Original Article Topical Ocular Anesthetic Abuse among Iranian Welders: Time for Action Ali Sharifi1, Hamid Sharifi2, Mohammad Karamouzian3, Mahmoud Mokhtari4, Hamidreza Hosein Esmaeili4, Afshin Sarafi Nejad5, Mohammad Rahmatian4
Access this article online
ABSTRACT Purpose: The purpose of this study is to estimate the prevalence of topical ocular anesthetic abuse among welders in Iran and suggest public health solutions for this issue. Methods: In this cross‑sectional study, 390 welders were randomly recruited and queried on the use of anesthetic drops. A questionnaire was administered through structured one‑on‑one interviews conducted by the first author. Results: A total of 314 welders (80.5%) declared that they had used topical anesthetics at least once during their working lives. Almost 90% of them stated a preference for self‑treatment over seeking help from a physician due to cultural and financial reasons. The most commonly used topical anesthetic was tetracaine. Most of the subjects (97.4%) had obtained the drugs from pharmacies without a prescription. Conclusions: The prevalence of topical ocular anesthetic abuse among welders in Iran is alarmingly high and may partially be due to cultural issues. Although most physicians are aware that topical anesthetics should only be used as a diagnostic tool, there is a crucial need to re‑emphasize the ocular risks associated with chronic use of these medications. Educational programs for both physicians and the public are necessary to address the problem.
Website: www.meajo.org DOI: 10.4103/0974-9233.120023 Quick Response Code:
Key words: Iran, Topical Ocular Anesthetics, Welder
INTRODUCTION
T
oday’s ophthalmologists and their patients are fortunate to have many topical medications on hand for the treatment of a broad variety of ocular disorders. Topical ocular anesthetics play a vital role in the diagnosis and treatment of ocular diseases. The five most commonly used topical ophthalmic anesthetics are proparacaine, tetracaine, benoxinate (oxybuprocaine), lidocaine and cocaine, which are typically used for topical anesthesia before eye surgery or during eye examinations in clinic.1,2 Unlike injected anesthetic agents, which may be associated with a number of potentially sight threatening or even life threatening complications, topical anesthetics are
only accompanied with minimum discomfort. Due to their short duration of action, they have the advantage of prompt post‑operative visual rehabilitation. Additionally, their lower cost is an added advantage.3‑5 Although topical ocular anesthetics are generally safe, complications may rarely occur from their use. Balanced prescribing for specific diagnoses in addition to careful clinical monitoring of the effects of treatment can minimize the risks. However, the arbitrary use of these medications is likely to do more harm than good. Local anesthetics restrain the corneal epithelial cell migration rate by damaging the superficial corneal epithelial microvilli.6 They may also have a direct toxic effect on
Department of Ophthalmology, School of Medicine, Kerman University of Medical Sciences, 2Department of Food Hygiene and Public Health, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, 3Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran, 4Department of Ophthalmology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran, 5Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran 1
Corresponding Author: Dr. Mohammad Karamouzian, Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Shariati Street, Kerman, Iran. E-mail: [email protected]
336
Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013
Sharifi, et al.: Ocular Anesthetic Abuse Among Welders
the stromal keratocytes.7 Ring infiltrates have been described in association with topical anesthetic abuse.8 Pathological mechanisms such as immunologic, irritation, toxic, cumulative deposition, photoimmunologic or phototoxic and microbial imbalance may occur. The ocular or adnexal tissues can respond to these insults by manifesting cutaneous changes including papillary, follicular, keratinizing, or cicatrizing conjunctivitis; ulcerative, vascularizing, or cicatrizing keratitis; hyper‑ or hypopigmentation; and infectious complications.9‑12 The haphazard use of topical eye drops, the lack of prescription monitoring and the availability of over the counter (OTC) topical anesthetic eye drops are common factors in the predisposition to abuse these agents in developing countries.13 Due to the nature of the welding industry, welders are highly prone to topical ocular anesthetic abuse. Of interest, welding is also a known risk factor for uveal melanoma.14 To the best our knowledge, there is no published data addressing the frequency of ocular anesthetic abuse in an at‑risk community. We conducted the current study to evaluate the prevalence of topical ocular anesthetic abuse among Iranian welders and propose strategies to address this issue.
METHODS This cross‑sectional study was conducted between January and April 2012 in Iran and included 390 welders. A list of all registered welders was acquired from the welding union of Kerman province and participants were randomly selected using statistical package for the social sciences (SPSS) (version 15 for Windows; IBM Corp., Armonk, NY, USA) to avoid selection bias. An 18‑item questionnaire was used, which covered the subjects’ demographic information, history of self‑treatment, topical anesthetic abuse and access to eye drops. The questionnaire was administered through structured one‑to‑one interviews conducted by the first author at the welder’s office for added convenience. All participants were provided with an educational pamphlet on the risks of topical anesthetics abuse. Those who reported recently abusing topical anesthetics were referred to a participating hospital for treatment. Data analysis
Statistical analysis was performed with SPSS. Pearson and Spearman’s rank correlation coefficients and Chi‑square tests were used to measure the association between variables. Adjusted frequency distributions were calculated along with 95% confidence intervals (CI) and P 0.05) [Table 2]. Surprisingly, those who had a higher level of education reported significantly greater misuse of drops than those who never Table 1: Frequency of treatment methods for welding flash used by participants Treatment Visiting a physician
No. (%)
Self treatment
No. (%)
General practitioner Ophthalmologist
7 (1.8) 35 (9)
Analgesic usage Tetracaine Potato Tea Rice water Rose water Ice Epinephrine Naphazoline
45 (11.5) 302 (77.4) 97 (24.9) 8 (2.3) 1 (0.3) 55 (14.1) 71 (18.2) 6 (1.5) 20 (5.1)
Ethical considerations
The current study was registered with the scientific committee at the Kerman University of Medical Sciences (KUMS), Iran. The clinical protocols were reviewed and approved by the Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013
337
Sharifi, et al.: Ocular Anesthetic Abuse Among Welders Table 2: Characteristics of the participants who reported abusing topical anesthetic drops Education Never attended school Primary school Secondary school High school diploma Some university courses
No. (%)
Frequency
(59) 16.6 (84) 23.4 (159) 44.2 (36) 10 (20) 5.8
Always Sometimes Analgesics were ineffective Severe pain At nights According to physicians’ prescription
Source of information on drops Family members Colleagues Supervisor Physicians Pharmacy technicians
Always Sometimes Never ‑ ‑ Once Twice Frequently ‑ Aware Somewhat aware Not aware ‑ ‑
85 (21.8) 86 (22.2) 219 (56) ‑ ‑
Use of drops after being educated 303 (77.7) 12 (3.1) 70 (17.9) 5 (1.3)
Would stop using the drops completely Would use them drops sometimes Would keep on abusing the drops frequently ‑
attended school (P
Access this article online
ABSTRACT Purpose: The purpose of this study is to estimate the prevalence of topical ocular anesthetic abuse among welders in Iran and suggest public health solutions for this issue. Methods: In this cross‑sectional study, 390 welders were randomly recruited and queried on the use of anesthetic drops. A questionnaire was administered through structured one‑on‑one interviews conducted by the first author. Results: A total of 314 welders (80.5%) declared that they had used topical anesthetics at least once during their working lives. Almost 90% of them stated a preference for self‑treatment over seeking help from a physician due to cultural and financial reasons. The most commonly used topical anesthetic was tetracaine. Most of the subjects (97.4%) had obtained the drugs from pharmacies without a prescription. Conclusions: The prevalence of topical ocular anesthetic abuse among welders in Iran is alarmingly high and may partially be due to cultural issues. Although most physicians are aware that topical anesthetics should only be used as a diagnostic tool, there is a crucial need to re‑emphasize the ocular risks associated with chronic use of these medications. Educational programs for both physicians and the public are necessary to address the problem.
Website: www.meajo.org DOI: 10.4103/0974-9233.120023 Quick Response Code:
Key words: Iran, Topical Ocular Anesthetics, Welder
INTRODUCTION
T
oday’s ophthalmologists and their patients are fortunate to have many topical medications on hand for the treatment of a broad variety of ocular disorders. Topical ocular anesthetics play a vital role in the diagnosis and treatment of ocular diseases. The five most commonly used topical ophthalmic anesthetics are proparacaine, tetracaine, benoxinate (oxybuprocaine), lidocaine and cocaine, which are typically used for topical anesthesia before eye surgery or during eye examinations in clinic.1,2 Unlike injected anesthetic agents, which may be associated with a number of potentially sight threatening or even life threatening complications, topical anesthetics are
only accompanied with minimum discomfort. Due to their short duration of action, they have the advantage of prompt post‑operative visual rehabilitation. Additionally, their lower cost is an added advantage.3‑5 Although topical ocular anesthetics are generally safe, complications may rarely occur from their use. Balanced prescribing for specific diagnoses in addition to careful clinical monitoring of the effects of treatment can minimize the risks. However, the arbitrary use of these medications is likely to do more harm than good. Local anesthetics restrain the corneal epithelial cell migration rate by damaging the superficial corneal epithelial microvilli.6 They may also have a direct toxic effect on
Department of Ophthalmology, School of Medicine, Kerman University of Medical Sciences, 2Department of Food Hygiene and Public Health, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, 3Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran, 4Department of Ophthalmology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran, 5Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran 1
Corresponding Author: Dr. Mohammad Karamouzian, Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Shariati Street, Kerman, Iran. E-mail: [email protected]
336
Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013
Sharifi, et al.: Ocular Anesthetic Abuse Among Welders
the stromal keratocytes.7 Ring infiltrates have been described in association with topical anesthetic abuse.8 Pathological mechanisms such as immunologic, irritation, toxic, cumulative deposition, photoimmunologic or phototoxic and microbial imbalance may occur. The ocular or adnexal tissues can respond to these insults by manifesting cutaneous changes including papillary, follicular, keratinizing, or cicatrizing conjunctivitis; ulcerative, vascularizing, or cicatrizing keratitis; hyper‑ or hypopigmentation; and infectious complications.9‑12 The haphazard use of topical eye drops, the lack of prescription monitoring and the availability of over the counter (OTC) topical anesthetic eye drops are common factors in the predisposition to abuse these agents in developing countries.13 Due to the nature of the welding industry, welders are highly prone to topical ocular anesthetic abuse. Of interest, welding is also a known risk factor for uveal melanoma.14 To the best our knowledge, there is no published data addressing the frequency of ocular anesthetic abuse in an at‑risk community. We conducted the current study to evaluate the prevalence of topical ocular anesthetic abuse among Iranian welders and propose strategies to address this issue.
METHODS This cross‑sectional study was conducted between January and April 2012 in Iran and included 390 welders. A list of all registered welders was acquired from the welding union of Kerman province and participants were randomly selected using statistical package for the social sciences (SPSS) (version 15 for Windows; IBM Corp., Armonk, NY, USA) to avoid selection bias. An 18‑item questionnaire was used, which covered the subjects’ demographic information, history of self‑treatment, topical anesthetic abuse and access to eye drops. The questionnaire was administered through structured one‑to‑one interviews conducted by the first author at the welder’s office for added convenience. All participants were provided with an educational pamphlet on the risks of topical anesthetics abuse. Those who reported recently abusing topical anesthetics were referred to a participating hospital for treatment. Data analysis
Statistical analysis was performed with SPSS. Pearson and Spearman’s rank correlation coefficients and Chi‑square tests were used to measure the association between variables. Adjusted frequency distributions were calculated along with 95% confidence intervals (CI) and P 0.05) [Table 2]. Surprisingly, those who had a higher level of education reported significantly greater misuse of drops than those who never Table 1: Frequency of treatment methods for welding flash used by participants Treatment Visiting a physician
No. (%)
Self treatment
No. (%)
General practitioner Ophthalmologist
7 (1.8) 35 (9)
Analgesic usage Tetracaine Potato Tea Rice water Rose water Ice Epinephrine Naphazoline
45 (11.5) 302 (77.4) 97 (24.9) 8 (2.3) 1 (0.3) 55 (14.1) 71 (18.2) 6 (1.5) 20 (5.1)
Ethical considerations
The current study was registered with the scientific committee at the Kerman University of Medical Sciences (KUMS), Iran. The clinical protocols were reviewed and approved by the Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013
337
Sharifi, et al.: Ocular Anesthetic Abuse Among Welders Table 2: Characteristics of the participants who reported abusing topical anesthetic drops Education Never attended school Primary school Secondary school High school diploma Some university courses
No. (%)
Frequency
(59) 16.6 (84) 23.4 (159) 44.2 (36) 10 (20) 5.8
Always Sometimes Analgesics were ineffective Severe pain At nights According to physicians’ prescription
Source of information on drops Family members Colleagues Supervisor Physicians Pharmacy technicians
Always Sometimes Never ‑ ‑ Once Twice Frequently ‑ Aware Somewhat aware Not aware ‑ ‑
85 (21.8) 86 (22.2) 219 (56) ‑ ‑
Use of drops after being educated 303 (77.7) 12 (3.1) 70 (17.9) 5 (1.3)
Would stop using the drops completely Would use them drops sometimes Would keep on abusing the drops frequently ‑
attended school (P
