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Topical Anesthetic Misuse in Patients Admitted to Sabzevar Eye Clinic in Iran

Topical Anesthetic Misuse in Patients Admitted to Sabzevar Eye Clinic in Iran ACTA FACULTATIS MEDICAE NAISSENSIS DOI: 10.1515/afmnai-2016-0030 UDC: 615.457.035.2:617.7-06(55) Ebrahim Shirzadeh1, Nematullah Shomoossi2, Hasan Abdolahzadeh2 Department of Ophthalmology, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran 2School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran SUMMARY Topical anesthetic eye drops are used extensively for ophthalmic examinations but selftreatment and non-technical removal of foreign bodies using tetracaine drops can be hazardous. The present study intended to determine the inadmissible uses of anesthetic tetracaine eye drops, manner of drug obtaining and likelihood of the ocular complications in the patients. This cross-sectional study was conducted on 162 patients with ocular pain and foreign body sensation, red eye or lid edema admitted to the Eye clinic in Sabzevar, Iran. Variables included age, sex, chief compliant, job, site of foreign bodies, diagnosis of problem, use of tetracaine drops, drug provision, times patients referred to the eye clinic, and kinds of treatment. The most common chief complaint for admission to the Eye clinic was lacrimation (55.6%), followed by ocular pain, and foreign body sensation (35.8%). Some patients (30.9%) (mostly welders) inadmissibly used topical tetracaine eye drops; 21.6% of cases obtained tetracaine eye drops from drugstores without doctor's prescription, and only 3.7% provided drugs by prescription. Corneal site (81.5%) was the most common location of foreign body; metallic foreign body (63%) was the most common. One patient was admitted in hospital for management. Topical inadmissible tetracaine (0.5%) is commonly used by welders, who obtain it from drugstores without prescriptions due to its simple usage and short acting pain relief. Supervision is required over drugstores for denying it if demanded without a prescription. Enhancing clients' awareness is also suggested. Key words: tetracaine, drug misuse, foreign body, eye drop Corresponding author: Nematullah Shomoossi E-mail: nshomoossi@yahoo.com INTRODUCTION Various drugs may be available to lay people for potential use and misuse, and the number of victims misusing them is on the rise. Erroneous cultural and socioeconomic attitudes as well as the easy accessibility of over-the-counter drugs play an important role in the acceptance of these substances (1). Topical anesthetic eye drops are mostly used in the emergency departments and they provide superb analgesia to the painful eyes; they are also applied for ocular urgency without routine prescriptions (2, 3). Superficial ocular foreign bodies take victims to drugstores upon ophthalmic urgencies, where they conveniently find these eye drops appropriate for eliminating ocular pain, foreign body sensation and relief of ocular discomfort. In a major town like Sabzevar in the northeastern part of Iran, the most common topical anesthetic eye drop used is tetracaine (i.e. anisthocain 0.50% Sina Daru Co, Iran). Most patients tend to misuse it either after ultra-violate keratitis (UVK) or for corneal foreign body removal (4, 5). Self-treatment and non-technical removal of ocular foreign bodies by the help of anesthetic tetracaine eye drops can be a hazardous procedure particularly when they are used by lay people (6-8). Clinical evidence reveals that unauthorized uses of this ophthalmic drop by workers like welders, turners, blacksmiths, aluminum makers, and similar occupations are common; therefore, the aim of the present study was to determine the conditions of inadmissible uses of anesthetic tetracaine eye drop, application of the drug, site of ocular foreign bodies and likelihood of the ocular complications in patients seeking medical advice from a physician for eye discomfort. manner of providing tetracaine eye drops, times patients were referred to the eye clinic, and kinds of treatment. Patient management consisted of foreign body removal and medication, mere medication, and hospitalization if required. The variables were categorized as follows: Yes-No for using tetracaine eye drops, if the patient's response was Yes, then the manner of drug providing was categorized as follows: from drugstore, by prescription, and other. Also, the duration of discomfort and times of patients admitted for medical consultation were enquired and determined by their related variables. There were no limitations for this study and the informed consent was obtained from all patients. Statistical analyses were performed using STATA for windows software (version 11). Descriptive and analytic statistics were used for data analysis. RESULTS Of 162 examined patients, 86.4% were male and 13.6% were female. Their mean age was 30.89±12.95 years with a range of 1 to 70 years old. Distribution of patients by demographic data is presented in Table 1. The results showed a significant relationship between gender and occupation with the use of tetracaine eye drops (p < 0.001). The most common chief complaint was observed to be ocular lacrimation (55.6%) and then ocular pain and foreign body (FB) sensation (35.8%). The frequency of patients admitted to the clinic due to their ocular symptoms is displayed in Table 2. The study revealed the rate of inadmissible use of tetracaine eye drops to be 30.9%; also, the manner of drug provision from a drugstore without prescription was 21.6%. Table 3 displays the distribution of patients' affected eye, anatomical site and type of the FB. Corneal FB with 81.5% (132) was the common site and metallic FB with 63% (102) was the most common type. Distribution of patients by duration of exposure to the ocular FB and admission to the eye clinic are displayed in Table 4. As Table 4 indicates, around 68% of the patients with FB referred to the eye clinic three days after the exposure and the lowest rate of admission (20%) was on the first day of the exposure. Furthermore, the present study revealed that 13.6% of patients underwent ocular FB removal by unauthorized and non-medical people, distribution of which is shown in Table 5. Also, the study revealed that about 1.2% (2) of the patients used diclofenac eye drops (Sina Daru Co, Iran) for their pain control. PATIENTS AND METHODS This clinically-based and cross-sectional study was conducted on 162 patients admitted to the ophthalmological clinic for eye discomforts. The study population included all patients admitted with the chief complaints of ocular pain and foreign body sensation, lacrimation, red eye or lid edema in Sabzevar Eye Clinic in Sabzevar, Iran. The study was performed from July 2014 to September 2014. Data collection was achieved by the eye examination as well as filling out a questionnaire. Variables consisted of age, sex, chief compliant, job, site of foreign bodies, diagnosis of the problem, use of tetracaine eye drops, DISCUSSION The present study was designed to investigate the inadmissible uses of anesthetic tetracaine eye drop, application of the drug, site of ocular foreign bodies and likelihood of the ocular complications in patients seeking medical advice and treatment in Sabzevar Eye Clinic in Iran. As Table 1 indicates, the prevalence of eye disorders is higher in men (86.4%) than in women, which shows the effect of masculine occupations with higher risks of ocular FB. Also, the most frequent age affected by FB was 25-59 years of age, while the least frequent age was among the elderly (older than 60). The most frequent FB cases had lower education which enhances the likelihood of their being unaware of security at workplaces, where about 46% of the cases were involved in metal working; this may highlight the need for wearing personal protective equipment (PPE) as well as training health and safety executive (HSE) rules for workers with lower education; this may require responsibilities for employers, too. In addition, about 54% of the cases were involved in non-metal works, which further stresses the need for public education about the safety and security in the workplace. Topical ocular anesthetic eye drops abuse can lead to superficial punctuate keratitis, persistent corneal epithelial defects, stromal/ring infiltrates, corneal edema, endothelial damage and ocular inflammation (2). It is thought that preservatives in anesthetics may play a further role in toxicity (9). Symptoms of such patients included photophobia, ocular pain FB sensation, red eye, Table 1: Distribution of patients by demographic variables Variable Use tetracaine N (%) 50 (35.7) 22(100) Age Childhood (1-10) Adolescence (11-25) Middle age (26-59) Old age(>60) Illiterate Diploma< Academic Welder Blacksmith Turner Worker Aluminum maker Mechanic Shepherd Other 0 16(40) 32(29.3) 2 Education 6(30) 40(31.25) 4(28.5) Occupation 22(51.1) 3(75) 10(35.7) 4(30.77) 1(25) 4(66.67) 0(0) 6(9.84) 21(48.8) 1(25) 18(64.2) 9(69.23) 3(75) 2(33.33) 3(100) 55(90.16) 0.000 43(26.5) 4(2.4) 28(17.28) 13(8.02) 4(2.47) 6(3.70) 3(1.85) 61(37.6) 14(70) 88(68.7) 10(71.4) 0.9 20(12.3) 128(79.01) 14(8.64) 11(100) 24(60) 0.2 77(70.6) 0 109(67.2) 2(1.2) 11(6.79) 40(24.6) Not using tetracaine N (%) Sex Male Female 90(64.2) 0(0) 0.000 86.4)(140 13.5)(22 p-value Total Table 2: Distribution of patients by ocular symptoms and tetracaine eye drops misuse and their providing Variable Frequency Percent Lacrimation 90 55.6 Foreign body sensation and 58 35.8 pain Red eye 8 4.9 Inflamed eye 6 3.7 Total 162 100.0 Use of tetracaine eye drop Yes No 50 112 Tetracaine provide Drugstore Physician Other No provide 35 6 10 111 21.6 3.7 6.2 68.5 30.9 69.1 decreased vision and tearing (4). Because of concerns for delayed healing and corneal erosion (2), corneal keratitis secondary to the misuse of tetracaine eye drops may initially be treated for acanthamoeba keratitis since topical ocular anesthetic drops abuse may appear misdiagnosed as acanthamoeba keratitis (9). In the present study, the most common chief complaint was observed to be ocular lacrimation (55.6%), and then ocular pain and FB sensation (35.8%). The results of this study showed that 30.9% of patients inadmissibly used topical tetracaine eye drops; also, 21.6% of cases provided tetracaine eye drops from drugstores without doctor's prescription, and only 3.7% provided drugs by prescription. As indicated in Table 2, about 27.8% of the cases with FB in the eye were observed to have obtained drugs from non-experts, a really remarkable threat of self-treatment which requires public education and cultural change. This has occurred despite the contraindication of anesthetic eye drops (even by medical doctors) except in eye clinics for emergency medical cases including eye burns, measuring intraocular pressure and extracting eye foreign bodies. However, in the present study, 3.7% of the cases obtained the eye drop by medical prescription; this may also be considered a non-scientific medical measure, requiring refresher courses for GPs to re-emphasize its use in emergency cases. Similarly, Sharifi and colleagues studied the prevalence of topical ocular anesthetic abuse among welders in Iran; they found that from 390 welders included in the study, a total of 314 welders (80.5%) had used topical anesthetics at least once during their career (10). Almost 90% of them stated a preference for selftreatment over seeking help from a physician due to cultural and financial reasons; also, the most commonly used topical anesthetic was tetracaine; most of the subjects (97.4%) had obtained the drugs from pharmacies without a prescription (10). In another study by Erdem and coworkers, the misuse of topical anesthetic eye drops abuse was shown from 12 eyes of 8 patients who were evaluated retrospectively, and one of the patients provided the drug with a primary care practitioner's prescription, but for the other 7 patients, it was available from pharmacies without prescription (11). Also, Katsimpris and coworkers described the clinical findings in five patients with topical anesthetic abuse with a detailed history in all patients; it was revealed that topical anesthetic abuse led to keratitis by obtaining anesthetic drops from the pharmacy without medical prescription (12). However, in the present study, 21.6% of all patients with different occupations provided the drug from drugstores without doctor's prescription, and only 3.7% provided drugs by physician's prescription. Topical anesthetic drops easily provided from pharmacies can be considered as an important alarm for topical anesthetic drug misuse and needs strict supervision over pharmacies. Pharmacists dispensing these drugs have a professional obligation that these products are being used appropriately and under the supervision of an ophthalmologist. Unfortunately, these findings can be alarming signs of health problems in the target community we studied. Applicable to similar contexts, the causes of topical tetracaine abuse can be attributed to a number of factors including: (a) unawareness of patients from the side effects of topical anesthetics, (b) easy access to overthe-counter medical drugs, (c) low cost of drugs offered in drugstores, (d) prescription of the drug by nonspecialists, (e) idiosyncratically applied name of tetracaine as welder's drops, (f) recommendation of unauthorized people, and finally (g) removal of the foreign bodies from ocular surface by a bank note at the work place, since they think this form of foreign body removal is economically of low cost. As for the last option stated (i.e. the use of a bank note for easy removal), it can be infected and produce ocular re-infection particularly producing keratitis and conjunctivitis. Also, further Table 3: Distribution of patients by affected eye, anatomic site and type of foreign body Variable RE LE Both Eye Cornea Subpalpebral Conjunctiva and limbus Metallic Woods Myiasis Corneal ulcer Rust material Metallic FB and ulcer Other Frequency Eye 83 76 3 Anatomical site 132 18 12 Kind of FB 102 20 3 4 10 1 22 63 12.3 1.9 2.5 6.2 0.6 13.6 81.5 11.1 7.4 51.2 46.9 1.9 Percent Table.4: Distribution of patients' approach times Frequency Percent Approach times One 124 76.5 Two 37 22.8 Three 1 0.6 Time they referred to ophthalmologist One day 20 12.3 Two days 42 25.9 Three days 48 29.6 3 days> 52 32.1 Total 162 100.0 corneal abrasion by the mechanical action and trauma of the bank note may follow; as topical tetracaine is a shortacting drug and their anesthetic effect is about 20 minutes (13), patients may like to use it as frequently as possible for pain relief and eye comfort. Variable Among the findings, no significant difference was observed between the left and right eye FB cases (Table 3). However, it was observed that about 81.5% of the cases had corneal damages due to the ease of exposure of this part of the eye; since corneal involvement can increase more severe symptoms and early effects on the patient's sight, the sufferers normally refer to eye clinics sooner than other sufferers. Also, as indicated in Table 3, about 63% of the cases had metal particles as FB, they are mostly expected to wear protective equipment while doing metal welding. As Table 4 indicates, around 61.7% of the patients with eye discomfort referred to the eye clinic three days after the exposure, which shows that either they underestimated the severity of the injury or they might have experienced less severe symptoms or misuse of anesthetic eye drops. However, the low rate of admission on the first day of the exposure (20%) is likely to indicate either their awareness of the severity of the issue or the severity of the injury symptoms or avoiding to use anesthetic eye drops. Also, most cases referring to the eye clinic were those with first time experience of ocular FB (74.7%), which can be considered as an advantage in public awareness; however, it may be compared with others referring to non-experts and preferring selftreatment, which is scientifically damaging and harmful (Table 5). Among these, one patient required hospitalization for treatment. Since topically applied anesthetics like tetracaine eye drops interfere with corneal epithelial metabolism and repair, they cannot be accordingly used for chronic pain relief. However, topical anesthetics can become drugs of misuse eventually leading to chronic pain syndromes and vision loss; therefore, these drugs Table 5: Distribution of patients with the first person' management and method of removing eye FB Variable Frequency First removal by GP 19 Ophthalmologist 121 Other 22 Management FB removal and 154 medication Only medication 7 Admission 1 Percent 11.7 74.7 13.6 95.1 4.3 0.6 should not be dispensed to patients (8) since the consequences of this inadmissible use except unwanted complications cannot be anything else. Also, the prolonged use of topical anesthetic eye drops may cause corneal erosions, including slow corneal wound healing (9, 10). In the present study, corneal ulcer was found in 2.5% of the cases (4). CONCLUSIONS Topical anesthetic misuse is mostly common among welders; ease of access in providing them from drugstores without prescription, simple usage and short-acting effects in pain relief are important reasons for its inadmissible usage. Repeated use of these products or duration of use can result in serious ocular complications. Therefore, essential measures are expec-ted in enhancing the awareness of the clients through educational programs; consequently, these products must be used appropriately and only under the super-vision of ophthalmologists. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Acta Facultatis Medicae Naissensis de Gruyter

Topical Anesthetic Misuse in Patients Admitted to Sabzevar Eye Clinic in Iran

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Publisher
de Gruyter
Copyright
Copyright © 2016 by the
ISSN
2217-2521
eISSN
2217-2521
DOI
10.1515/afmnai-2016-0030
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Abstract

ACTA FACULTATIS MEDICAE NAISSENSIS DOI: 10.1515/afmnai-2016-0030 UDC: 615.457.035.2:617.7-06(55) Ebrahim Shirzadeh1, Nematullah Shomoossi2, Hasan Abdolahzadeh2 Department of Ophthalmology, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran 2School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran SUMMARY Topical anesthetic eye drops are used extensively for ophthalmic examinations but selftreatment and non-technical removal of foreign bodies using tetracaine drops can be hazardous. The present study intended to determine the inadmissible uses of anesthetic tetracaine eye drops, manner of drug obtaining and likelihood of the ocular complications in the patients. This cross-sectional study was conducted on 162 patients with ocular pain and foreign body sensation, red eye or lid edema admitted to the Eye clinic in Sabzevar, Iran. Variables included age, sex, chief compliant, job, site of foreign bodies, diagnosis of problem, use of tetracaine drops, drug provision, times patients referred to the eye clinic, and kinds of treatment. The most common chief complaint for admission to the Eye clinic was lacrimation (55.6%), followed by ocular pain, and foreign body sensation (35.8%). Some patients (30.9%) (mostly welders) inadmissibly used topical tetracaine eye drops; 21.6% of cases obtained tetracaine eye drops from drugstores without doctor's prescription, and only 3.7% provided drugs by prescription. Corneal site (81.5%) was the most common location of foreign body; metallic foreign body (63%) was the most common. One patient was admitted in hospital for management. Topical inadmissible tetracaine (0.5%) is commonly used by welders, who obtain it from drugstores without prescriptions due to its simple usage and short acting pain relief. Supervision is required over drugstores for denying it if demanded without a prescription. Enhancing clients' awareness is also suggested. Key words: tetracaine, drug misuse, foreign body, eye drop Corresponding author: Nematullah Shomoossi E-mail: nshomoossi@yahoo.com INTRODUCTION Various drugs may be available to lay people for potential use and misuse, and the number of victims misusing them is on the rise. Erroneous cultural and socioeconomic attitudes as well as the easy accessibility of over-the-counter drugs play an important role in the acceptance of these substances (1). Topical anesthetic eye drops are mostly used in the emergency departments and they provide superb analgesia to the painful eyes; they are also applied for ocular urgency without routine prescriptions (2, 3). Superficial ocular foreign bodies take victims to drugstores upon ophthalmic urgencies, where they conveniently find these eye drops appropriate for eliminating ocular pain, foreign body sensation and relief of ocular discomfort. In a major town like Sabzevar in the northeastern part of Iran, the most common topical anesthetic eye drop used is tetracaine (i.e. anisthocain 0.50% Sina Daru Co, Iran). Most patients tend to misuse it either after ultra-violate keratitis (UVK) or for corneal foreign body removal (4, 5). Self-treatment and non-technical removal of ocular foreign bodies by the help of anesthetic tetracaine eye drops can be a hazardous procedure particularly when they are used by lay people (6-8). Clinical evidence reveals that unauthorized uses of this ophthalmic drop by workers like welders, turners, blacksmiths, aluminum makers, and similar occupations are common; therefore, the aim of the present study was to determine the conditions of inadmissible uses of anesthetic tetracaine eye drop, application of the drug, site of ocular foreign bodies and likelihood of the ocular complications in patients seeking medical advice from a physician for eye discomfort. manner of providing tetracaine eye drops, times patients were referred to the eye clinic, and kinds of treatment. Patient management consisted of foreign body removal and medication, mere medication, and hospitalization if required. The variables were categorized as follows: Yes-No for using tetracaine eye drops, if the patient's response was Yes, then the manner of drug providing was categorized as follows: from drugstore, by prescription, and other. Also, the duration of discomfort and times of patients admitted for medical consultation were enquired and determined by their related variables. There were no limitations for this study and the informed consent was obtained from all patients. Statistical analyses were performed using STATA for windows software (version 11). Descriptive and analytic statistics were used for data analysis. RESULTS Of 162 examined patients, 86.4% were male and 13.6% were female. Their mean age was 30.89±12.95 years with a range of 1 to 70 years old. Distribution of patients by demographic data is presented in Table 1. The results showed a significant relationship between gender and occupation with the use of tetracaine eye drops (p < 0.001). The most common chief complaint was observed to be ocular lacrimation (55.6%) and then ocular pain and foreign body (FB) sensation (35.8%). The frequency of patients admitted to the clinic due to their ocular symptoms is displayed in Table 2. The study revealed the rate of inadmissible use of tetracaine eye drops to be 30.9%; also, the manner of drug provision from a drugstore without prescription was 21.6%. Table 3 displays the distribution of patients' affected eye, anatomical site and type of the FB. Corneal FB with 81.5% (132) was the common site and metallic FB with 63% (102) was the most common type. Distribution of patients by duration of exposure to the ocular FB and admission to the eye clinic are displayed in Table 4. As Table 4 indicates, around 68% of the patients with FB referred to the eye clinic three days after the exposure and the lowest rate of admission (20%) was on the first day of the exposure. Furthermore, the present study revealed that 13.6% of patients underwent ocular FB removal by unauthorized and non-medical people, distribution of which is shown in Table 5. Also, the study revealed that about 1.2% (2) of the patients used diclofenac eye drops (Sina Daru Co, Iran) for their pain control. PATIENTS AND METHODS This clinically-based and cross-sectional study was conducted on 162 patients admitted to the ophthalmological clinic for eye discomforts. The study population included all patients admitted with the chief complaints of ocular pain and foreign body sensation, lacrimation, red eye or lid edema in Sabzevar Eye Clinic in Sabzevar, Iran. The study was performed from July 2014 to September 2014. Data collection was achieved by the eye examination as well as filling out a questionnaire. Variables consisted of age, sex, chief compliant, job, site of foreign bodies, diagnosis of the problem, use of tetracaine eye drops, DISCUSSION The present study was designed to investigate the inadmissible uses of anesthetic tetracaine eye drop, application of the drug, site of ocular foreign bodies and likelihood of the ocular complications in patients seeking medical advice and treatment in Sabzevar Eye Clinic in Iran. As Table 1 indicates, the prevalence of eye disorders is higher in men (86.4%) than in women, which shows the effect of masculine occupations with higher risks of ocular FB. Also, the most frequent age affected by FB was 25-59 years of age, while the least frequent age was among the elderly (older than 60). The most frequent FB cases had lower education which enhances the likelihood of their being unaware of security at workplaces, where about 46% of the cases were involved in metal working; this may highlight the need for wearing personal protective equipment (PPE) as well as training health and safety executive (HSE) rules for workers with lower education; this may require responsibilities for employers, too. In addition, about 54% of the cases were involved in non-metal works, which further stresses the need for public education about the safety and security in the workplace. Topical ocular anesthetic eye drops abuse can lead to superficial punctuate keratitis, persistent corneal epithelial defects, stromal/ring infiltrates, corneal edema, endothelial damage and ocular inflammation (2). It is thought that preservatives in anesthetics may play a further role in toxicity (9). Symptoms of such patients included photophobia, ocular pain FB sensation, red eye, Table 1: Distribution of patients by demographic variables Variable Use tetracaine N (%) 50 (35.7) 22(100) Age Childhood (1-10) Adolescence (11-25) Middle age (26-59) Old age(>60) Illiterate Diploma< Academic Welder Blacksmith Turner Worker Aluminum maker Mechanic Shepherd Other 0 16(40) 32(29.3) 2 Education 6(30) 40(31.25) 4(28.5) Occupation 22(51.1) 3(75) 10(35.7) 4(30.77) 1(25) 4(66.67) 0(0) 6(9.84) 21(48.8) 1(25) 18(64.2) 9(69.23) 3(75) 2(33.33) 3(100) 55(90.16) 0.000 43(26.5) 4(2.4) 28(17.28) 13(8.02) 4(2.47) 6(3.70) 3(1.85) 61(37.6) 14(70) 88(68.7) 10(71.4) 0.9 20(12.3) 128(79.01) 14(8.64) 11(100) 24(60) 0.2 77(70.6) 0 109(67.2) 2(1.2) 11(6.79) 40(24.6) Not using tetracaine N (%) Sex Male Female 90(64.2) 0(0) 0.000 86.4)(140 13.5)(22 p-value Total Table 2: Distribution of patients by ocular symptoms and tetracaine eye drops misuse and their providing Variable Frequency Percent Lacrimation 90 55.6 Foreign body sensation and 58 35.8 pain Red eye 8 4.9 Inflamed eye 6 3.7 Total 162 100.0 Use of tetracaine eye drop Yes No 50 112 Tetracaine provide Drugstore Physician Other No provide 35 6 10 111 21.6 3.7 6.2 68.5 30.9 69.1 decreased vision and tearing (4). Because of concerns for delayed healing and corneal erosion (2), corneal keratitis secondary to the misuse of tetracaine eye drops may initially be treated for acanthamoeba keratitis since topical ocular anesthetic drops abuse may appear misdiagnosed as acanthamoeba keratitis (9). In the present study, the most common chief complaint was observed to be ocular lacrimation (55.6%), and then ocular pain and FB sensation (35.8%). The results of this study showed that 30.9% of patients inadmissibly used topical tetracaine eye drops; also, 21.6% of cases provided tetracaine eye drops from drugstores without doctor's prescription, and only 3.7% provided drugs by prescription. As indicated in Table 2, about 27.8% of the cases with FB in the eye were observed to have obtained drugs from non-experts, a really remarkable threat of self-treatment which requires public education and cultural change. This has occurred despite the contraindication of anesthetic eye drops (even by medical doctors) except in eye clinics for emergency medical cases including eye burns, measuring intraocular pressure and extracting eye foreign bodies. However, in the present study, 3.7% of the cases obtained the eye drop by medical prescription; this may also be considered a non-scientific medical measure, requiring refresher courses for GPs to re-emphasize its use in emergency cases. Similarly, Sharifi and colleagues studied the prevalence of topical ocular anesthetic abuse among welders in Iran; they found that from 390 welders included in the study, a total of 314 welders (80.5%) had used topical anesthetics at least once during their career (10). Almost 90% of them stated a preference for selftreatment over seeking help from a physician due to cultural and financial reasons; also, the most commonly used topical anesthetic was tetracaine; most of the subjects (97.4%) had obtained the drugs from pharmacies without a prescription (10). In another study by Erdem and coworkers, the misuse of topical anesthetic eye drops abuse was shown from 12 eyes of 8 patients who were evaluated retrospectively, and one of the patients provided the drug with a primary care practitioner's prescription, but for the other 7 patients, it was available from pharmacies without prescription (11). Also, Katsimpris and coworkers described the clinical findings in five patients with topical anesthetic abuse with a detailed history in all patients; it was revealed that topical anesthetic abuse led to keratitis by obtaining anesthetic drops from the pharmacy without medical prescription (12). However, in the present study, 21.6% of all patients with different occupations provided the drug from drugstores without doctor's prescription, and only 3.7% provided drugs by physician's prescription. Topical anesthetic drops easily provided from pharmacies can be considered as an important alarm for topical anesthetic drug misuse and needs strict supervision over pharmacies. Pharmacists dispensing these drugs have a professional obligation that these products are being used appropriately and under the supervision of an ophthalmologist. Unfortunately, these findings can be alarming signs of health problems in the target community we studied. Applicable to similar contexts, the causes of topical tetracaine abuse can be attributed to a number of factors including: (a) unawareness of patients from the side effects of topical anesthetics, (b) easy access to overthe-counter medical drugs, (c) low cost of drugs offered in drugstores, (d) prescription of the drug by nonspecialists, (e) idiosyncratically applied name of tetracaine as welder's drops, (f) recommendation of unauthorized people, and finally (g) removal of the foreign bodies from ocular surface by a bank note at the work place, since they think this form of foreign body removal is economically of low cost. As for the last option stated (i.e. the use of a bank note for easy removal), it can be infected and produce ocular re-infection particularly producing keratitis and conjunctivitis. Also, further Table 3: Distribution of patients by affected eye, anatomic site and type of foreign body Variable RE LE Both Eye Cornea Subpalpebral Conjunctiva and limbus Metallic Woods Myiasis Corneal ulcer Rust material Metallic FB and ulcer Other Frequency Eye 83 76 3 Anatomical site 132 18 12 Kind of FB 102 20 3 4 10 1 22 63 12.3 1.9 2.5 6.2 0.6 13.6 81.5 11.1 7.4 51.2 46.9 1.9 Percent Table.4: Distribution of patients' approach times Frequency Percent Approach times One 124 76.5 Two 37 22.8 Three 1 0.6 Time they referred to ophthalmologist One day 20 12.3 Two days 42 25.9 Three days 48 29.6 3 days> 52 32.1 Total 162 100.0 corneal abrasion by the mechanical action and trauma of the bank note may follow; as topical tetracaine is a shortacting drug and their anesthetic effect is about 20 minutes (13), patients may like to use it as frequently as possible for pain relief and eye comfort. Variable Among the findings, no significant difference was observed between the left and right eye FB cases (Table 3). However, it was observed that about 81.5% of the cases had corneal damages due to the ease of exposure of this part of the eye; since corneal involvement can increase more severe symptoms and early effects on the patient's sight, the sufferers normally refer to eye clinics sooner than other sufferers. Also, as indicated in Table 3, about 63% of the cases had metal particles as FB, they are mostly expected to wear protective equipment while doing metal welding. As Table 4 indicates, around 61.7% of the patients with eye discomfort referred to the eye clinic three days after the exposure, which shows that either they underestimated the severity of the injury or they might have experienced less severe symptoms or misuse of anesthetic eye drops. However, the low rate of admission on the first day of the exposure (20%) is likely to indicate either their awareness of the severity of the issue or the severity of the injury symptoms or avoiding to use anesthetic eye drops. Also, most cases referring to the eye clinic were those with first time experience of ocular FB (74.7%), which can be considered as an advantage in public awareness; however, it may be compared with others referring to non-experts and preferring selftreatment, which is scientifically damaging and harmful (Table 5). Among these, one patient required hospitalization for treatment. Since topically applied anesthetics like tetracaine eye drops interfere with corneal epithelial metabolism and repair, they cannot be accordingly used for chronic pain relief. However, topical anesthetics can become drugs of misuse eventually leading to chronic pain syndromes and vision loss; therefore, these drugs Table 5: Distribution of patients with the first person' management and method of removing eye FB Variable Frequency First removal by GP 19 Ophthalmologist 121 Other 22 Management FB removal and 154 medication Only medication 7 Admission 1 Percent 11.7 74.7 13.6 95.1 4.3 0.6 should not be dispensed to patients (8) since the consequences of this inadmissible use except unwanted complications cannot be anything else. Also, the prolonged use of topical anesthetic eye drops may cause corneal erosions, including slow corneal wound healing (9, 10). In the present study, corneal ulcer was found in 2.5% of the cases (4). CONCLUSIONS Topical anesthetic misuse is mostly common among welders; ease of access in providing them from drugstores without prescription, simple usage and short-acting effects in pain relief are important reasons for its inadmissible usage. Repeated use of these products or duration of use can result in serious ocular complications. Therefore, essential measures are expec-ted in enhancing the awareness of the clients through educational programs; consequently, these products must be used appropriately and only under the super-vision of ophthalmologists.

Journal

Acta Facultatis Medicae Naissensisde Gruyter

Published: Dec 1, 2016

References