Eyelid surgery is performed to correct changes to the eyelid that may be caused by reasons such as aging or genetic disposition. Among middle-aged and elderly individuals, the removal of the orbicular muscle and fat tissue during an upper eyelid blepharoplasty provides and increases the field of vision, particularly in the upper temporal region.
Because of the complexity and intricate nature of eyelid anatomy, complications do exist. The management of complications is just as important as the surgical technique. The success of the surgery lies in the hands of the patient as well as the surgeon. The best surgeon on earth will not obtain satisfactory results if the patients do not properly care for themselves after surgery.
Due to the COVID-19 pandemic, the use of facemasks or face coverings in the clinical setting has become necessary. It is important to recognize that facemasks can be a source of infection after eye surgery and consider ways to minimize the risk of post-op infection in at-risk cases.
The Coronavirus 2019 (COVID-19) pandemic has led to a lockdown globally. Whilst routine surgeries were suspended, our oculoplastic unit continued urgent surgery in line with recommendations.
Urgent procedures were performed for eyelid laceration repairs, well-defined eyelid tumors suitable for one stage excision, and immediate reconstruction under local anesthesia and sight-threatening entropion. To limit transmission from an asymptomatic carrier to others, 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.
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.
Studies have shown that the inside and outside of surgical masks are potential sources of bacterial load. 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.
It has been reported an interventional study that showed air leaks from the superior edges of facemask blowing towards the eyes. 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, 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 emphasized to minimize the risk of post-op infection. Surgeons should consider the use of post-op oral antibiotics in high-risk cases to minimize 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 recognize how changes in surgical practice can affect patients’ surgical outcomes.