Reply to the Letter to the Editor: Is Ocular Safety in Orthopaedics Overlooked? A Systematic Review of Annual Ocular Radiation Exposure and Protective Measures

To the Editor,

We thank Mordukhovich and colleagues for their thoughtful commentary [7] on our recent publication, “Is Ocular Safety in Orthopaedics Overlooked? A Systematic Review of Annual Ocular Radiation Exposure and Protective Measures” [2]. We appreciate their interest in this important occupational health topic, and we are encouraged that our findings prompted evaluation of similar risks among plastic surgeons performing fluoroscopy-intensive hand procedures. As Mordukhovich et al. stated in their letter [7], a substantial proportion of academic plastic surgeons pursue hand fellowship training, with a large share of plastic surgery hand cases involving osseous and joint procedures that are also performed by orthopaedic surgeons. This supports the rationale for cross-specialty and procedure-specific evaluation of ocular radiation exposure risks. We commend Mordukhovich and colleagues for their efforts to replicate our review methodology in the context of plastic surgery. Their finding that there were no eligible studies on ocular radiation exposure in plastic surgery underscores the pressing need for additional investigations on the topic.

While there is a relative lack of studies evaluating radiation exposure from fluoroscopy usage during hand surgery, we hope that a consolidation of our findings may provide some answers to their proposed inquiry. Among the 29 articles included in our systematic review [2], only six distinctly investigated ocular irradiation in the context of hand surgery [1, 3, 4, 6, 8, 10]. Three of these studies used matching methodologies, consisting of a phantom anthropomorphic model exposed to 15 minutes of continuous C-arm radiation to mimic a month of hand surgeon radiation exposure [3, 4, 6]. These studies found that ocular radiation was markedly increased when the C-arm was in the inverted position (nearly 3.5 times higher), but even when estimated across an entire year’s anticipated caseload, this remained below the recommended annual radiation exposure limit for the eyes [3]. Furthermore, ocular irradiation was substantially higher when the flat detector was above the table compared to below the table [6]. With a maximal rate of eye exposure of 16.7 mrem over 15 minutes, a volar plating caseload would have to be over 13,000 before exceeding the yearly limit [6]. While these exposures do not exceed the recommended annual radiation limit, we don’t know whether ocular complications might occur as a result of being exposed to radiation over decades, so the authors of these studies still recommend the use of protective equipment for surgeons’ eyes [3, 4, 6].

Additionally, only one study [1] in our review assessed radiation exposure according to the type of procedure, finding that the highest mean dose area product (Gy*cm²) occurred during reduction of fractures (0.12) and arthroscopic joint surgery (0.07). That study also stratified by type of fracture among those repaired surgically with the help of intraoperative fluoroscopy, and reported the highest maximum dose area products (Gy*cm²) among scaphoid hand fractures (0.57), metacarpal bone fractures (0.45), and both-bone forearm fractures (0.39). They concluded that while the 20 mSv annual limit for ocular irradiation is not reached in those settings, leaded ocular protective equipment should still be recommended because the risk of cataract formation is still possible considering the unknown risk of long-term exposure [4, 6]. We hope that these findings may prompt additional research regarding the ocular impacts of intraoperative fluoroscopy among hand surgeons.

While our review focused on orthopaedic procedures, particularly those with high fluoroscopic demands, we agree that risk stratification by procedure type may offer a more precise framework for assessing radiation exposure across all surgical disciplines. This is particularly relevant for hand surgery, which involves a broad range of fluoroscopy duration, commonly ranging from 1 to 152 seconds of total fluoroscopy time across various hand and wrist procedures [5, 9]. We hope that future investigations will expand upon these themes. Prospective dosimetry studies, procedure-specific and specialty-specific analyses, and cross-sectional studies should investigate the prevalence of cataracts in surgeons compared to the general population. These types of studies would more comprehensively characterize the long-term ocular risks associated with intraoperative radiation exposures. Ultimately, increased awareness and preventive strategies, such as those outlined in our review (such as sport wrap-around leaded eyewear and strategic positioning relative to fluoroscopic sources) [2], should be emphasized across all surgical disciplines that utilize intraoperative fluoroscopy.

We thank the authors of this letter [7], again, for their valuable contribution to this topic.