position throughout the procedure and underwent a 10-minute surgical preparation using chlorhexidine gluconate (Exidine 4%; CareFusion, Vernon Hills, Illinois, USA) with protective patching of the eyes using a transparent nylon breathable membrane

Discussion

Ocular injuries are infrequent after nonocular surgical procedures; 1 large retrospective study showed an incidence of approximately 0.056%.8 Anesthesiologists take various precautions, including eyelid taping and bio-occlusive dressing (e.g., Tegaderm) application to prevent ocular damage.9 However, in contrast to the cases in this report, such ocular injuries are generally superficial, resulting in corneal epithelial disruption, and usually heal completely within 24–48 hours without specific

Conclusions

The significant long-term patient consequences described in this report are reminders that special attention should be paid to protecting the eyes from exposure when employing chlorhexidine skin preparation in high-risk cases. Additionally, preoperative discussion of surgical risks should include possible toxicity from surgical scrubs balanced against risk of surgical site infections. Measures that may lessen such risks include using povidone-iodine skin scrubs as an alternative to

References (10)

There are more references available in the full text version of this article.

Cited by (26)

  • Review, analysis, and education of antiseptic related ocular injury in the surgical settings: Antiseptic Related Ocular Injuries

    2021, Ocular Surface
    Citation Excerpt :

    The collective adverse events of chlorhexidine are rare [3], and particular attention should be paid to its toxicity to the ears, meninges, and eyes. Severe corneal damage due to inadvertent exposure of tissues to chlorhexidine during orofacial surgeries, craniotomies, and facial reconstructive surgeries have been reported repetitively [8,9,11]. The ototoxicity of chlorhexidine has been explored in past studies.

View all citing articles on Scopus

Conflict of interest statement: This work received unrestricted grant support from That Man May See, Research to Prevent Blindness, and NIH NEI Core Grant for Vision Research EY002162. The authors have no financial interest in or affiliation with any of the products or companies described in this report.

View full text