Transcription:

Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and I invite you to listen as we examine lid abscess associated with personal protective eyewear in COVID-19 units.

Joining me is Dr. Preeti Thyparampil. She's an assistant professor in the Division of Ophthalmology at Northwestern Medicine. Doctor, I'm so glad to have you join us today. Can you start by telling us a little bit about yourself, your area of expertise and how you came to Northwestern Medicine?

Dr Preeti Thyparampil: Thank you, Melanie, for having me. I am an oculoplastic specialist in the Department of Ophthalmology. I specialize in the eyelids, the orbits, the tear drain, basically all of the structures surrounding the eyeball. I came to Northwestern from Houston, where I completed my training and I was looking to practice in a tertiary referral center with teaching opportunities. And I was fortunate enough to find a spot right here in Chicago where I have family connections as well.

Melanie: That's fantastic. Well, we are glad to have you here in Chicago. So you recently published work in the Canadian Journal of Ophthalmology that described a case of a nurse working in a COVID-19 ward who was diagnosed with eyelid abscess associated with her protective goggles. I'd like you to tell us more about this case, your diagnostic process and what you did to help HER.

Dr Preeti Thyparampil: Absolutely. So this was a very interesting case that occurred early on in the COVID pandemic when so much was unknown. And PPE was not standard and was not distributed by hospitals to their staff. And there was just a lot of fear and concern and this nurse who was in a high-risk situation, understandably took it upon herself to protect herself and brought in her own goggles to wear with her mask.

And to protect herself even further, she took what seemed like a very reasonable, additional step of wiping down her goggles after each patient encounter with hospital-grade viricidal wipes that we all see that are very potent. And her particular goggles were the type that had a tight seal around her entire eye area. So it formed a seal around her forehead, right above her eyebrows and then followed around onto her cheek area. And what was happening was that each time she wiped down these goggles, some residue of that very strong viricidal agent was then being applied onto her skin.

She presented to the emergency room initially with an abscess that was actually above her eyelid with a collection of purulent-appearing material right on her eyelid, and then was referred to Ophthalmology. And we saw her and looking more carefully at the abscess, it appeared that while the bulk of the purulent material was on her eyelid. There was actually a track that followed to a very small opening in her skin above her brows, suggesting that the actual origin of the infection was in that small suprabrow area and that it had tracked and formed an abscess in her eyelid region.

And upon more history taking, we realized that that suprabrow area was right where the tight seal of her goggles was placed. And then we deduced that likely the constant touching of her skin by this dermatoxic substance had broken down her protective skin barrier and that allowed the entry of skin flora into her body, and then allowed this abscess formation.

Melanie: Wow, what an interesting case. So what does this case demonstrate, doctor? And what advice are you giving patients or even other healthcare workers that are working in these units using that protective eyewear?

Dr Preeti Thyparampil: Well, first of all, I think that case was for me a very good instruction in really detailed history taking, because this was not something that she had thought was relevant and had not really offered initially. And she's a nurse, you know, a colleague. So we were having just a very straightforward conversation where I was saying, "It's kind of strange to develop these sort of abscesses. Normally, our skin protects us and we shouldn't really develop skin abscesses without cause."

And so we were both just kind of mulling over what possible etiologies could have taken place. And then she sort of mentioned, " I don't know if this is relevant, but I didn't tell anybody, but I do do this." And that's when we kind of came to the realization that in fact this was significant. So finding an etiology is always important because if you don't eliminate that, then the problem can continue to persist.

Since then, we've actually published on this to emphasize to care providers that we should be telling patients that if they're cleaning their personal protective equipment of any sort, be it goggles, shields, masks, do not clean it with dermatoxic substances if that part of the protective equipment is going to touch your skin, because those substances that we clean surfaces and so on with are not indicated for the skin. So just making your patients aware that, while they understandably want to protect themselves, only use substances that are indicated for the skin on protective wear that touches your skin.

Melanie: Wow. We're just learning so many new and different things. What a mysterious situation that we're in. But this is so interesting. So since the start of the pandemic, doctor, your team has seen an increase in ocular injuries as a result of wearing masks. Can you tell us a little bit about that?

Dr Preeti Thyparampil: Yes. All of these are not things we could have predicted and so we're learning as we go along. We are seeing injuries related to mask wearing. And this is not in any way to diminish the importance of continuing to wear masks, but what we're seeing is a lot of injuries related to visual obscuration from wearing masks.

As many of us have personal experience, when you wear a mask, it often fogs your eyewear, which can fog your vision. And we've seen patients with falls resulting in orbital traumas as a result of mask fogging. We've seen falls related to just the mask blocking the visual field. In one instance, it was a gentleman who was wearing his mask a little lower on his nose because it was causing fogging if he wore it higher and because he was wearing it so low, it obscured his inferior visual field, blocked his vision and he tripped and fell.

So us as a population adjusting to apparatus that we're not used to wearing. And so as we go through this adjustment period, we're experiencing accidents and injuries. So we have seen orbital traumas, orbital fractures related to mask wearing.

Melanie: As you said, these are things nobody could have predicted really. So what else have you seen? How has COVID affected your practice? What challenges have you faced as far as being able to work with patients in person? How have you used televisits? Tell us how your practice has evolved.

Dr Preeti Thyparampil: Absolutely. As ophthalmologists, the safety of our patients and ourselves is very important, especially because our exam is done very up close and personal with the patient. Our faces are very close to each other when we perform an eye exam. And so this is certainly something that our whole department gave great consideration to. We've adapted our clinic and our exam apparatus to allow us to more safely examine patients.

Of course, everyone wears masks. We have shields put in place between us and the patient when they sit at the slit lamp, for example. And we've modified our clinic structure as have all the clinics in terms of keeping patients socially distant and not waiting in waiting rooms for large periods of time.

The eye exam lends itself to telehealth a little less than other fields may because, for many things, you need to be able to see things very minutely and in fine detail. And, as of yet, that's not entirely possible with telehealth. With that being said, I certainly am doing more telehealth than I was before for conditions where it is a feasible option.

Melanie: As we wrap up, and again, I say this is such an interesting topic and such an interesting progression that we've seen in the mysteries of this disease, so is there anything else you'd like ophthalmologists to know and take forward to their patients in this COVID-19 era as we're talking about lid abscesses with protective eyewear?

Dr Preeti Thyparampil: Absolutely. I am an oculoplastic specialist. So in the world of ophthalmology, I do more of the macro stuff. And interesting information is emerging about actual ocular consequences of infection from the virus. But as of now, the things I've seen more are sequelae of the lifestyle changes we've had to make with COVID.

And so advice that I can give patients again, while protecting yourself, be aware of the delicacy of the structures around your eye. The eyelid skin is the most thin skin in your body. So it's fragile, it's delicate. Be very gentle with it when you're cleaning and applying cleansing products. And with regards to mask wearing, take precautions to not compromise your vision as a result of wearing masks. So apply tape over the top of the mask or twist the straps of the mask so that it's forming a nice tight seal on top and so it's less likely to cause fogging. Make sure that when you're protecting yourself, you're also keeping yourself safe in other ways.

Melanie: Great advice. Thank you so much, doctor, for joining us today and sharing this very interesting topic. To refer your patient, please visit our website at nm.org to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.