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BRIEF COMMUNICATION
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 82-84

Pesticide exposure presenting as acute conjunctival necrosis


Department of Ophthalmology, MS Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Submission02-Apr-2021
Date of Decision05-Jun-2021
Date of Acceptance08-Jun-2021
Date of Web Publication18-Jul-2022

Correspondence Address:
R H Deepthi
Department of Ophthalmology, MS Ramaiah Medical College, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_48_21

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  Abstract 


Acute direct ocular exposure to insecticides is rare and can present as a chemical injury. We present a case of a 21-year-old male patient who had an accidental exposure to chlorpyrifos and propoxur while spraying it as an insecticide. He presented with severe conjunctival ischemia and necrosis involving the inferior fornix. He underwent amniotic membrane transplantation to preserve the ocular surface. The case report highlights the chemical effects of organophosphorus compounds on the ocular surface.

Keywords: Acute exposure, chlorpyrifos, conjunctival necrosis, organophosphorus, pesticide, propoxur


How to cite this article:
Deepthi R H, Thanuja G P. Pesticide exposure presenting as acute conjunctival necrosis. J Clin Ophthalmol Res 2022;10:82-4

How to cite this URL:
Deepthi R H, Thanuja G P. Pesticide exposure presenting as acute conjunctival necrosis. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 Aug 17];10:82-4. Available from: https://www.jcor.in/text.asp?2022/10/2/82/351295



Organophosphates are commonly used as pesticides and insecticides worldwide. Acute exposure to organophosphate compounds (OPC) has been reported to involve multiple organ systems. However, reports of acute ocular manifestations following direct exposure to OPC have not been documented thus far as per the literature search. Acute exposure to pesticides results in irritation, burning sensation, itchiness, and blurring of vision. Ocular surface injury has been limited to either conjunctival congestion or corneal epithelial injury and limbal stem cell deficiency.[1] There have been no reports of conjunctival necrosis reported following pesticide exposure. We report a case of conjunctival necrosis and ischemia following exposure to OPC.


  Case Report Top


A 27-year-old male patient presented to the eye department with red-eye and pain in the right eye. The patient had an accidental exposure to chlorpyrifos (CPS) and propoxur, which splashed into his right eye while spraying it as an insecticide to control mosquitoes. The patient reported to the hospital after 2 days.

On examination, his visual acuity was 6/6 in both eyes. The right eye showed lower lid edema and tenderness. A 10 mm by 15 mm conjunctival forniceal epithelial defect with underlying necrosis was seen on everting the lower lid [Figure 1]. The inferior conjunctiva revealed mild congestion. Superior conjunctiva was normal with no evidence of congestion. The cornea and the rest of the anterior segment were normal. The posterior segment was also normal. Extraocular movements were full and painless. The left eye anterior and posterior segment examinations were normal.
Figure 1: A 10 mm by 15 mm conjunctival forniceal epithelial defect with underlying necrosis due to exposure to Organophosphorus Compound - Chlorpyrifos and Propoxur

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The pH was 6 in the inferior fornix. The patient was given a thorough ocular saline wash and started on topical moxifloxacin 0.5%, dexamethasone 0.5%, hydroxypropyl methylcellulose 0.3%, carboxymethylcellulose gel 1%, along with tablet vitamin C 500 mg TID. In conjunction with the medical therapy, amniotic membrane transplantation was performed after a meticulous debridement of the necrotic material [Figure 2]. The patient improved, and a 3-months' follow-up showed well-formed inferior fornix and normal extraocular movements. Rest of the anterior segment including the cornea was unremarkable at 3-months' follow-up.
Figure 2: Postamniotic membrane transplantation after meticulous debridement of the necrotic material

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Case history

A 27-year-old male patient presented to the eye department with red-eye and pain in the right eye. The patient had an accidental exposure to CPS and propoxur, which splashed into his right eye while spraying it as an insecticide to control mosquitoes. The patient reported to the hospital after 2 days.

On examination, his visual acuity was 6/6 in both eyes. The right eye showed lower lid edema and tenderness. A 10 mm by 15 mm conjunctival forniceal epithelial defect with underlying necrosis was seen on everting the lower lid [Figure 1]. The inferior conjunctiva revealed mild congestion. Superior conjunctiva was normal with no evidence of congestion. The cornea and the rest of the anterior segment were normal. The posterior segment was also normal. Extraocular movements were full and painless. The left eye anterior and posterior segment examinations were normal.

The pH was 6 in the inferior fornix. The patient was given a thorough ocular saline wash and started on topical moxifloxacin 0.5%, dexamethasone 0.5%, hydroxypropyl methylcellulose 0.3% carboxymethylcellulose gel 1%, along with tablet vitamin C 500 mg TID. In conjunction with the medical therapy, amniotic membrane transplantation was performed after a meticulous debridement of the necrotic material [Figure 2]. The patient improved, and a 3-months' follow-up showed well-formed inferior fornix and normal extraocular movements.


  Discussion Top


Organophosphorus compounds can affect the eye by either systemic absorption or direct exposure. Chronic exposure to OPC has shown to cause myopia and a progressive optical autonomic peripheral neuropathy known as Saku's disease in Japan.[2] The mechanism of retinopathy has been attributed to inhibition of Acetylcholinesterase enzyme (AchE) affecting the retinal neurotransmission and increased free radicals resulting in oxidative damage to the retina.

Misra et al. reported macular changes and blurring of vision following chronic exposure to fenthion.[3] There are case reports of cortical visual loss and gaze palsy following acute exposure to OPC.[4]

Direct ocular exposure to OPC occurs as an occupational injury or accidental exposure. This is usually due to drift in protocols, failure to use required protective gear, or equipment failure.[5] Direct exposure usually is mild, and there are reports of conjunctival congestion and corneal epithelial injury. There is a case report of bilateral acute depigmentation of the iris been reported following exposure to insecticide.[6] There have been no reports of conjunctival ischemia so far in literature.

CPS is an organophosphate pesticide used on crops and buildings to kill pests in other settings. It affects the nervous systems of insects by inhibiting the AchE enzyme. It is acidic with a pH of 5.7. Acute exposure to CPS is known to cause tearing of eyes.[7] Propoxur is chemically a carbamate and is chiefly used against household fleas and pests. It is known to be an inhibitor of acetylcholinesterase.[8]

In our patient, direct ocular exposure to the mixture which splashed into his eye resulted in chemical injury. The patient also did not receive immediate eyewash and reported late to the hospital. All these could have aggravated his condition. CPS was in an amorphous form which could have collected in the lower fornix and caused further damage.

Following examination, the patient was managed symptomatically and treated as per our institute's chemical injury protocol and underwent amniotic membrane transplantation to preserve his ocular surface.


  Conclusion Top


Exposure to OPC in the form of insecticide can result in acute conjunctival necrosis. Treatment for which should be meticulously performed by means of thorough eyewash, symptomatic treatment, and watchful observation to prevent any untoward events. Amniotic membrane transplantation can be resorted to in the case of acute necrosis as was done in our case. Above all, appropriate preventive measures should be taken to avoid accidental exposure of chemicals to the eyes.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient thus understands that his names and initials will not be published and all due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McKeag D, Maini R, Taylor HR. The ocular surface toxicity of paraquat. Br J Ophthalmol 2002;86:350-1.  Back to cited text no. 1
    
2.
Dementi B. Ocular effects of organophosphates: A historical perspective of Saku disease. J Appl Toxicol 1994;14:119-29.  Back to cited text no. 2
    
3.
Misra UK, Nag D, Misra NK, Mehra MK, Ray PK. Some observations on the macula of pesticide workers. Hum Toxicol 1985;4:135-45.  Back to cited text no. 3
    
4.
Jaga K, Dharmani C. Ocular toxicity from pesticide exposure: A recent review. Environ Health Prev Med 2006;11:102-7.  Back to cited text no. 4
    
5.
Hudson NL, Kasner EJ, Beckman J, Mehler L, Schwartz A, Higgins S, et al. Characteristics and magnitude of acute pesticide-related illnesses and injuries associated with pyrethrin and pyrethroid exposures--11 states, 2000-2008. Am J Ind Med 2014;57:15-30.  Back to cited text no. 5
    
6.
Singh S, Diwan S, Sachdev MS. Bilateral acute depigmentation of the iris in a child following exposure to insecticide spray. Indian J Ophthalmol 2020;68:1191-3.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Robb EL, Baker MB. Organophosphate Toxicity. In: StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470430/. [Last accessed on 2021 May 04; Last updated on 2020 Jul 27].  Back to cited text no. 7
    
8.
Colović MB, Krstić DZ, Lazarević-Pašti TD, Bondžić AM, Vasić VM. Acetylcholinesterase inhibitors: Pharmacology and toxicology. Curr Neuropharmacol 2013;11:315-35.  Back to cited text no. 8
    


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