Coronavirus 2019 disease (COVID-19) caused by SARS COV-2 was first identified in Wuhan, China, and due to its high transmission power, it quickly spread to other countries. 1 Since the load of virus in the nasal cavity, sinuses, and nasolacrimal system is high, virus shedding from sinonasal cavity and nasolacrimal duct is one of the important routes of disease transmission. 2 Oculoplastic surgeons are at high risk for infection during orbital decompression due to direct contact with the ocular surface, nasolacrimal system, and sinonasal cavities. 3
Since no definitive treatment has been introduced for COVID-19, prevention and reduction of the risk of disease transmission is the most important way to prevent infection. 3 For this reason, in the oculoplasty department of Feiz Ophthalmology Hospital, Isfahan, Iran, we implement a special protocol for patients who are candidates for orbital decompression, which is based on our experience and existing guidelines for surgery during COVID-19 pandemic. The purpose of this paper is also to share this experience.
According to most of the oculoplastic societies, during the COVID-19 pandemic, to reduce the risk of infection transmission in orbital decompression surgery, surgery should be performed only in urgent and sight-threatening conditions such as optic neuropathy and orbital decongestion that have not responded to other medical treatments, and elective surgeries should be delayed if possible. 4 All patients who are candidates for orbital decompression should undergo chest x-ray and nasopharyngeal swab for COVID-19 Reverse transcription polymerase chain reaction (RT-PCR) test before surgery to determine their disease status. 5
Everyone in the operating room should wear personal protective equipment including N95 or FFP2 mask plus face shield, complete facial/head cap, non-porous gown, goggles, and gloves. 4 Povidone-iodine (iodine with the water-soluble polymer polyvinylpyrrolidone [PVP-I]) has high antimicrobial and antiviral properties and has been shown to be effective in vitro against severe acute respiratory syndrome and Middle East respiratory syndrome coronaviruses (SARS-CoV and MERS-CoV) but has not been shown to be effective in vivo. The use of PVP-I in the nasal cavity and mucosal surfaces has been safe, so it can be used to reduce the possibility of COVID-19 transmission through infected droplets and aerosols to the health-care workers during surgery. 6
Based on the available evidence, PVP-I has been used for many years as an intranasal cavity disinfectant before surgery to reduce surgical site infection and is also used to treat chronic rhinosinusitis. At concentrations less than 1.25% PVP-1, no evidence of thyroid dysfunction, mucociliary damage, or olfactory loss has been observed. 7 PVP-I solution of 5% or 10% can be ciliotoxic and cause mucosal damage, but the use of 1% solution on the surface of the eye, 0.4% solution in sinonasal cavity, and 0.5% solution for oral mucosa is safe. 8,9 Several protocols have suggested the use of PVP-I during surgery on the oral cavity or sinonasal cavity to reduce virus loading at the surgical site and reduce the risk of infection transmission. 7, 8 For preoperative patients, we use the novel strategy for the intranasal and intraoral preoperative use of povidone-iodine (PVP-I) presented by Mady et al.; 1 day before the operation, irrigation of the nasal cavity with 250 cc of diluted 0.4% PVP-I solution (10 ml of 10% PVP-I solution diluted with 240 ml of saline solution) and the oropharynx with 0.5% PVP-1 solution (resulting in dilution of 10% PVP-1 with a ratio of 1:20) is done at least four times. 8
In the operating room, to reduce the exposure to respiratory secretions during anesthesia, the surgical team stays out of the room during the induction of anesthesia and enters the operating room after the induction of anesthesia. After the patient underwent general anesthesia, some drops of 1% PVP-I solution are used on the ocular surface and cul-de-sac of the conjunctiva, and after 3 min, it is washed. 0.4% PVP-I-impregnated neurosurgical patty is also placed in the nasal cavity after the use of anesthetics and decongestants (used routinely before surgery) and removed after 5 min. 9
To avoid contact with the sinonasal mucosa in some special patients (e.g. COVID-19-positive patients), lateral orbital wall decompression can be considered as a temporary method to reduce optic neuropathy and orbital congestion, and complementary orbital decompression can be performed at another time. 10
We use transcaruncular approaches for decompression of the medial orbital wall and transconjunctival lower-lid approach for the lower wall. We first make a small osteotomy in the medial wall so that the tip of a 25-gauge straight lacrimal cannula enters the ethmoid sinus and then inject 0.4% PVP-I solution into the ethmoid sinus cavity using a 25- or 27-gauge straight lacrimal cannula and a 5-cc syringe and, after 5 min, complete the osteotomy and simultaneously suction the injected PVP-I. This should be done carefully and gently to prevent regurgitation splashes. These steps are also performed for decompression of the inferior wall and maxillary sinus cavity.
Irrigation of the maxillary sinus and ethmoid during orbital decompression surgery with PVP-I solution is a new idea. This method is safe and easy. Based on the available evidence, using PVP-I is one of the ways to reduce the virus load and reduce the possibility of COVID-19 transmission. 8 Therefore, this method can be used along with other proposed protocols for orbital decompression surgery during the COVID-19 pandemic.
In conclusion, to reduce the risk of COVID-19 transmission, orbital decompression surgery should be limited to urgent cases, and the use of PVP-I solution before and during surgery can be one of the ways to reduce disease transmission.