The eye exposure incidents below underscore the need not only to include protective eye equipment as part of proper surgical attire, but also to make sure that goggles and faceshields don't slip down or leave unprotected gaps.

• A nurse assisting in an OR is splashed in the eye with a small amount of blood through a gap at the top of her goggles.
• A surgeon removing a piece of bone from a patient is hit in the eye by a bone chip and blood that flies up under his faceshield.
• An OR nurse is splashed in the eye with blood through the side opening of her goggles when laparoscopic trocars are removed from an abdomen, and the forced air from the pneumoperitoneum escapes.
• An OR attendant flushing a used suction tip is hit in the face and eyes by blood that splashes under his faceshield.
• A nurse injects cleansing solution through a contaminated endoscopy scope; stool blows through the air channel, over the plastic shield on her mask, under her glasses and into her eyes.

Eye exposures are a documented route of bloodborne pathogen transmission to healthcare workers.1-2 In one case, a healthcare worker was infected with both HIV and hepatitis C from a conjunctival exposure.3

Less than perfect
Goggles and faceshields have been shown to be effective in reducing the risk of blood and body fluid (BBF) exposures to eyes.4 But an analysis of 367 BBF exposures to workers in surgical settings (EPINet, 1997-2001) showed that in 74 percent of cases, workers were not wearing protective eyewear - goggles, faceshields or eyeglasses with sideshields - at the time of exposure. Unfortunately, even when healthcare workers wear protective eyewear, it isn't foolproof. Of the 367 BBF incidents, 271 involved exposures to workers' eyes; in 24 percent of these cases, goggles or faceshields were worn at the time of exposure. These data underscore that protective eyewear can fail to protect when blood and body fluids are ejected or squirt under pressure. They also can fail when goggles or faceshields either slip or leave unprotected gaps at the top or sides, or when they provide no seal above the eyes, letting blood or body fluids run down the forehead and into the eyes. Improved designs for protective eye and facewear may provide greater protection for workers under such circumstances.

Even though it's common for blood to spray or splash significant distances in surgical settings, typically only those working closest to the operative site wear protective eyewear. But all OR staff, regardless of their proximity to the operative site, should wear protective eyewear as routinely as surgical masks. That includes circulating nurses. A surgeon or scrub nurse might choose to wear both goggles and a faceshield, whereas a circulating nurse might wear goggles or a faceshield.

Practical wear tips
Consider these wearing tips:

• If goggles or faceshields don't fit comfortably, you'll be less likely to use them consistently. Try different brands until you find the proper fit.
• Wear protective eyewear that has a foam brow band that prevents blood and body fluids from dripping into eyes.
• Look for anti-fog coating on the lens to ensure good vision at all times.
• Face shields have a "certain amount of glare and shimmy" that can slightly reduce visibility, says Mark Davis, MD, in his book Advanced Precautions for Today's OR.5 At least one brand, Face-It Shields by Onyx Medical, has a "flat viewing area to minimize glare and distortion."
• Users often wear face shields over goggles. One brand of face shield, American Allsafe MonoShield Goggle/ Faceshield, integrates goggles into its design.
• Goggles come in both ventilated and non-ventilated models. Ventilated models can have either direct or indirect ventilation. You'll likely prefer the ones with indirect ventilation; they prevent fogging by allowing air circulation and also protect against (but don't fully prevent) exposures from BBF sprays or splashes. Non-ventilated models more fully protect against penetration of BBF but are also more likely to fog.
• You can order goggles with prescription lenses; you can also find oversized models designed to fit over prescription glasses.
• Some goggle makers claim to offer better peripheral vision (for example, the American Allsafe MRXV Safety Goggle).
• Blood splashes to eyes sometimes occur during removal and disposal of gloves and other contaminated items, according to Advanced Precautions for Today's OR. "For this reason, eye protection and masks should be worn during the entire procedure. The procedure isn't considered over until all biohazardous materials have been placed in appropriate bags or containers."
• Use hooded face shields for procedures where massive blood exposures are anticipated, such as orthopedic surgery, and in high-risk procedures on patients known to be infected with a bloodborne pathogen.
• If a loupe or other magnifier is required, face shields may not be practical.

Other hazards
Don't ignore other sources of eye exposure in ORs. Evaluate the safety features of infusion and blood-pumping equipment, blood bags, irrigation devices, suction canisters and other equipment containing blood or blood-contaminated fluids. Do junctions in tubing segments have positive-locking or Luer lock connections, not friction-fit ones? In a positive-locking mechanism, the parts snap together and are released by pressing a lever or tab; in a Luer lock, the two parts screw together. Include these safety criteria into the product evaluation and selection process to help reduce the risk of eye exposures for your surgical personnel.

References
1. Gioannini P, Sinicco A, Cariti G, Lucchini A, Paggi G, Giachino O. HIV infection acquired by a nurse. European Journal of Epidemiology. 1988;4:119-120.
2. Sartori M, La Terra G, Aglietta M, Manzin A, Navino C, Verzetti G. Transmission of hepatitis C via blood splash into conjunctiva. Scandinavian Journal of Infectious Diseases. 1993;25:270-271.
3. Ippolito G, Puro V, Petrosillo N, et al. Simultaneous infection with HIV and hepatitis C virus following occupational conjunctival blood exposure. Journal of the American Medical Association. 1998;280:28.
4. Jagger J, Balon M. Blood and body fluid exposures to skin and mucous membranes. Advances in Exposure Prevention. 1995;1(2):1-2,6-9.
5. Davis, M. Advanced Precautions for Today's OR. Atlanta, GA: Sweinbinder Publications, 2001; pp. 40-42.