Ophthalmologist's research explores the presence of coronavirus, other pathogens on medical instruments

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Ophthalmologist Mark Breazzano worked with researchers at Johns Hopkins University School of Medicine to research the presence of coronavirus on medical instruments, and their work was published recently in a medical journal for eye doctors. Dr. Breazzano is a Central New York native who got his medical degree from Upstate Medical University. And he's been on the faculty at the Wilmer Eye Institute at Johns Hopkins in Baltimore. He's returning to Upstate this summer and joining the practice of Retina-Vitreous Surgeons of Central New York in Liverpool. Welcome to "The Informed Patient," Dr. Breazzano.

Mark Breazzano, MD: Thank you so much for having me.

Host Amber Smith: This study goes back to the beginning of the pandemic, when we have so many unanswered questions. Did you and other eye doctors see fewer patients because they were afraid of being infected with the coronavirus early in 2020?

Mark Breazzano, MD: Yeah, I think that's exactly right. There was quite a bit of hesitation on the part of patients and doctors to limit the spread of this disease that we knew so little about. And we did find that there was a dramatic decrease in the number of, patient visits and care that was being performed, especially in fields such as ours, in ophthalmology.

We actually, together with some colleagues across the country in vitreoretinal diseases like myself, we actually did publish, in (the journal) JAMA Ophthalmology, a study that showed how there was a decrease in these procedures that are known to be critical for saving vision, like retinal detachment repairs and intravitreal injections. That seemed to decrease from March through May of 2020, which, as you recall, is when the pandemic was really at its height here in America. And specifically in New York City is the first epicenter.

Host Amber Smith: Yeah, it was certainly scary times. Is there, or was there a specific risk of transmission of the virus through the instruments that eye doctors use?

Mark Breazzano, MD: It's a great question, and I think more evidence is definitely pointing in that direction, and that's why it's really important for many of us, you know, even the just routine patient encounters with thesesubsequent mutations of the virus. But we did know that early on, it probably all started actually with Li Wenliang, who was an ophthalmologist in China, who actually sounded the alarm bells to this whole pandemic and novel coronavirus to begin with. And so that actually set the stage for some work and research that we did in New York City while I was there, as a fellow at Columbia New York-Presbyterian and a few other collaborative hospitals, we actually surveyed residency program directors from all different specialties in New York city, because in a way, it gave us a very good cross-sectional analysis. So basically a single time point across the city with different specialties to see if there was a difference in rate of resident doctors or physicians being infected with the disease, relative to one another. And we actually published this in the Journal of Clinical Investigation in the spring of 2020 as well.

And we would actually demonstrate it was ophthalmology, emergency medicine and anesthesiology were among the three most highly infected specialties across medicine. And we hypothesize that this is because of the nature of it being a little bit higher risk. So aerosolizing procedures with emergency medicine and anesthesia make sense. So, as we know, novel coronavirus is primarily a respiratory disease that's spread with aerosolized particles. The ophthalmology part may not be quite as obvious, but given Li Wenliang in China and our own experience, a couple of my colleagues were some of the first to be infected I knew of in New York that triggered this study,it actually makes sense pathophysiologically because ofjust the nature of the anatomy.

Host Amber Smith: Do you know of any cases where it's been documented that a person contracted the coronavirus through their eye?

Mark Breazzano, MD: Li Wenliang was actually a good example, supposedly in the contract tracing, I believe anecdotally, some of the information surrounding this isn't widely known, but it is thought that he was performing gonioscopy, which is basically this lens we put on top of the eye to look at the drainage system in the front of the eye. And so, there is quite a bit of evidence to that effect. That's why it's actually very important in treating COVID-positive patients, that there's eye protection. And so it's been a pretty much standard safety measure for a lot of our practice.

And so, with ophthalmology, virtually every slit lamp will havea Plexiglas shield, that's actually very cheap and easy to implement, on the slit lamp that's placed between the patient and the examiner. Typically with our ophthalmology exams, we are only inches from the patient's eyes or in the face, and so, that's been pretty well established to reduce the rates. Now, the other aspect, too, is, it makes sense because there have been reports that have been published with the virus actually replicating from the surface of the eye and findings with the tears, so the liquid that comes around the eyes actually harboring the virus. And so, there's a lot of evidence that directly links the periocular and ocular tissue to transmitting or being a part of the transmission process. And, for those that might not be as familiar with the anatomy around the eye, the tear duct actually does open up into the nasal cavity, which directly connects it to the respiratory system. So it does physiologically make sense.

Host Amber Smith: Now, you mentioned a slit lamp. Is that different than a regular lamp that someone might have at their house?

Mark Breazzano, MD: Yeah. People who've had contact lens fittings or other type of routine sort of eye visits, but not necessarily a complex retinal detachment, but anything and everything in between, often typically involves a slit lamp exam. So it's a very specialized piece of equipment that most eye doctors will use. Some ocular plastic surgeons may use it less frequently than other eye doctors, but essentially it's a piece of equipment that helps us examine the anatomy, in great detail: the front of the eye back of the eye and around the eye.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Mark Breazzano. He's an ophthalmologist who went to medical school at Upstate, and he's in the process of returning to his alma mater from the Wilmer Eye Institute at Johns Hopkins University.

What can you tell us about how the study was set up, and what you were hoping to learn?

Mark Breazzano, MD: Well, the study was set up because as the other studies had kind of shown were that ophthalmology did have a unique risk of potentially transmitting the disease between patients and between staff and doctors, and given this heightened risk relative to other specialties, we wanted to sort of investigate and see if there was anything, particularly with this equipment and with other aspects of the practice that might lead to that increased risk. And what we found was interesting. So with the slit lamp we were talking about and other pieces of equipment, there was actually isolation of some of these pathogens, including the coronavirus, so germs and bugs that could cause infection, not only with the coronavirus, but other commonly encountered bacteria that can be found in the environment and sometimes can be pathogenic. And this was despite normal cleaning measures that we do encounter every day to help protect our patients. And these were most likely heightened from the pandemic itself and maybe not performed as rigorously as they normally would be.

Host Amber Smith: So we have heard that the virus, the coronavirus, spreads through the air, mostly when someone coughs or sneezes. Early on, there was this fear that the virus might spread on surfaces. A lot of people were wiping down groceries or not touching things. So, I thought that was disproven, that it was mostly just airborne. Is the surface of medical instruments different, from the virus's point of view, than the surface of a countertop or a doorknob?

Mark Breazzano, MD: Yeah, it's a really good question. So certain surfaces, like copper, are actually very good at being viricidal, so it's very hard for pathogens, like the novel coronavirus, to actually reside there and not be damaged. So that we don't really have to worry about.

But other more inert objects, like plastic and whatnot, it can actually hang around for quite a bit. It can hang around for hours. Now, the question and the real limitation to all of this is, is it enough to be pathogenic? And like you suggested from the other studies and what we do know, and wiping down groceries seemed silly in retrospect, the answer to that is probably that it's very much less likely to actually cause infection, if that makes sense. But what's notable about this study is, the virus is certainly still hanging around even up to a day after that was supposedly cleaned the day before. And so it just is more of a telltale sign that we just need to make sure that we are being diligent with these cleaning practices. And I think the other aspect of it, too, is that there is a potential that other more innocuous pathogens, some might actually normally occur on our body, can actually, potentially, cause disease and colonize on the body if not already present there.

Host Amber Smith: So your study looked at 33 patients or samples from patients from one location. Is that enough to make these conclusions, or are you aware of other studies that have similar findings to yours?

Mark Breazzano, MD: Well, these weren't taken from patients. These were samples taken from different locations within different clinics. And we did do several different samples from each type of situation within those clinics, and so we felt that it was relatively generalizable. At the Wilmer Eye Institute here in Baltimore, it is convenient in the sense that there are multiple subspecialty clinics to give that external validity to other places where you might only have one kind of clinic, and so that, I think helped increase the generalizability of the findings.

And it actually also supported some findings that were done in a similar study back in 2005. Ophthalmology, the journal, actually published something similar where they took 34 samples from across the country, using ultrasound equipment. So the same technology you would use for looking at a fetus or an unborn baby in an obstetrics clinic, we actually use the same kind of technology to look inside an eyeball that you can't look into if something's in the way. And with that equipment, there's jelly that's put on the surface of the eyelid to look into the eye, and so there's patient contact there. And a team of doctors actually looked, out of the university of Texas, and they did find that there wereabout half of samples that, despite cleaning measures, including wiping with alcohol wipes, over about half of these samples actually grew different bacteria and pathogens.

So this isn't a new issue, and it's one that's still challenging because it comes back to the issue that it's very hard to directly link any causes of infection because of these isolated incidents, because we are not routinely looking for these, and maybe we don't need to.

Host Amber Smith: Well, let me ask you, can patients expect, or should they be able to expect, that medical instruments are 100% free of microorganisms of any sort when they come for a procedure?

Mark Breazzano, MD: There is a distinct difference between sterile and clean procedures. When you go to the operating room, that's a sterile procedure, and there are certain aspects to that that have been proven to reduce the chance of infection. So, for instance, applying iodine, 10% solution, and to the eye tissue itself, 5%, has been proven to reduce the rates of complications and infection in the surgical setting.

But other aspects, like let's say a laser procedure to the eye. You might not actually need that because you're not entering inside the eye tissue to give that chance of infection inside the eye, also known as endophthalmitis. And so anything that we do has a risk, and it doesn't matter what we're doing, everything has a potential risk. As a profession, we do what we need to, to minimize those risks, but it is very challenging to make anything a hundred percent or decrease it to zero percent.

Host Amber Smith: So the study that you were involved in, do you see it as a big reminder to your fellow ophthalmologists about the importance of being aware and making sure that things are as clean as they can be?

Mark Breazzano, MD: Absolutely. I think it is just a really important reminder, like you said. We are in a relatively higher-risk profession in terms of the spreading of the novel coronavirus and any potential future pandemics that may occur from this, but also, other organisms that have already been around and we know can also cause disease and problems as well.

Host Amber Smith: Is there anything patients themselves can do to help reduce the risk of transmission coming in for an ophthalmic procedure?

Mark Breazzano, MD: This is a great question, by the way. There is something called blepharitis that is basically inflammation or some kind of gunk around your eyelids and whatnot. And there are some basic measures that can be done to help reduce that. There have been a number of studies, whether it's an injection in the back of the eye for diabetes or macular degeneration that can reduce the chances of Infection by making sure that that's as well controlled as possible.

So, if you're someone with blepharitis or rosacea and whatnot, and just really managing those underlying issues, that can help reduce the chances of that sort of devastating infection or complication from happening, which thankfully is very rare in our field. But, if we can further decrease this rate, that would be very helpful. So, I think that's really one thing that patients can do. And for the vast majority of patients, it's usually not an issue.

Host Amber Smith: I appreciate you making time for this interview, Dr. Breazzano.

Mark Breazzano, MD: Thank you so much, Amber, for having me.

Host Amber Smith: My guest has been Upstate graduate and ophthalmologist Dr. Mark Breazzano. He's on faculty at the Wilmer Eye Institute at Johns Hopkins University in Baltimore, but he's returning to Central New York this summer to Upstate and to Liverpool at the practice of Retina-Vitreous Surgeons of Central New York. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.