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International Journal of Nursing Practice 2014; 20: 179–186

RESEARCH PAPER

Surgical glove perforation among nurses in

ophthalmic surgery: A case-control study
Karen Mei-Yan Shek RN BN MN
Senior Registered Nurse, Eye and Refractive Surgery Center, St. Teresa’s Hospital, Kowloon, Hong Kong

Janita Pak-Chun Chau RN BN MPhil PhD

Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong

Accepted for publication December 2012

Shek KM-Y, Chau JP-C. International Journal of Nursing Practice 2014; 20: 179–186
Surgical glove perforation among nurses in ophthalmic surgery: A case-control study

Many of the ophthalmic surgical instruments are extremely fine and sharp. Due to the dim light environment required for
ophthalmic surgical procedures, the passing of sharp instruments among surgeons and scrub nurses also poses a risk for
glove perforations. A case-control study was performed to determine the number and site of perforations in the surgical
gloves used by a group of scrub nurses during ophthalmic surgery. All six nurses working in an eye and refractive surgery
centre in Hong Kong participated in the study. A total of 100 (50 pairs) used surgical gloves were collected following
50 ophthalmic surgeries. Fifty pairs of new surgical gloves were also collected. Every collected surgical glove underwent
the water leak test. The surgical procedure perforation rate was 8%, and none of the perforations were detected by the
scrub nurses. No perforations were found in any unused gloves. The findings indicate that glove perforations for scrub
nurses during ophthalmic surgery do occur and mostly go unnoticed. Future studies should continue to explore factors
contributing to surgical glove perforation.
Key words: glove, nursing, operative, personal protective equipment, professional–patient disease
transmission, surgical.

INTRODUCTION glove perforation rate has been reported in major plastic

Surgical gloves are worn by surgical personnel as part of
their personal protective equipment. However, the action
of pulling, pinching or twisting, and the use of surgical
blades or needles can result in glove perforations. Glove
perforations increase the risk for contamination of surgical
wounds and the transmission of blood-borne diseases
between patients and surgical personnel.1,2 A high surgical
Correspondence: Janita Pak-Chun Chau, The Nethersole School of
Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong.
Email: janitachau@cuhk.edu.hk
surgery (21.4%),3 gynaecological malignancies surgery
(93%)4 and orthopaedic surgery (15.8%).5 In ophthalmic
surgery, the reported perforation rate ranged 0.3–
21.8%.6,7 Types and duration of surgery were the two
main factors identified as contributing to surgical glove
perforation.8 Other contributing factors include the
experience of surgical personnel and techniques in han-
dling scalpels and sutures.9 As glove quality surgical tech-
niques and surgical instruments are improving, factors
contributing to glove perforation might have changed. A
more updated study of surgical glove perforation is thus
warranted.

doi:10.1111/ijn.12136 © 2013 Wiley Publishing Asia Pty Ltd

180
LITERATURE REVIEW
Surgical glove perforation
As surgeons’ and scrub nurses’ hands have direct contact
with patients’ blood and internal organs, surgical gloves
act as a protective barrier against blood-borne pathogens
from infected patients and vice versa. Surgical site infec-
tion (SSI) is a common nosocomial infection among hos-
pitalized patients. There are well-established guidelines
for hand hygiene, and the use of gloves aims to reduce
SSI.10 However, surgical hand scrubbing only reduces the
resident flora on the hands of surgical personnel.10 A
recent study reported that in 20 visceral surgeries, 21%
(27 out of 128) of the collected surgical gloves were
perforated, and there was evidence of bacterial migration
in 22% (6 out of 27) of the perforated gloves.11 Bacterial
migration was observed in six (55%) of 11 perforated
gloves (n = 194) in a study by Hübner et al.12 Misteli
et al.2 also examined surgical glove perforation and the
risk of SSI. In the 914 surgical procedures considered,
glove perforation was associated with a significantly
higher SSI rate of 12.7%, as opposed to 2.9% when glove
integrity was not breached.2
Although surgical glove perforation is common, most
cases are not identified at the time of the incident.4 In a
study examining glove perforations in general surgical
procedures, 61% of surgeons and almost 90% of scrub
nurses were unaware of their glove perforations.13
Factors contributing to surgical
glove perforation
Surgical glove perforations have been found to correlate
with the duration of wear. In a study of general surgery,
gloves worn for < 90 min had a lower perforation rate
(15.4%) compared with gloves worn for 91–150 min
(23.7%).8 Certain invasive surgical and dental procedures
that involve working with bony fragments or sharp instru-
ments have a higher risk of surgical glove perforation.14
The transmission of the hepatitis B virus from infected
surgical personnel to patients has been reported during
these procedures, and they are considered to be exposure
prone.15 Glove perforation can also be caused by mechani-
cal punctures or exposure to fluids, fat or chemical sub-
stances. For instance, the permeability of an intact glove
increases over time as it is exposed to aqueous fluids.
Hentz et al. reported that after 30 min of use, surgical
latex gloves had measurable latex hydration.16 In ophthal-
mic surgery, although irrigation fluids such as balanced
salt solutions are commonly used to maintain a stable
© 2013 Wiley Publishing Asia Pty Ltd
KM-Y Shek and JP-C Chau
intra-ocular pressure, direct contact with these fluids for a
long period with gloved hands does not often occur.
Moreover, the ophthalmic procedures are less invasive
and of shorter duration than other surgeries and might
lead to a smaller incidence of surgical glove perforations.9
Surgical glove perforation in
ophthalmic surgery
Three studies have investigated glove perforation in oph-
thalmic surgery. All three studies were case-control
studies. The sample sizes of these studies were ≈ 1000
gloves. The perforation rates for scrub nurses (10–16%)
were higher than for surgeons (0.3–4%).7,17 However,
there were limitations to these studies. The study con-
ducted by Miller and Apt did not include scrub nurses
among the participants.6 Although scrub nurses might
have a relatively low chance of direct contact with
patients’ wounds, they participate in equipment assem-
bly, and the handling and transfer of surgical equipment.
Moreover, a reliable and valid test for glove perforation is
essential as an accurate outcome measurement. The
amount of water used in glove perforation testing in these
studies is either much less than the US Food and Drug
Administration (FDA) approved water leak test (WLT)7
or not even reported.17 This lack of methodological rigour
adversely affects the validity of the studies and might lead
to biased results. Miller and Apt used a total of five tests
for each glove to detect perforations, including sensitive
tests such as air inflation and water submersion with
external compression.6 The high incidence of glove
perforations could be related to the series of vigorous
tests imposed on each surgical glove. Furthermore, with
the advancement of surgical techniques, most cataract
surgeries have shifted to an extra-capsular extraction
approach. Operation times for cataracts are shorter,
and new types of instruments such as the ultrasonic
phacoemulsification probe are now used.18 Thus, it is nec-
essary to re-examine the rate of and contributing factors
to surgical glove perforation in ophthalmic surgery to
inform clinical practice guidelines.
METHODS
Objectives
The objectives were: (i) to determine the number and site
of perforations in the surgical gloves used by a group of
scrub nurses during ophthalmic surgery; (ii) to compare
the surgical glove perforation rates between ophthalmic
surgeries of varying durations; and (iii) to compare the
Surgical glove perforation
difference in surgical glove perforation rates among dif-
ferent types of ophthalmic surgery.
Operation definitions
In this study, the presence of surgical glove perforations
was tested by the WLT.19 The FDA defines glove perfo-
ration as the existence of visible water drops leaking
outside the sample glove during a WLT.19 The WLT is
recommended to test for surgical glove leakage19 and is
frequently used by glove manufacturers to test for perfo-
ration.20,21 Surgery starting time is defined as the time
when the first surgical instrument is applied to the patient.
The surgery ending time is defined as the time when all
surgical instruments are removed from the patient. The
time between the starting and ending time was calculated
as the duration of surgery in terms of minutes.
Research design
This was a case-control study of used and unused surgical
gloves. A case-control design was adopted to compare
cases with matched controls.22 The cases were the gloves
worn by nurses during ophthalmic surgery, whereas the
matched controls were the new, unused surgical gloves of
the same brand and lot number.
Setting and samples
This study was conducted in an eye and refractive surgery
centre of a private hospital in Hong Kong. Quota sampling
was adopted. Ophthalmic surgeries were divided into two
groups according to the duration of the surgery. In the
study conducted by Miller and Apt, the glove perforation
rate for ophthalmic surgery completed within 61–90 min
was threefold (25.34%) higher than ophthalmic surgery
completed within 60 min (6.9%).6 Thus, in this study,
surgeries with a duration of ≤ 60 min were assigned to
Group I, and those with durations of > 60 min were
assigned to Group II.
As there is no reported data from previous research for
the estimation of effect size, a conventional medium effect
size, 0.3 for chi-squared test, was used. According to
Cohen,23 a sample size of 87 will be able to yield a power
of 80% in detecting a medium difference at a 5% level of
significance for a chi-squared test. Due to a lack of
reported data, a conventional 10% attrition rate was
added on top of the sample size to compensate for poten-
tial glove damage during the testing procedures. There-
fore, a minimum of 96 pairs of surgical gloves was
necessary for the study, and a total of 100 pairs were
finally collected.
181
Surgical gloves worn by scrub nurses were collected
after surgery. Every surgical glove worn by the scrub
nurses, including all surgical gloves replaced during the
surgery for any reason, was collected. Surgical gloves
from scrub nurses who adopted a double glove practice
were excluded. Gloves used in procedures involving
patients with known ocular or systemic diseases such as
hepatitis were excluded to reduce the potential risk of
infection when handling the used gloves.
Data collection procedures
Ethical approval was sought from the study hospital and
the Cluster Hospitals Clinical Research Ethics Commit-
tee. All six nurses working in the operating theatre of the
study hospital were approached and invited to participate
in the study. Participation was entirely voluntary, and
nurses had the right to decline participation at any time.
Informed written consents were obtained. Data regard-
ing ophthalmic surgery scrubbing experiences, hand
orientation and gloving practice were obtained.
Immediately after each surgery, scrub nurses collected
all their used gloves and put them in a sealed plastic bag
together with a data collection sheet. The data collection
sheet included information about the date of surgery, type
of surgery, and starting and ending time of surgery. A
collection box was placed in the operating theatre for
participating nurses to place their used gloves. At the end
of each surgery day, the researcher collected all the study
gloves from the collection box. A pair of unused surgical
gloves with the same brand and size as the used gloves was
randomly collected and put into a separate plastic bag
together with the data collection sheet. In this way, for
each pair of used gloves collected, another pair of unused
gloves was collected as a control. A case number was
assigned to each pair of collected gloves to replace the data
collection sheets. Thus, information about the type and
duration of the surgery was hidden from the assessor to
minimize any detection bias in the testing procedure.
Test procedures
The same assessor performed all the WLT. First, each
glove was examined for gross tears. The presence of any
gross perforations in the wrist region of the gloves, which
most likely occurred during glove removal, was assumed
to be not directly related to the surgical procedures.
Therefore, these gloves were regarded as damaged and
were excluded from the WLT.9 Second, used surgical
gloves were often wet and stained with patients’ body
© 2013 Wiley Publishing Asia Pty Ltd
182
Table 1 Duration of ophthalmic surgeries
Type of surgery Duration (minutes)
n Mean
Phacoemulsification cataract surgery 18 39.33
Extra-capsular cataract extraction 11 63.18
Vitreoretinal surgery 11 148.64
Strabismus surgery 5 128.00
Miscellaneous 5 47.00
Total 50 78.26
SD, standard deviation.
fluid and blood, resulting in glove adhesion, which made
them unsuitable for testing. Any breakages of surgical
gloves that occurred during the collection or testing pro-
cedure were recorded. Data concerning brand, model and
size of surgical gloves were determined by the imprint on
the gloves. Full personal protective equipment was worn
by the assessor, and standard precautions for handling
potentially transmissible infectious agents24 were adopted
throughout the glove testing procedure. The WLT was
carried out to determine the site and the number of per-
forations in each glove.19 The amount of water used in the
test was 1000 mL.
Statistical analysis
The data were analysed using spss-PC version 16.0 (SPSS
Inc., Chicago, IL, USA). Descriptive statistics were used
to summarize the incidence and clinical data. Surgery
duration was treated as a rank-ordered categorical vari-
able (≤ 60 min, > 60 min). Chi-squared test or Fisher’s
exact test was used to determine whether there was a
significant difference in the number of perforations
between groups. The level of significance was set at 0.05.
Normality assumption of the data was not required for the
binary data obtained in this study.25
RESULTS
Surgery information
A total of 100 (50 pairs) used surgical gloves were col-
lected following 50 ophthalmic surgeries, representing
10.4% of all ophthalmic surgery over the period from
December 2010 to January 2011 period. A total of 482
ophthalmic surgical operations were performed in the
study setting during this period. All surgeries were
© 2013 Wiley Publishing Asia Pty Ltd
KM-Y Shek and JP-C Chau
SD Minimum Maximum
12.57 20 65
7.65 50 80
53.90 65 240
28.79 80 165
41.58 10 100
54.48 10 240
performed under either local or general anaesthesia.
The 50 pairs of used gloves were collected from five
different types of ophthalmic surgery: 18 (36%) were
phacoemulsification cataract surgeries, 11 (22%) were
extra-capsular cataract extraction surgeries, 11 (22%)
were vitreoretinal surgeries, five (10%) were strabismus
surgeries and five (10%) were miscellaneous ophthalmic
surgeries.
The mean duration of surgery was 78.26 min (standard
deviation, 54.48; range, 10–240 min). The used surgical
gloves collected were subdivided into two groups: 25
pairs of used gloves were collected from surgery com-
pleted in ≤ 60 min (Group I), whereas another 25 pairs of
used gloves were collected from surgery lasting > 60 min
(Group II) (Table 1).
Glove information
All of the used gloves were manufactured by Ansell
Healthcare. Two different models, (i) Gammex Powder-
Free and (ii) Gammex Powder-Free Sensitive (Ansell UK
Ltd, West Midlands, UK), were identified 5.5–7.5. No
glove was replaced during the ophthalmic surgeries due to
detection of perforation, which implied no scrub nurse
detected any perforation during the surgical procedure.
Fifty pairs of new surgical gloves were also collected to
determine the presence of perforations in unused surgical
gloves. The types and sizes of unused surgical gloves cor-
responded to those of the used gloves collected (Table 2).
Nurse participants
All six nurses working in the eye and refractive surgery
centre participated in the study. Four were registered
nurses, and two were enrolled nurses. Their experience
Surgical glove perforation 183

Table 2 Surgical gloves information 100 used surgical gloves

(from 50 surgeries)
Control
Size of glove Gloves (N)

Used glove Unused glove Total Group I Group II

(≤ 60 minutes) (> 60 minutes) 100 unused
50 gloves 50 gloves surgical gloves
5.5 26 26 52
6 50 50 100
6.5 2 2 4
7 20 20 40
Intact Perforated Intact Intact
7.5 2 2 4 46 gloves 4 gloves (4%) 50 gloves 100 gloves (100%)
Total 100 100 200 (46%) (50%)

2 Phacoemulsification 2 Extra-capsular cataract

cataract surgery (2%) extraction (2%)
as scrub nurses ranged from 2 months to 4 years. All
nurses used their right hand as their dominant working
hand. Figure 1. Summary of findings of glove perforations.

Glove perforation glove perforation between surgeries of varying duration:

Every collected surgical glove underwent the WLT. All 19
the collected gloves were in good condition and suitable
for the WLT, and no glove was damaged by the testing
procedure. Perforations were found in four used surgical
gloves. Hence, the glove perforation rate was 4% (four
out of 100 used gloves). The wearers’ protection barrier
was regarded as broken when either or both gloves in a
pair had perforated; therefore, the surgical procedure
perforation rate was 8% (four out of 50 surgical cases).
No perforation was found in any unused gloves. A
summary of the glove perforations detected is presented
in Figure 1.
A single hole was found in each of the four perforated
surgical gloves, and all of them were right-hand gloves.
All four holes were found in the glove’s finger region.
Two of them were located in the thumb, one in the index
finger and the other in the fourth finger. Surgical suturing
needles were used in two cases (out of four) according to
the operation record. None of the perforations were
detected by the scrub nurses, as no glove substitutions
were performed during the surgical procedures. Details
regarding these four perforated gloves are shown in
Table 1.
There was no significant difference between the exist-
ence of perforations in used and unused surgical gloves
(P = 0.12). All of the perforated gloves were found in
surgeries that were completed in < 60 min (Group I).
Fisher’s exact test showed no significant difference in
≤ 60 min (Group I) and surgery > 60 min (Group II)
(P = 0.12).
Among the four perforated surgical gloves, two were
from phacoemulsification surgery for cataracts, whereas
the other two were from extra-capsular cataract extrac-
tion surgery (Table 3). No surgical glove perforation was
detected from vitreoretinal surgery or strabismus surgery.
Fisher’s exact test was used to identify any significant
difference in the existence of perforations per glove
among the five different types of ophthalmic surgery, and
none was observed (P = 0.66).
DISCUSSION
This study was limited by the small number of surgical
gloves collected. All the data are from a single centre,
and only one glove brand was examined; thus, the
generalizability of the findings is reduced. The present
findings revealed no perforations in the unused surgical
gloves. The result was consistent with a recent study,
which also revealed a zero perforation rate in unused
surgical gloves.9 Although some studies reported a higher
incidence of perforations (5.8%) in the unused gloves
using the same FDA testing method,6 it is difficult to
compare results between studies as different brands, types
and materials of surgical gloves were tested.
With regard to glove perforation during ophthalmic
surgery, the perforation rate was lower than the findings
reported by Nakazawa et al.17 and Prendiville et al.7 in

© 2013 Wiley Publishing Asia Pty Ltd

184
Table 3 Characteristics of surgical glove perforations in ophthalmic surgery
N Type of surgery Duration of
surgery
1 Phacoemulsification cataract surgery 20 min
2 Extra-capsular cataract extraction 60 min
3 Extra-capsular cataract extraction 60 min
4 Phacoemulsification cataract surgery 45 min
1984 and 1992, which were 10% and 16%, respectively.
Their high incidence might partly be explained by the use
of different glove testing methods. In these studies, gloves
were filled with water, and external pressure was applied
to the gloves to detect perforation. However, application
of external pressure on the tested gloves might create
extra openings on the weakened spots of the gloves
thereby yielding a falsely high perforation rate. Such per-
foration might not have directly resulted from the surgical
procedures and could have been induced by the testing
processes. Furthermore, there have been rapid changes in
ophthalmic surgical techniques in the last decade, and
most surgeries now adopt a minimally invasive approach
with different kinds of surgical instruments used. For
example, in the phacoemulsification surgery for cataracts,
the wound is small and, in most cases, no suturing is
needed.18 Since 2002, a new method of performing vit-
rectomy has been introduced, and new micro-instruments
and a trans-conjunctival approach are used to avoid the
need for either scleral or conjunctival sutures.26 The use of
lasers has also replaced traditional methods, which means
that surgical blades are no longer used in most eye refrac-
tive surgery.27 All these changes in surgical techniques
have decreased the use of sharp instruments during the
procedures and could have contributed to the overall
lower surgical glove perforation rate in the current
study.
Regardless of the relatively low incidence of surgical
glove perforations among scrub nurses, the unique intra-
operative environment of ophthalmic surgery might be
conducive to the occurrence of surgical glove perforation.
First, in addition to surgical scalpels and sutures, many of
the ophthalmic surgical instruments such as the lens hook
and intra-ocular scissors are extremely fine and sharp and
might easily puncture the surgical glove. Second, ophthal-
mic surgeons rely on the use of a microscope for highly
precise and delicate procedures in the patients’ eyes. The
© 2013 Wiley Publishing Asia Pty Ltd
KM-Y Shek and JP-C Chau
Glove size Location of perforation Experience as
scrub nurses
6 Right hand, palm side of index finger 1.5 year
6 Right hand, palm side of thumb 2.5 years
6 Right hand, palm side of thumb 2.5 years
5.5 Right hand, dorsum side of fourth finger 1 year
surgical instruments are transferred between the scrub
nurses and surgeons, whereas the surgeons usually keep
looking into the microscope instead of at the sharp instru-
ments. Moreover, the lighting of the operating room has
to be dimmed during the surgery to facilitate a clear view
for the surgeons under the microscope. It is therefore an
unfavourable working environment for both the scrub
nurses and surgeons to handle and deliver the sharp instru-
ments or needles to each other; these conditions might
contribute to accidental punctures.
The results of this study show that all the glove perfo-
rations occurred during cataract surgery completed
within 60 min, but no statistically significant difference
was found in the total number of glove perforations in
terms of duration or types of surgery. The results are
consistent with the findings of Prendiville et al.7 who also
reported no significant differences in the number of per-
forations on the basis of ophthalmic surgery duration and
type. In contrast, Miller and Apt found a higher incidence
of glove perforations in ophthalmic surgery of longer
duration such as vitreoretinal surgery.6 However, their
study examined the surgical gloves worn by surgeons
only, and this discrepancy might explain the different
result.
All surgical glove perforations found in this study were
located on the nurses’ dominant (right) hand finger
region. Contradictory findings were reported by Miller
and Apt who found more perforations on the surgeons’
non-dominant (left) hand finger region.6 This could be
explained by the different intra-operative role within an
ophthalmic surgery for scrub nurses and surgeons. It has
been suggested that the glove perforations were present
mainly on surgeons’ non-dominant hand because they
used the non-dominant hand to hold and load needles into
needle holders.6 For scrub nurses, their major intra-
operative activities are delivering, receiving, arranging
and assembling surgical instruments, activities which
Surgical glove perforation
mainly use their dominant hand.7 Therefore, the chance
of getting a puncture on their dominant hand could be
higher.
Two different models of surgical gloves were tested in
this study: Gammex Powder-Free and Gammex Powder-
Free Sensitive. In the study setting, different models of
surgical gloves were available, and the scrub nurses chose
whichever model of glove they preferred. All perforations
were detected in the Gammex Powder-Free Sensitive
type. According to the specifications provided by the
manufacturer, Gammex Powder-Free Sensitive gloves are
25% thinner than the Gammex Powder-Free gloves.20
There are no previous studies comparing the perforation
rate of these two specific types of surgical gloves.
Whether the thinner characteristic of Gammex Powder-
Free Sensitive gloves makes it more prone to perforation
was undetermined. Furthermore, a majority of the used
surgical gloves collected in this study were the Gammex
Powder-Free Sensitive type (94%); the Gammex
Powder-Free type only accounted for 6% of the 100 used
gloves collected. A more balanced sampling between the
two types of surgical gloves would be necessary to make
a comparison.
The operation record showed that the perforated
gloves identified belonged to three different nurses, and
they were all experienced scrub nurses. Although a higher
surgical glove perforation rate was found for a less experi-
enced radiologist than for the experienced counterpart in
another study,9 the total number of participating nurses in
this study was exceptionally small so the result for glove
perforations in terms of scrub nurses’ experience was not
conclusive.
The results from this study highlight the risk of glove
perforations and indicate that nurses should take every
measure to prevent surgical glove perforations. Due to
the dim light environment required for ophthalmic surgi-
cal procedures, the passing of sharp instruments among
surgeons and scrub nurses poses a risk for glove perfora-
tions. Using hands-free passing techniques such as passing
trays, magnetized mats or designated ‘neutral zones’ to
ensure that only one person touches the sharp instrument
at any time could reduce the risk.28,29 A Cochrane review
conducted by Tanner and Parkinson reported strong evi-
dence for the effectiveness of the colour-indicator double
gloving system,30 and the summary results showed that
using a colour perforation indicator system significantly
improves the awareness of glove punctures by wearers as
compared with standard double gloving.31 Routine use of
185
a glove integrity monitoring system for early detection of
a breach of glove integrity should be recommended.
CONCLUSION
In this study, 4% of used surgical gloves were found to be
perforated, and the surgical procedure perforation rate
was 8%. None of the perforations were noticed by the
nurses wearing the perforated gloves, all of which were
collected from surgery of the same type and similar dura-
tion. The findings indicate that glove perforations for
scrub nurses during ophthalmic surgery do occur and
mostly go unnoticed. Future studies should continue to
explore factors contributing to perforations. A larger
sample size, involving more participating nurses, would
be needed. An observational study exploring the intra-
operative activities of scrub nurses is recommended to
examine the causal relationship between surgical glove
perforations and surgery. The adoption of special intra-
operative skills while handling sharp objects should be
recommended. A glove perforation monitoring system
should also be developed to enhance the detection of an
intra-operative perforated surgical glove.
CONTRIBUTIONS
Study design: KMYS; Data collection: KMYS; Data
analysis: KMYS, JPCC; Manuscript preparation: KMYS,
JPCC.
REFERENCES
1 Centers for Disease Control and Prevention. Exposure to
blood what healthcare personnel need to know. 2003.
Available from URL: www.cdc.gov/HAI/pdfs/bbp/Exp
_to_Blood.pdf. Accessed 5 September 2012.
2 Misteli H, Weber WP, Reck S et al. Surgical glove perfo-
ration and the risk of surgical site infection. Archives of
Surgery 2009; 144: 553–558.
3 Barbosa MV, Nahas FX, Ferreira LM, Farah AB, Ayaviri
NA, Bariani RL. Risk of glove perforation in minor and
major plastic surgery procedures. Aesthetic Plastic Surgery
2003; 27: 481–484.
4 Manjunath AP, Shepherd JH, Barton DP, Bridges JE, Ind
TE. Glove perforations during open surgery for gynaeco-
logical malignancies. BJOG: An International Journal of
Obstetrics and Gynaecology 2008; 115: 1015–1019.
5 Al-Habdan I, Corea JR, Sadat-Ali M. Double or single
gloves: Which is safer in pediatric orthopedic surgery.
Journal of Pediatric Orthopaedics 2006; 26: 409–411.
6 Miller KM, Apt L. Unsuspected glove perforation during
ophthalmic surgery. Archives of Ophthalmology 1993; 111:
186–193.
© 2013 Wiley Publishing Asia Pty Ltd
186
7 Prendiville P, McDonnell PJ, Lee PP. Glove perforations in
ophthalmic surgery. American Journal of Ophthalmology 1992;
114: 397–404.
8 Partecke LI, Goerdt AM, Langner I et al. Incidence of
microperforation for surgical gloves depends on duration of
wear. Infection Control and Hospital Epidemiology 2009; 30:
409–414.
9 Leena RV, Shyamkumar NK. Glove perforations during
interventional radiological procedures. Cardiovascular and
Interventional Radiology 2010; 33: 375–378.
10 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis
WR. Guideline for prevention of surgical site infection.
1999. Available from URL: http://www.cdc.gov/hicpac/
SSI/001_SSI.html. Accessed 5 September 2012.
11 Harnoss JC, Partecke LI, Heidecke CD, Hubner NO,
Kramer A, Assadian O. Concentration of bacteria passing
through puncture holes in surgical gloves. American Journal of
Infection Control 2010; 38: 154–158.
12 Hübner NO, Goerdt AM, Stanislawski N et al. Bacterial
migration through punctured surgical gloves under real
surgical conditions. BMC Infectious Diseases 2010; 10:
192.
13 Brough SJ, Hunt TM, Barrie WW. Surgical glove perfora-
tions. The British Journal of Surgery 1988; 75: 317.
14 Tanner J. Choosing the right surgical glove: An overview
and update. British Journal of Nursing (Mark Allen Publishing)
2008; 17: 740–744.
15 Centers for Disease Control and Prevention. Recommen-
dations for preventing transmission of human immuno-
deficiency virus and hepatitis B virus to patients during
exposure-prone invasive procedures. Report. Centers for
Disease Control and Prevention, 1991. no. 40 RR08:
1–9.
16 Hentz VR, Cadossi R, Traina G. Double gloving and hydra-
tion. The Lancet 2000; 355: 1914.
17 Nakazawa M, Sato K, Mizuno K. Incidence of perforations
in rubber gloves during ophthalmic surgery. Ophthalmic
Surgery 1984; 15: 236–240.
18 Snellingen T, Evans JR, Ravilla T, Foster A. Surgical
interventions for age-related cataract. Cochrane Database
of Systematic Reviews 2002; (2): CD001323. doi: 10.1002/
14651858.CD001323.pub2.
© 2013 Wiley Publishing Asia Pty Ltd
KM-Y Shek and JP-C Chau
19 Food and Drug Administration. Code of federal regulations
title 21. 2010. Available from URL: http://www.
accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch
.cfm?fr=800.20. Accessed 5 September 2012.
20 Ansell Professional Healthcare. Gammex PF sensitive: Fea-
tures and benefits. 2009. Available from URL: http://
www.ansell.eu/medical/pdf/gloves/EN/Gammex%20PF
%20Sensitive.pdf. Accessed 5 September 2012.
21 Mölnlycke Health Care. Surgical gloves. 2010. Available
from URL: http://www.molnlycke.com/us/Surgical-
Products/Product-Selector—Surgical-Division/Tabs/
Product-Categories/Surgical-gloves/?activeTab=0.
Accessed 5 September 2012.
22 Portney LG, Watkins MP. Foundations of Clinical Research:
Applications to Practice, 3rd edn. Upper Saddle River, NJ,
USA: Pearson/Prentice Hall, 2009.
23 Cohen J. A power primer. Psychological Bulletin 1992; 112:
155–159.
24 Centers for Disease Control and Prevention. Standard pre-
cautions. 2007. Available from URL: http://www.cdc
.gov/ncidod/dhqp/gl_isolation_standard.html#.
Accessed 5 May 2011.
25 Cann A. Introduction to statistics. In: Cann AJ (ed.). Maths
from Scratch for Biologists. New York: Wiley-Blackwell,
2003; 69.
26 Aylward GW. Sutureless vitrectomy. Ophthalmologica
2011; 225: 67–75.
27 Slade SG. The use of the femtosecond laser in the
customization of corneal flaps in laser in situ keratomileusis.
Current Opinion in Ophthalmology 2007; 18: 314–317.
28 Stringer B, Haines T. Hands-free technique: Preventing
occupational exposure during surgery. Journal of Perio-
perative Practice 2006; 16: 495–500.
29 Watt AM, Patkin M, Sinnott MJ, Black RJ, Maddern GJ.
Scalpel safety in the operative setting: A systematic review.
Surgery 2010; 147: 98–106.
30 Tanner J, Parkinson H. Double gloving to reduce surgical
cross-infection. Cochrane Database of Systematic Reviews
2006; (3): CD003087. doi: 10.1002/14651858.CD003087
.pub2.
31 Tanner J, Parkinson H. Surgical glove practice: The evi-
dence. Journal of Perioperative Practice 2007; 17: 216–218.