Comment on: Purifying air over the operating field with a new mobile laminar airflow device to reduce the possibility of airborne contamination.

Abstract

We were interested to read the recent article by Osher et al.1 We had also previously reviewed the poster by Osher and Figueiredo, “A New Technology for Purifying the Surgical Field”, at the 2019 ASCRS Annual Meeting in San Diego that had a nice picture of the Operio System located adjacent to the patient and the surgical field. Point 1, we wish that photograph had been included in this article and the reason for the orientation or of the machine discussed further in the article. Prior to the San Diego meeting, we became concerned with the plethora of lint-like fibers on the surgical field at our institution, both clear and blue, particularly after visualizing one in Bela Lugosi-like horror in the anterior chamber on the first postoperative day (Figure 1). After recovery and ensuring that the patient did not develop endophthalmitis, we initiated a Quality Assurance Project that sought to identify the number, risk factors, and location of these fibers during a senior resident's 3-month surgical rotation (A.H.). Eighty-nine surgeries were performed between the attending and the senior resident, and 15 fibers were identified. Most fibers were seen on the approach to the eye as an instrument was inserted, but 7 were seen in the eye during nucleus manipulation, capsulorhexis, and cortex removal. Similar to the article by Osher et al., we had no episodes of toxic anterior segment syndrome, chronic uveitis, or endophthalmitis (Table 1).Figure 1 Table 1. - Fiber Location During Phacoemulsification Surgery. Cataract procedure step Cases, n Intracameral moxifloxacin injection 3 Cortex removal 3 Capsulorhexis 2 Nuclear cracking and manipulation 2 Wound closure 2 IOL injection 1 Viscoelastic removal 1 Trabecular microbypass device 1 Regarding Table 2, the denominator is 99 in the laminar flow group and 50 in the control group. We noted on initial review that the total number of fibers seen in the laminar air flow group was 13 in 99 eyes vs the control group of 16 in 50 eyes, which is only a difference of 3, which if we increased the denominator to 100 in the control group, the total number of fibers would probably double. In personal communication with the primary author, it became clear that the salient point that the article conveyed is that in the laminar air flow group, the number of fibers directly on the field was zero. In other words, all fibers in the laminar air flow group were brought onto the surgical field by an instrument that is similar to our small series, which had a very high fiber rate of 16.9%. Watson et al. in their comment on this article focus on the trend to move toward office-based surgery and they discuss a laminar downflow hood that they have been using for 1 year.2 As such, Osher et al. and Watson et al. should be complimented for addressing important factors in our surgical microenvironments including air flow, ventilation systems, the revolving door-like atmosphere in a teaching environment, and our drapes and gowns. Point 2, we would go further, like our orthopedic colleagues, to attempt to close our operating rooms to transit to protect the laminar flow, locate our automated medication dispensing systems inside our operating rooms, and recommend that we seek to eliminate or find alternatives to article and cloth-based drapes and towels. We support the efforts by Osher et al. to eliminate what we aptly defined in our Quality Assurance Project as “Fibers, Fibers, Everywhere!”