Introduction/Background:

• • Conventionally radiation (as radio-pharmaceuticals or as x-rays or high energy radiations) has been used in radiation departments (Nuclear Medicine, radiology and radiotherapy/ Radiation Oncology). There has been growing use of radiation mainly as x-ray fluoroscopy in clinical departments outside the imaging and therapy departments in recent years [1]. Unfortunately, clinicians in these departments (Cardiology, Electro-physiology, Vascular surgery, Urology, Orthopedic surgery, Gastroenterology to name a few) are not trained in radiation protection and that poses risks to patients and staff [1].
  • Recent studies under the leadership of Dr Madan Rehani published in reputed medical journals [2-6] has demonstrated eye lens opacities among 38 to 53% of main operators and 21-45% of nurses in cardiac catheterization labs. These lens opacities have the potential to lead to cataract.
  • This is a new observation and it has created new areas of research in which many countries in world are currently showing interest. Radiation induced cataract is a major threat among staff working in interventional suites. Nearly 16 million interventional procedures are performed annually in USA and the work load in most countries is quite large and is increasing. In Kuwait, there are more than five thousand interventional procedures performed every year.
  • The International Commission on Radiological Protection has reduced dose limit for staff by a factor of 7.5 (from 150 mSv/y to 20 mSv/y) [7]. At the moment no information is available on eye doses in staff working in interventional suites in Kuwait and there is similar lack of information from neighboring countries in the region. With increasing emphasis on radiation induced cataracts and reduction in threshold dose for eye lens, there is a need to assess the radiation doses to staff working in interventional suites in Kuwait.

Objectives:

1. 1. To assess radiation doses to eyes of medical and paramedical staff involved in interventional procedures.
   2. Based on assessment of doses prepare needs for protective devices and develop guidelines for reduction in radiation doses.
   3. To implement guidelines and procedures to reduce radiation doses.
   4. Establish an electronic national database for the radiation dose to the eye.
   5. Developing awareness and training modules using modern technology such as Apps.

Research methodology

• • The field of eye lens dosimetry is very new and it is exciting area of contemporary research both for development of dosimetry and for assessment of doses. Various approaches are being tried namely direct measurement using active or passive dosimeters kept close to eyes, retrospective estimations, correlating patient dose in interventional procedures with staff eye dose and estimations using Monte Carlo calculations.
  • In view of feasibility in local conditions, the work will involve following:

1. 1. Select interventional units in hospital covering active work load of interventional procedures preferable in interventional cardiology
   2. Prepare data collection sheets for interventional procedure, exposures factors and dose values
   3. Using the semiconductor based small electronic dosimeter, assess doses to staff near the eyes in international suite
   4. Also record kerma-area-product (KAP) of patient in procedures in which eye doses were recorded.
   5. Correlate eye doses with KAP values

• • Based on assessment of doses prepare needs for protective devices and develop guidelines for reduction in radiation doses. For some fields like interventional cardiology, the protective devices like ceiling suspected screen and lead glass eye wears are good whereas for interventional procedures performed in operation theatres by orthopedic surgeons, urologists etc., it is somewhat difficult as their procedures demand free space wherein mainly lead glass eye wear may be only option and practicability of mobile screens can be tried. Thus it will require investigation.
  • To implement guidelines and procedures to reduce radiation doses. This will require not only implementation but reassessment of radiation doses after implementation of radiation protection actions.
  • Establish an electronic national database for the radiation dose to the eye. This database will enable future inter-comparison studies with other centers in the world. The initial research methodology will include developing Excel sheets with relevant information about the procedures performed with personal identifier and patient doses for correlation of multiplier factor estimation.
  • Developing awareness and training modules using modern technology such as Apps. Training is essential component for impact assessment. The research methodology will include adaptation of training material for specific target groups as clinicians are not interested in technical details and one has to develop simplified versions of training material. Further, it is proposed to develop Apps that will provide higher level of outreach with convenience. There is no App at the moment available for eye dose management and occupational protection in interventional procedures.

Importance of the Research Outcomes

• • The importance lies not only in making baseline assessment of radiation risk to eyes of medical professionals working in interventional suites in Kuwait, but in developing and implementing safety measures and in reassessment to evaluate impact. Thus it is not only a project that will yield strategic directions on avoidance of radiation effect on health of medical professionals but will implement guidelines and assess impact on improvement. It must be mentioned that unlike carcinogenic effects of radiation where one cannot prevent radiation effect, the situation with cataract is favorable as effect can not only be reduced but it can be prevented and thus the importance of including implementation actions. This being new area of research, the information available from developed countries is limited and thus contribution of findings from Kuwait will be of contemporary interest in developed countries and will bring name to Kuwait in academic circles.

Anticipated Research Outcomes

The anticipated research outcomes against each objective cited above are:

1. 1. Assessment: Being a relatively new area of research, information on eye lens doses is currently known from few developed countries primarily in interventional cardiology and latest data published in 2016 has added some assessments in other clinical areas [8]. The work from Kuwait will be comprehensive covering interventional procedures performed in interventional cardiology, electrophysiology, vascular surgery, urology, orthopedic surgery and gastroenterology and thus it will fill up current need in contemporary area of research. It will open up research areas for further work as interventional procedures are advancing rapidly in variety and complexity and there is need to build research capability for eye dose assessment.
   2. Need of protective devices: The results will help management in allocation of financial resources on protectives devices to achieve rational protection. Thus the research outcome will be rationalization of protection.
   3. Implementation of protection: The research outcome will be assessment of improvement of protection achieved through implementation of guidelines to reduce radiation doses to eye lens. This will help in establishment of recommendations by international organizations who are currently looking for more and more data before developing recommendations.
   4. Electronic database. This will be highly futuristic as there is great interest among international organization involved in radiation protection on development of dose records for eye doses. Being involved in this part will bring Kuwait team at forefront in the field.
   5. Educational material and App. Once again, there is no App available currently globally. Having Dr Rehani involved, who is on forefront on radiation cataract studies among interventionalists and is actively involved at international level with International Commission on Radiological Protection (ICRP) and IAEA, and thus has latest knowledge about the field. He will be able to provide educational material. Also the local team in Kuwait consisting of Dr Mohammad Alfares and Dr Meshari Al Nuaimi have got some experience in App development.

References

1. 1. Rehani MM, Ciraj-Bjelac O, Vañó E, Miller DL, Walsh S, Giordano BD, Persliden Radiological protection in fluoroscopically guided procedures performed outside the imaging department. ICRP Publication 117, J. Ann ICRP. 2010 Dec;40(6):1-102. (released in 2012) http://www.ncbi.nlm.nih.gov/pubmed/22732420
   2. Rehani MM, Vano E, Ciraj-Bjelac O, Kleiman NJ. Radiation and cataract. Radiat Prot Dosimetry. 2011. http://www.ncbi.nlm.nih.gov/pubmed/21764807
   3. Ciraj-Bjelac O, Rehani M, Minamoto A, Sim KH, Liew HB, Vano E. Radiation induced eye lens changes and risk for cataract in interventional cardiology. Cardiology 2012 Oct 31;123(3):168-171.
   4. Ciraj-Bjelac O, Rehani MM, Sim KH, Liew HB, Vano E, Kleiman NJ Risk for radiation induced cataract for staff in interventional cardiology:  Is there reason for concern? Catheterization and Cardiovascular Interventions. 2010; 76: 826-834.
   5. Vano, E., Kleiman, N.J., Duran, A., Rehani, M.M., Echeverri, D. Cabrera, M. Radiation Cataract Risk in Interventional Cardiology Personnel. Radiat Res. 2010; 174: 490-495.
   6. Vano E, Kleiman NJ, Duran A, Romano-Miller M, Rehani MM. Radiation-associated Lens Opacities in Catheterization Personnel: Results of a Survey and Direct Assessments. J Vasc Interv Radiol. 2013 Feb;24(2):197-204.
   7. ICRP. Statement on Tissue Reactions. April 2011. ICRP ref 4825-3093-1464. http://www.icrp.org/docs/2011%20Seoul.pdf
   8. Vano E, Fernandez JM, Resel LE, Moreno J, Sanchez RM. Staff lens doses in interventional urology. A comparison with interventional radiology, cardiology, and vascular surgery values. J Radiol Prot. 2016 Mar;36(1):37-48.