Tracking infection source after blepharoplasty

Reviewed by Mark A. Alford, MD

Infections after blepharoplasty are uncommon with or without the use of an antibiotic ointment. However, if infections occur, be suspicious of community-acquired methicillin-resistant Staphylococcus aureus (MRSA), said Mark A. Alford, MD. 

He made those conclusions based on his prospective, cohort, observational study on the topic.¹ When antibiotic ointments are used, the infection rate after blepharoplasty is extremely low, at only 0.2%.

However, there are always concerns about contact sensitivity, bacterial resistance, and cost, explained Dr. Alford, North Texas Ophthalmic Plastic Surgery, Fort Worth, TX.
Though patients with an ointment allergy may fare fine in the long term, the short-term effects on appearance can be concerning, he said.
 

Two groups

Dr. Alford’s study compared two similar consecutive groups undergoing upper eyelid blepharoplasty.

In the first group, 384 patients who had blepharoplasty between 2011 and 2013 used bacitracin twice a day for a week. The average patient age was 69.2 years old, with a range of 38 to 87 years old. Patients were excluded if they had an obvious allergy or systemic antibiotic use within a week of surgery.

The second group included 158 patients who used lubricant eye ointment (Refresh PM, Allergan) twice a day for a week. The average patient age was 69.3 years old, with a range of 30 to 96 years old. Patients were excluded if they had an allergy to previous topical ointments or if they used systemic antibiotics. 

All surgeries were performed by Dr. Alford at two surgical centers. There was an identical surgical technique and surgical prep in all cases. Preoperative antibiotics were not used. All patients were seen at a week after surgery.

Results

In the bacitracin group, 3.65% of patients had an allergic reaction. Symptoms included bilateral erythema, edema, and itching. All cultures were negative. Once the ointment was discontinued, patients improved. Only 1 of the 384 patients had an infection, which turned out to be a unilateral non-MRSA infection. The patient received oral antibiotics, Dr. Alford said.

In the lubricant eye ointment group, 10 (6.3%) of patients had an infection. All infections were culture-positive for community-acquired MRSA. Nine of 10 infections were bilateral; after 158 patients, the study was discontinued.

Patients with community-acquired MRSA had their sutures removed and were given oral antibiotics, according to their culture.

“All resolved without sequelae, but patients were left with hypertrophic scarring,” he said.

Dr. Alford did a further analysis of patients with infection and found an average age of 68.2 years old; two had diabetes, there were no smokers, and there were no previous Staphylococcal infections. The center’s infection rate was only 0.2%, and he and other surgical staff were tested for MRSA but tests were negative.

So, Dr. Alford wanted to know why were there so many MRSA cases.

“It’s not unexpected,” he said. “It’s virulent, diverse, and epidemic in the United States. It’s increasing every year. I expect the source was postoperative wound contamination from a community source or self-inoculation from a nasal cavity.”

Dr. Alford concluded that allergic reactions to bacitracin were a little lower than the 8% reported before in the dermatology literature. He also said postoperative infections are uncommon with/without ointment but if they do occur, suspect community-acquired MRSA.

This research was not meant to promote any particular antibiotic but to encourage further investigation of this topic, he said.

Reference

1. Alford M. Infection rates comparing topical antibiotic versus antibiotic free ointment in blepharoplasty surgery. Am J Cosm Surg. 2015;32:149-153.

Mark A. Alford, MD

E: Alfordmark@charter.net

This article was adapted from Dr. Alford’s presentation at the 2016 meeting of the American Academy of Ophthalmology. He did not indicate any financial interest in the subject matter.