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Conjunctival contamination during surgery: A possibility to avoid

Alfred A, Mansour III, MD, answers 4 Questions about preventing eye contamination in the OR.

Issue: September 2009

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I realized I had not given enough thought to eye protection prior to reading Alfred A. Mansour III, MD’s, recent article in the Journal of Bone and Joint Surgery on conjunctival contamination during surgery. It is an avoidable hazard that we all should be aware of and protected against.

For this month’s interview I asked him to share some of his work and thoughts for orthopedic surgeons to consider when making choices to protect their eyes from contamination during surgery.

Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: What is conjunctival contamination and why should surgeons consider it in their choice of eye wear?

Alfred A. Mansour III, MD: Conjunctival contamination refers to splashed foreign debris into a surgeon’s eye, specifically during a surgical procedure. This debris can contain potentially infectious agents such as Hepatitis C (HCV) and HIV. Just as surgeons choose other types of universal precautions such as gloves and gowns to protect themselves, so too should they protect an equally vulnerable portal of entry for infection — the eye, particularly since it is an easy task.

Jackson: Which types of cases deserve special consideration and how high is the rate of expulsed debris?

Mansour: Cases that deserve special consideration are all trauma cases and those during which splashed debris can be expected. These would include cases using oscillating saws, reamers, pulsatile lavage, burrs, high-speed drills, and arthroscopic equipment. Trauma cases are particularly important because often a detailed history of communicable diseases is unobtainable or limited due to the patient’s critical or compromised status.

The rate of expulsed debris is variable based on many factors, but can be as high as 100% of the time in some cases. The question I pose is the following: Even if the potential rate of expulsed debris is relatively low, why take the risk of conjunctival contamination? Our study suggests that readily available and easily applied disposable eye protection that is commonly found in every operative suite significantly reduces that risk when compared to wearing low-profile prescription glasses or nothing.

Jackson: What eyewear do you use and what do you recommend to your residents?

Mansour: I typically use the disposable plastic glasses available at our operative suites and recommend the same or contoured plastic glasses to other surgeons. I occasionally use standard loupes for upper extremity cases and place a full-face shield over the loupes if I either think the patient is high-risk for HIV or HCV, or if I expect a high rate of splashed debris during the procedure.

I have minimized my use of the combination facemask and eye shield because it rapidly develops condensation and limits my visualization when I wear it close to my face. This causes me to keep the eye shield a fair distance from my face, and as we found in our study this allows a large portal of entry for splashed debris above the eye shield.

Jackson: In your recently published paper on this topic, were there limitations in drawing conclusions for surgeons?

Mansour: There were several limitations in our study. First, there are nearly limitless combinations of head positions and various low-profile prescription glasses. We only tested a single type of glasses at a single head position, and therefore may have introduced bias our results based. The other limitation is that our study used a simulation model and used a femoral osteotomy as the generator of splashed debris. Operative exposure to splashed debris can vary greatly depending on the specifics of the case.

For more information:

• Alfred A. Mansour III, MD, is chief resident of orthopedic surgery at Vanderbilt University Medical Center. He can be reached at 1215 21st Ave. South, MEC, South Tower, Suite 4200, Nashville, TN 37232-8774. E-mail: alfred.mansour@vanderbilt.edu.

Reference:

• Mansour III AA, Even JL, Phillips S, Halpern JL. Eye protection in orthopaedic surgery: An in vitro study of various forms of eye protection and their effectiveness. J Bone Joint Surg (Am).2009;91:1050-1054.