key: cord-0884677-18s2mu3p authors: McGhee, Charles N.J.; Dean, Simon; Freundlich, Simone E.N.; Gokul, Akilesh; Ziaei, Mohammed; Patel, Dipika V.; Niederer, Rachael L.; Danesh‐Meyer, Helen V. title: Microdroplet and spatter contamination during phacoemulsification cataract surgery in the era of COVID‐19 date: 2020-09-19 journal: Clin Exp Ophthalmol DOI: 10.1111/ceo.13861 sha: c077d85ab7aa120b89fa6443f71a684ca43f09db doc_id: 884677 cord_uid: 18s2mu3p IMPORTANCE: Determine phacoemulsification cataract surgery risk in a Covid‐19 era. BACKGROUND: SARS‐CoV‐2 (Covid‐19) transmission via microdroplet and aerosol generating procedures present a risk to medical professionals. As the most common elective surgical procedure performed globally; determining contamination risk from phacoemulsification cataract surgery may guide personal protection equipment use. DESIGN: Pilot study involving phacoemulsification cataract surgery on enucleated porcine eyes by experienced ophthalmologists in an ophthalmic operating theatre. PARTICIPANTS: Two ophthalmic surgical teams. METHODS: Standardised phacoemulsification of porcine eyes by two ophthalmologists accompanied by an assistant. Fluorescein incorporated into phacoemulsification irrigation fluid identifying microdroplets and spatter. Contamination documented using a single‐lens reflex camera with a 532 nm narrow bandpass (fluorescein) filter, in‐conjunction with a wide‐field blue light and flat horizontal laser beam (wavelength 532 nm). Quantitative image analysis using Image‐J software. MAIN OUTCOME MEASURES: Microdroplet and spatter contamination from cataract phacoemulsification. RESULTS: With phacoemulsification instruments fully within the eye, spatter contamination was limited to <10 cm. Insertion and removal of the phacoemulsification needle and bimanual irrigation/aspiration, with irrigation active generated spatter on the surgeons' gloves and gown extending to >16 cm below the neckline in surgeon 1 and > 5.5 cm below the neckline of surgeon 2. A small tear in the phacoemulsification irrigation sleeve, presented a worse‐case scenario the greatest spatter. No contamination above the surgeons' neckline nor contamination of assistant occurred. CONCLUSIONS AND RELEVANCE: Cataract phacoemulsification generates microdroplets and spatter. Until further studies on SARS‐CoV‐2 transmission via microdroplets or aerosolisation of ocular fluid are reported, this pilot study only supports standard personal protective equipment. Globally, phacoemulsification cataract surgery is the most frequently performed elective surgical procedure. 1 Since the emergence of SARS-CoV-2 (Covid-19), experience with earlier coronaviruses (e.g. SARS-CoV-1, MERS) has prompted ophthalmologists to question transmission risks between patients and health care workers during aerosol and microdroplet generating procedures, specifically phacoemulsification and vitrectomy. 2-7 Elsewhere, concerns have been raised by specialties utilising ultrasonic equipment and the appropriate level of protective equipment required by health professional during a time of both symptomatic and asymptomatic Covid-19 transmission. 4, [8] [9] [10] [11] [12] [13] [14] Furthermore, knowledge of ocular tropism of viral agents is well-recognized, with several existing viruses (including SARS-CoV-1) isolated in the tear film, cornea, aqueous humor and crystalline lens. 6, [15] [16] [17] [18] [19] As SARS-CoV-2 has demonstrated both an extended incubation period between 2-14 days in patients, high rates of asymptomatic carriers and extended surface stability with a half-life >5 hours on steel and plastic, there appears to be multiple opportunities for virus transmission within health settings. 14, 20-23 Although SARS-CoV-2 RNA has been identified both in tears and exhaled air samples where symptomatic COVID-19 patients have been treated, no viable virus has been recovered from the tear film therefore the risk of This article is protected by copyright. All rights reserved. transmission by this route currently appears to be low. 19, [24] [25] [26] In addition to the unique viral characteristics that SARS-CoV-2 exhibits; piezosurgical procedures in maxillofacial, dental and orthopedic surgery have demonstrated significant aerosol, microdroplet and spatter generation resulting in contamination of the surgeon, assistant and surgical field. 8-10 During phacoemulsification cataract/lens surgery, piezoelectric crystals convert electrical energy into mechanical energy-producing ultrasonic vibration of a titanium phacoemulsification needle. 11 Emulsified lens is aspirated through the hollow needle, while pressurized irrigation in a surrounding sleeve maintains the anterior chamber, and cools the needle and surrounding tissue. 11 The purpose of this pilot study was to assess the extent of micro-droplet generation and spatter distribution during simulated phacoemulsification cataract surgery on porcine lens and provide insight into required personal protective equipment (PPE) use during cataract surgery. Notably, in the latter part of Experiment 2 Surgeon 2, a small tear was identified in the distal irrigation sleeve surrounding the phacoemulsification needle, associated with greater gown spatter (Figure 2 ) and the greatest extent of drape contamination (33cm). This may represent the "worst-case scenario" for routine phacoemulsification*. (Table 1) As with previous experiments demonstrating piezosurgical procedures in maxillofacial and dentistry, 10 This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved. Rising cataract surgery rates: demand and supply Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies Int Forum Allergy Rhinol New phacoemulsification technologies and special precautions in dentistry coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon Presumed Asymptomatic Carrier Transmission of COVID-19 Herpes simplex virus DNA in the lens one year after an episode of retinitis The severe acute respiratory syndrome coronavirus in tears The presence and impact of herpes virus DNA in recipient cornea and aqueous humor on graft survival following penetrating keratoplasty COVID-19 patients in earlier stages exhaled millions of SARS-CoV-2 per hour Dissemination of aerosol and splatter during ultrasonic scaling: a pilot study Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong Press. This article is protected by copyright. All rights reserved The authors wish to acknowledge support given to this pilot study by Dr Sarah Welch, This article is protected by copyright. All rights reserved.