Due to the COVID-19 pandemic, the use of facemasks or face coverings in the clinical setting has become necessary. It is important to recognise that facemasks can be a source of infection after eye surgery and consider ways to minimise the risk of post-op infection in at-risk cases.
The Coronavirus 2019 (COVID-19) pandemic lead to a lockdown in the UK on 23 March 2020. Whilst routine surgeries were suspended, our oculoplastic unit continued urgent surgery in line with recommendations [1]. Urgent procedures were performed for eyelid laceration repairs, well-defined eyelid tumours suitable for one stage excision and immediate reconstruction under local anaesthesia and sight-threatening entropion. To limit transmission from an asymptomatic carrier to others [2,3], we required patients and staff to wear a mask in the operating theatre.
Our usual surgical skin preparation involves cleaning the entire face with Chlorhexidine. A surgical drape is wrapped around the forehead and another placed under the chin. With patients wearing a non-sterile facemask, only the skin above the facemask could be cleaned to avoid contamination. A surgical drape is placed over the face to cover the facemask. We have concerns that the facemask may have compromised the sterility of the surgical operating field and also may have directed mouth pathogens upwards into that field. We have thus reviewed postoperative infection rates for procedures done in our minor operations unit since the lockdown compared with post-op infection rates for similar procedures done before the lockdown when masks were not worn.
Result
Fifty-one patients had surgery during the lockdown for trauma repair, eyelid malignancy, entropion and other lid malpositions. Topical Chloramphenicol ointment was given postoperatively. One patient had oral antibiotics after multiple procedures. Seven (13.7%) patients had post-op infections and needed oral antibiotics. Six of these had surgery for eyelid malignancy. One patient had an enucleation just before lockdown. He required revision of the inferior fornix and a lid tightening procedure to enable proper fitting of a conformer. In comparison, before lockdown when patients did not wear facemasks, only one (2%) of forty-nine patients had a post-op infection requiring antibiotics. A chi-square test of independence showed there was a statistically significant difference in infection rates with a p-value of 0.027.
Discussion
Studies have shown that the inside and outside of surgical masks are potential sources of bacterial load [4]. Although the patient’s facemask is covered by the surgical drape, it is impossible to create an airtight barrier. We encountered problems with poor mask fitting and inadequate seal around the masks causing fogging and steaming. To reduce the effect of fogging and steaming, the edges of the surgical mask was sealed across the bridge of the nose and vertical sides of the mask with micropore tape. Due to inadequate seal on surgical facemasks, there is the potential that the patient’s bacterial flora will contaminate the sterile surgical field, either by changing the direction of flow or by making the mask wet and a source of bacteria. Amir et al. reported an interventional study that showed air leaks from the superior edges of facemask blowing towards the eyes [5]. Also, the presence of the facemask compromises the adequate cleaning of the operation site. The use of a facemask during surgery may have contributed to the increase in post-post-op infections.
Our study reviewed data for oculoplastic procedures and showed a statistically significant increase in post-op infections when patients wore a mask. It is important to consider the implication of this on other ophthalmic surgery; in particular intravitreal injections [5], as postoperative endophthalmitis is a devastating complication. In our unit, there was no evidence of increased infection rates after intravitreal injections when patients wore a facemask. Nevertheless, it is important for all ophthalmic subspecialties to consider the possibility that mask wearing may contribute to increased post-op infections and act where necessary to mitigate this.
The risk of contamination from a face mask to the operation site is not only present during the operation. Wearing a facemask is now required in many places in the community, so patients may continue wearing a mask after surgery which potentially further increases the risk of developing an infection after surgery. After surgery, patients should be made aware that a face mask can be a potential source of infection. Good hygiene practices should be emphasised to minimise the risk of post-op infection. Surgeons should consider the use of post-op oral antibiotics in high-risk cases to minimise the risk of post-op infection after eyelid surgery.
Many of the changes to our clinical practice due to COVID-19 will remain in place for the foreseeable future. It is important to recognise how changes in surgical practice can affect patients’ surgical outcomes.
TAKE HOME MESSAGE
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Clinicians should be aware that facemask can be a potential source of infection after eyelid surgery.
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The importance of good hygiene practices should be emphasised to patients to reduce risk of transmitting infective particles from the facemask to the operated eye.
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When patients wear masks during surgery, the surgeon should consider post-op oral antibiotics in high-risk cases.
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All ophthalmic subspecialties should consider the implication of a patient wearing a mask during surgery.
References
1. RCOphth. Management of Ophthalmic Services during the Covid pandemic. March 2020:
https://www.rcophth.ac.uk/wp-content/
uploads/2020/03/RCOphth-Management
-of-Ophthalmology-Services-during-the
-Covid-pandemic-280320.pdf
(Last accessed October 2020)
2. Givi B, Schiff B, Chinn S, et al. Safety Recommendations for Evaluation and Surgery of the Head and Neck during the COVID-19 Pandemic. JAMA Otolaryngol Head Neck Surg 2020;146(6):579-84.
3. British Oculoplastic Surgery Society. Update Guidance on Infection Risk and Personal Protective Equipment (PPE) for Oculoplastic Surgery during the COVID-19 Pandemic. April 2020:
https://www.rcophth.ac.uk/wp-content/
uploads/2020/06/NEW-PPE-in-Oculoplastic
-procedures-170420-converted.pdf
(Last accessed October 2020)
4. Zhiging L, Yongyun Ch, Wenxiang C, et al. Surgical masks as source of bacterial contamination during operative procedures. J Orthop Translat 2018;14:57-62.
5. Amir H, Alon Z, Eitan L, et al. Patients wearing facemasks during intravitreal injections may be at a higher risk of endophthalmitis. Retina 2020;40(9):1651-6.
Declaration of competing interests: None declared.
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