Many reports represent needle stick high frequency in surgical residents. A Cross-sectional study reports that 83% of orthopedic residents/fellows, and 100% of faculty at one institution, had been exposed to a sharps injury at some point in their career(1). Another survey studied the incidence of needle stick among all surgical personnel at a single academic institution(2). they showed higher rates of needle stick injury among surgical staff compared with other nonsurgical personnel.
Unfortunately, psychological stress after needle stick affects individual and occupational performance and leads to post-traumatic stress disorder and work loss.(3) there is a report demonstrate the average cost of a NSI is US$747 (range US$199-1,691). So prevention of such events helps health system economy.(4) The two factors of prevalence and cost of these events indicate the importance of prevention and education about it.
The case above demonstrates an injury could have been prevented by dispose of the needle properly using safety boxes. It didn’t happen If resident used safety boxes and didn’t try recapping process using hands. But this doesn’t work sometimes. we usually use syringe to send the sample to the lab. the needle helps prevent the sample being wasted. So we need to do recapping process carefully.
Some clinicians suggest to bend the needle for aqueous sampling. They presume bending may help better controlling the needle and the eye. We think this is not helpful and results in consequences like NSI and difficulties in aqueous sampling because of increased resistance of fluid flow. So needle bending is not routinely recommended.
Another consideration in this case is post-exposure prophylaxis(PEP). The key point to start PEP is risk assessment. WHO published a practical guideline in 2015 which declared exposures need PEP include (5): 1-Bodily fluids: blood, blood-stained saliva, breast milk, genital secretions; cerebrospinal, amniotic, peritoneal, synovial, pericardial, or pleural fluids. 2-Mucous membrane: sexual exposure; splashes to eye, nose, or oral cavity. 3-Parenteral exposures.
It also noted Exposures that do not require HIV PEP include: 1- exposed person is HIV already positive. 2- the source is established to be HIV negative. 3-Exposures to bodily fluids that do not pose a significant risk, ie, tears, non-blood-stained saliva, urine, and sweat.
Another published guideline in 2020 noted The transmission risk is significantly higher in cases of more than 1 risk factor: deep injury, hollow bore needle and high viral load (6).
Considering literature, we can not conclude whether there was a need for PEP in our case. But the Behavioral Diseases Counseling Center encouraged us to use PEP.
There are reports detecting HIV in anterior chamber aqueous humor (7,8). In both above guidelines, aqueous humor is not mentioned. NSI by Aqueous humor which is secreted from blood, can theoretically transmit blood borne pathogens like HIV. Nevertheless, there is neither any report of aqueous humor NSI nor HIV transmission in this way. Based on our best knowledge this case is the first report represents HIV+ aqueous humor NSI and further evidence is required.