Population-level investigation of the knowledge of ocular chemical injuries and proper immediate action

Objective Although the eyes occupy 0.1% of the total body surface, eye injuries are serious because vision is arguably the most important sense. We aimed to assess knowledge of Saudi Arabian residents regarding steps to be taken in cases of chemical eye injury, in order to promote awareness of such procedures. Results A cross-sectional design was done. A random sampling method was utilized to select 888 individuals in the Saudi community. Participants completed an electronic closed ended, validated, anonymous, self-administered questionnaire. Two experts assessed content and face validity. Respondents were 18–29 years of age. 74 (8.3%) had a history of chemical eye injury. Regarding the first step taken in case of chemical eye injury, 697 (78.5%) respondents indicated washing with water, 164 (18.5%) indicated visiting the emergency department, 11 (1.2%) indicated using eye drops, and 5 (0.6%) indicated covering the eye immediately. Seventy-five (8.4%) respondents agreed that an eye injured with an acidic material should be washed with an alkaline solution. These results should be confirmed by health authorities and appropriate interventions should be developed for improving knowledge among masses, thereby promoting a healthier society.


Introduction
The eyes occupy 0.1% of the total body surface and 0.27% of the anterior body surface; however, the seriousness of ocular injury is amplified relative to these proportions, as vision is arguably the most important sense. Loss of vision may affect quality of life because it can lead to job loss, dramatic lifestyle changes, and facial deformities [1,2]. Ocular injuries place a high burden on the community and are generally preventable [3]. Chemical injuries can involve alkaline and acidic injuries. Alkaline burns are more common, due to the widespread use of alkaline substances in industrial and home cleaning products; these burns typically result in more severe injuries [4].
Approximately 7% of work-related eye injuries treated in hospital emergency departments in the United States are related to chemical injuries [5]. Additionally, more than 60% of chemical injuries occur in workplace accidents, 30% occur at home, and 10% are the result of an accident [6]. Up to 20% of chemical injuries result in massive visual disability and facial disfigurement; notably, visual rehabilitation after an advanced chemical eye injury occurs in less than 15% of the affected individuals [5,6]. Men are threefold more likely to experience chemical injuries than women; furthermore, individuals aged 16-45 years are most likely to be affected [6].
In Saudi Arabia, a prior study reviewed the data regarding local chemical injuries in two major government hospitals. Among a total of 59 patients (3:1, male:female ratio; mean age, 25 years), alkaline drain cleaners were the most common cause of chemical burns (75% of the Open Access BMC Research Notes *Correspondence: hadeel.Seraj@gmail.com 3 Wasel Aalami SP-630355516, Jeddah 23622, Saudi Arabia Full list of author information is available at the end of the article patients). In remaining patients, causes comprised concentrated sulfuric acid, car battery acid, and topical application of herbs [7]. Familiarity with various types of ocular and periocular injuries is important for all community members, particularly those living in a predominantly oil-industry driven economy where a large proportion of the population is engaged and handles chemicals frequently. Epidemiological studies are needed to provide information on the rate of knowledge of ocular chemical injuries and proper immediate action. To our knowledge, there have been no investigations about such problem in the general population of Saudi Arabia or elsewhere. So, such study is needed in order to increase awareness of such injuries and to support a healthier society.

Materials and methods
A cross-sectional study was conducted among individuals in the Saudi community during November 2018. A random sampling method was utilized to select 888 individuals. Participants completed an electronic closed ended, validated, anonymous, self-administered open questionnaire. Two experts assessed content and face validity. Internal consistency reliability was 0.81 using alpha Cronbach's. The questionnaire was distributed online through e-mail and social media websites (Facebook, Twitter, and WhatsApp) Both descriptive and inferential statistics were applied.
The study included both men and women ≥ 18 years of age. Ethical approval was obtained from the Biomedical Ethics Committee at King Abdulaziz University (Jeddah, Saudi Arabia). The sample size was determined by using a sample size calculator site (http://www.raoso ft.com/ sampl esize .html); the minimum recommended sample size was 377, and we included 888 respondents, 74 (8.3%) of which had a history of chemical eye injury. Participants were informed about the length of time of the questionnaire (6-10 min). Furthermore, the purpose of the study was explained and attached to the questionnaire online link. The questionnaire was formulated on the basis of our study objectives. It was tested before fielding via a pilot study and responses were assessed to help refine the questionnaire. Responses were entered manually into a database.
The questionnaire consisted of two parts: the first part acquired demographic data (age, sex, marital status, educational degree, and job); the second part assessed knowledge of ocular chemical injuries and the proper immediate action. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 21.0. (IBM Corp., Armonk, NY, USA). Descriptive statistics was used. Chi-squared test, odds ratios and 95% confidence intervals were calculated. Frequency and percentages were used to describe categorical variables, while mean (standard deviation) was used to describe continuous numerical variables. P-values of < 0.05 were considered to be statistically significant.

Demographic information
This study included 888 individuals in the Saudi community during November 2018. Most of them were female (624, 70.3%) (see Additional file 1: Table S1).
Regarding type of job among the respondents, 286 (32.2%) had an office job, and 160 (18.0%) worked in the medical field (see Additional file 4: Table S4).
A total of 399 (44.9%) respondents selected "not applicable" or "other, " because they were either students or did not have a job, or because of the nature of their work. In our study, 72 (8.1%) respondents had a history of chemical eye injury, including minor food-related injury, such as hot sauce or cooking oil splash. Moreover, 64 (7.2%) respondents had a close friend or family member who experienced a chemical eye injury, including minor foodrelated injury ( Table 2).

Knowledge related to chemical eye injuries
In total, 784 (88.3%) respondents agreed that chemical substances can cause eye complications (Table 3). Regarding the first corrective action in case of chemical eye injury, majority of the respondents (697, 78.5%) said that washing the eye with water should be the first action; of these 697 respondents, 655 (73.8%) said that washing the eye with plenty of water should be performed, and 42 (4.7%) said that washing the eye with little water was appropriate. In contrast, 164 (18.5%) respondents said that going to the emergency department should be the first corrective action (Table 3).

Discussion
Vision is one of the most important human functions. Loss of vision from chemical injury may greatly affect quality of life. This study aimed to assess the knowledge of immediate corrective action in cases of chemical eye injury, among individuals in the Saudi community, in order to reduce the incidence of ocular injuries and related complications. When our participants were asked whether chemical substances can cause eye complications, we found that 88.3% agreed; this is consistent with the findings of another study conducted among Latino farm workers, where 97.3% agreed that wind, dust, and chemicals could cause eye problems [8].
In cases of chemical ocular injuries, rapid irrigation and dilution of the chemical with water should be the immediate first corrective action, in order to reduce tissue damage and protect vision [9,10]. In our study, 78.5% of the respondents indicated that washing the eyes with water should be the first corrective action. However, 8.4% of respondents in our study indicated that in cases of acidic eye injuries, the eyes should be washed with an alkaline solution, which is extremely dangerous; moreover, 6.8% indicated the opposite washing regimen, that eyes should be washed with an acidic solution in cases of alkaline eye injuries, which is also dangerous. Approximately 50% of our respondents did not know that both the washing regimens could be dangerous and therefore, should not be considered at all.
The severity of ocular injury is related to the type of chemical, the volume and pH (alkaline or acidic) of the solution, and the duration of exposure. Notably, alkaline solutions penetrate more rapidly into the eye, relative to acids; therefore, alkaline solutions are more damaging to intraocular structures such as the iris, lens, and ciliary body, resulting in rapid and irreversible damage [11]. In our study, 55.3% of the respondents agreed that alkaline eye injuries were more dangerous than acidic eye injuries. After ocular chemical injury, it is important to search for and remove solid particles that could be trapped in the conjunctival fornices and act as reservoir for continued chemical release and inflammation [6,9]. This was recognized by 62.2% of the respondents in our study, who agreed that particles should be located and removed in case of chemical eye injury.

Conclusion
The eye is an important, irreplaceable organ. Loss of vision through ocular chemical injury is a serious condition that can negatively affect quality of life, primarily through job loss and increased dependence on others.
Our findings indicate that individuals in the Saudi population need greater awareness regarding immediate corrective action in cases of ocular chemical injuries. Furthermore, there is a need to clearly communicate that water should be the only solution used to irrigate the eye; no other solutions should be used, regardless of pH. Expansion of these results should be performed by health authorities, in conjunction with the development of appropriate interventions, such as health awareness campaigns regarding ocular chemical injuries and immediate corrective actions, in order to improve knowledge and to create a healthier society.

Limitation
The primary limitation to the generalization of these results is the selection bias. We used an electronic questionnaire for our study; therefore, the results are subject to the bias that people with higher level of education (that could answer the questionnaire) were included. Future studies are needed that should include a wider section of population irrespective of the level of education.