Letters to the Editor Re: “Risk of Ocular Blood Splatter During Oculofacial Plastic Surgery” To the Editor: In their recent publication regarding blood splatter during oculofacial surgery, Stacey et al.1 have addressed an area of concern that is seldom accorded the importance that it deserves among ophthalmologists in general and oculofacial plastic surgeons in particular. Ophthalmic surgery is widely regarded to be relatively “bloodless” in nature. This may hold good for most ophthalmic subspecialties but not for oculoplastics. Most oculofacial plastic surgeons would clearly recollect more than 1 instance where they would have noticed blood on their spectacles, mask, or face at the end of a surgical turn. With the limelight being most often on needle-stick injuries and postexposure prophylaxis protocols, the conjunctival/mucous membrane exposure risk has frequently been overlooked. The study reports an alarmingly large percentage (80%) of blood splatters detected postoperatively on the eye shields used by the surgical team coupled with the observation that only 2% of blood splatters were recognized by the team intraoperatively. It is additionally worrisome to note that several other people in the operating room besides the surgeon are also at a definite risk of exposure. There are some additional issues that the authors would like to point out regarding the article by Stacey et al.1 Stacey et al.1 have not commented about blood splatter in surgeries involving patients on anticoagulants. This has been reported to be as high as 90% to 100%.2 They also discuss that the splatter rate was highly surgeon/surgical technique dependent, but there is no mention of whether any of the patients included in the study were actually known to be seropositive for HIV, HBV, or HCV. How much would this prior knowledge influence the surgeon to modify his or her surgical technique in such cases? Would this also have an influence on the search for blood splatter postoperatively on the eye shields in such cases? Additionally, it may probably be of benefit to look for blood splatter on permanently fixed operating room equipment because viruses such as HBV have been known to survive for up to a week in dried blood on environmental surfaces at room temperature.3 Stacey et al.1 have suggested a very simple and practical method of using luminol to detect blood stains on protective eyewear postoperatively that can suitably be applied to any surgical setup. In spite of certain limitations of the study, such as the lack of comparative analysis of blood splatter related to different oculofacial surgical locations, they are to be commended on their work that highlights the significant risk of intraoperative conjunctival blood splatter that oculofacial surgeons and their teams face on a routine basis.

Anuradha Ayyar, MD, FICO Devjyoti Tripathy, MS Suryasnata Rath, MS, FRCS Correspondence: Anuradha Ayyar, M.D., Ophthalmic Plastics, Orbit and Ocular Oncology Services, LV Prasad Eye Institute, Bhubaneswar, Odisha, India ([email protected]) The authors have no financial or conflicts of interest to disclose.

REFERENCES 1. Stacey AW, Czyz CN, Kondapalli SS, et al. Risk of ocular blood splatter during oculofacial plastic surgery. Ophthal Plast Reconstr Surg 2015;31:182–186.

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2. Holzmann RD, Liang M, Nadiminti H, et al. Blood exposure risk during procedural dermatology. J Am Acad Dermatol 2008;58:817–25. 3. Bond WW, Favero MS, Petersen NJ, et al. Survival of hepatitis B virus after drying and storage for one week. Lancet 1981;1:550–1.

Reply re: “Risk of Ocular Blood Splatter During Oculofacial Plastic Surgery” To the Editor: We appreciate the comments from Ayyar et al. regarding our article.1 They ask 2 interesting questions regarding the anticoagulation status and the infectious status of our patients. Unfortunately, neither of these outcome variables were part of our prospective study design. Patients in our practices and in this study were asked to stop all prescribed and homeopathic anticoagulation 10 days prior to oculofacial surgery. A small percentage of our patients are unable to do this due to systemic risks. We agree that patients who are anticoagulated are likely to present a higher risk for intraoperative blood splatter and should be treated accordingly. Likewise, whether or not patients had been diagnosed with human immunodeficiency virus, hepatitis B virus, or hepatitis C virus was not part of our study design. We agree that prior knowledge of these infectious sources should alter a surgeon’s mindset, leading to a decrease in periocular blood splatter. The purpose of our study was not so much to test this hypothesis but to assist this hypothesis in becoming reality.

Andrew W. Stacey, M.D., M.S. Craig N. Czyz, D.O., F.A.C.O.S., F.A.C.S. Correspondence: Andrew W. Stacey, M.D., M.S., Department of Ophthalmology, Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105 ([email protected]) The authors have no financial or conflicts of interest to disclose.

REFERENCE 1. Stacey AW, Czyz CN, Kondapalli SSA, et al. Risk of ocular blood splatter during oculofacial plastic surgery. Ophthal Plast Reconstr Surg 2015;31:182–186.

Re: “Orbital and Periorbital Extension of Congenital Dacryocystoceles: Suggested Mechanism and Management” To the Editor: We read with special interest the paper by Bernardini et al. “Orbital and periorbital extension of congenital dacryocystoceles: suggested mechanism and management”.1 We would like to report an additional iatrogenic case and pose to the authors a question the answer to which we believe is lacking in the literature.

CASE DESCRIPTION A 31-day-old male baby was referred for evaluation of orbital cellulitis. The patient had a history of bilateral congenital Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015

Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.

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