Australian Dental Journal, December, 1978

DECEMBER, 1978

45 3

Volume 23 : : Number 6

Eye injuries and the dentist::.

John Colvin, M.B., F.S., D.O., F.R.C.S., F.R.A.C.S., F.R.A.C.O.

Dircctor of Medical Education (EYE) , Royal Victoriati Eye & Ear Hospitcil Senior Ophthalmologist, Royal Australian Air Force

ABsrRKr-The risk of damage t o the eyes of the patient, the dentist and his assistant should be recognized. Protection can be achieved by the wearing of specially designed spectacles using CR 39 plastic tinted lenses. Contact lenses should be removed by patients who are to undergo general anaesthesia.

(Received for publication July, 1978)

The vital importance that eyes play in dentistry is soon appreciated when one realizes that vision provides 75 per cent of the sensory information received by our brain. The other senses contribute the following: hearing, 13 per cent: touch, 6 per cent; taste, 3 per cent; and smell, 3 per cent.

Since having the privilege of addressing the Fifth Convocation, Royal Australasian College of Dental Surgeons in Melbourne during February, 1977, on "The Care, Protection and Utilization of Dentists' Eyes"], I have had the unique opportunity of lecturing to over one-third of Australia's dentists.

As a result of direct questioning of the dental audience, it soon became apparent that less than 10 per cent of practitioners routinely provide eye protection for their patients.

It is because of this low figure of protection i n an area where the potential for eye injuries

* Lecture, Australian Dental Association, Jubilee Congress, February, 1978.

1 Colvin, J.-The care, protection and utilization of dentists' eyes, Ann R.A.C.D.S., 5: 76-80, 1977.

is so high that a need exists to educate the dentist on eye safety. In fact, during the last 15 years a number of papers have been published on this subject2-13.

ZBelting C M. Haberfelde G C. and Juhl L. K.- SpreAd of o&anisms fro; ddntal' air rotor. 'J.A.D.A., 685 648-651 (May) 1964.

3 Brow6 R. V.-Bacterial aerosols generated by ultra high- speed cutting instruments. J. Dent. Child., 32: 112-117, 1965.

1 Bahn, S. L.-Of the eyes and the dentist I speak. J. Conn. Dent. Ass., 40: 10-13 (July) 1%6.

6 Travaleini. E. A.. and Larato. D.-Dissemination o f

1966. 7 Larato D. C.-Emergency treatment and prevention of

eve 'iniuries in dental uractice. N.Y. State Dent. J.. 32.10 -353-358 (Oct.) 19&6. * Von'Khnrner R -High speed equipment and dentists' health. J. P;os.'Dent., !9:1. 46-50 (Jan.) 1968,.

0 Federico, A. N.-Occupational hazard< in dentistry. J. New Jersey Dent. SOC., 40: 73-79 (Oct.) 1968.

IoHales, R. H . 4 c u l a r injuries sustained in the dental pi%e. Greater Milw. Dental Bull., 36: 489-493 (Dec.) Ij.!".

11 Specialist warns about hazards to eyes in dentdl pro-

12 Casey, D. M.-Eye injuries in the dental office. Letter. cedures. Dental Survey,, 47; 67 (May) 1971.

J.A.D.A.. 91:3. 502-503 (Seot.) 1975. 13Miller, J. 'B.-The unseen iisk in your office. Dent.

Manage.. 16:6, 38 (June) 1976.

454 Australian Dental Journal, December, 1978

Patient eye protection l h e advent of the high speed turbine and the

concept of four-handed dentistry has placed the patient in the reclining position and greatly in- creased the possibility of ocular trauma to the patient. Sharp dental instruments are continually passed from assistant to dentist and back, passing within inches of the patient’s eyes.

Cotton pellets saturated with acids, especially phosphoric acid. substances with a pH of 0.1, and other potentially harmful medicaments, are also carried near the eyes. Dropping any of these into an unprotected eye could result in permanently affected vision.

An excellent article by Hales14 describes ten cases of ocular injury occurring in private dental offices over a four-year period and treated in private ophthalmic practice. One of the cases was a penetrating injury of the cornea and lens from a dropped excavator which caused permanently decreased vision and resulted in a law suit settled for $27,000. Other injuries reported by Hales were corneal abrasions, conjunctival foreign bodies, sub- conjunctival haemorrhage, recurrent corneal erosion. and chemical conjunctivitis, and dilated pupil after local anaesthesia. Nine of the ten injuries could have been prevented by the patient wearing safety glasses. None of these ten patients was wearing glasses at the time of injury and five had removed their own prescription glasses at their dentist’s request. There have also been cases reported of penetrating ocular injuries caused by dental hypodermic needles.

Case report A young man attended the Casualty Department

of The Royal Victorian Eye & Ear Hospital, Melbourne. on July 8, 1977. complaining of a painful left eye. He had been treated by his private dentist with 20 per cent stannous fluoride solution. which has a pH of 2.3, some of which had entered his left eye that day. He was not wearing eye protection at the time of the incident.

Clinical photographs were taken of this patient. On examination, he had a large white necrotic m;iss in the lateral fornix of the conjunctiva which was densely adherent. Removal was only achieved by surgical debridement. The eye was irrigated with sodium bicarbonate solution. H e was given antibiotic eye ointment. the eye was padded and he was requested to return to the Casualty Department.

He was seen in my Outpatient Clinic on July 1 1 . 1977. when i t was noted that the eye had normal vision. The involved area of conjunctiva

I 4 Hales, R. H.-Ocular injuries sustained in the dental office. Amer. J. Ophthal., 703 , 221 (Aug.) 1970.

w a ~ improving and he was requested to continue on his local antibiotics. He expressed a wish to see an ophthalmologist privately, and this was arranged.

It is extremely fortunate in this case that only the lateral conjunctiva was involved. Should this large amount of stannous fluoride have been adherent to his cornea then permanently decreased vision would have resulted. An identical case has occurred i n Sydney, New South Wales. As this substance is in regular daily use by all dentists and, in particular, etching liquid (37 per cent orthophosphoric acid) with a pH of 0.1, extreme care should be exercised in their use. In my opinion. the wearing of efficient eye protection is mandatory for patient, dental assistant and dentist.

Should any chemical enter the eye, it should be irrigated immediately with copious water - do tiof d14tr.v. Do not try to find the specific antidote as valuable time is only lost. Water irrigation immediately is the best ar.d safest method to adopt and should be continued for 15-20 minutes at least.

It would be my strong recommendation that all dental surgeries have immediately available a sterile eye irrigating solution*. It has a shelf life of almost three years and is stable and effective up to an ambient temperature of 45OC. It is isotonic to the eye and naturally is more comfort- able and effective than water irrigation for chemical burns. It must be used adequately and for the specified time.

Since 1961. 1 have been actively engaged with spectacle makers in the research and development of spectacles suitable for personnel of the Royal Australian Air Force, and have been very ably assisted by its Aircraft Research and Development Unit by their flight test reports and evaluation of the spectacles developed to meet changing operational requirements. Evaluations have also been performed in Antarctica and by selected N.A.S.A. astronauts. Minor variations of the design have been used successfully in parachuting, racing- car driving, and industrial eye protection showing ii wide adaptation and use for th.e Mark Ill design.

There is currently available a Mark V design that features 21 solid aluminium frame of mono- construction. which when integrated with CR 39 lenses is immensely strong and capable of holding adjustments. It can be marine anodized in matt and all gloss finishes. It is ideally suited for industrial eye protection.

I t is my opinion that currently the best available protection for all patients would be a CR 39 lens with a neutral density I5 tint, set either in a

Eye Stream. Alcon Laboratories, Brookvale.

Australian Dental Journal, December, 1978 455

solid aluminium frame or a plastic industrial eye protection frame. This t i n t is most helpful for the patient’s eyes with prolonged exposure to high intensity lighting as used in surgical procedures.

My own, and pati.ent experience with this type of tinted lens has been most favourable, and I would urge use of this type of patient eye protection as their risks are no longer theoretical.

Hypodermic needles and all instruments should always be passed to the dental surgeon bekitid the patient and never over the head or in front of the patient.

When general anaesthetics are administered to dental patients two important aspects should be considered:

1 . both eyelids should be firmly closed using micropore tape. This will prevent any accidental injury to the cornea from trauma or chemicals;

2. the patient must remove any contact lenses. If retained, then the patient will rub the eyes when regaining consciousness with consequent corneal damage resulting from the hard contact lens. The soft lens usually ruptures when sufficient external force is applied.

Personal eye protection The concept of eye protection in the dental

surgery by the dentist and his assistant is not a new one. The literature is replete with articles and references to the importance of the dentist’s eyesight.

To mechanically prevent amalgam or infected material from the patient entering the dentist’s or dental assistant’s eyes with consequent foreign body lodging in the cornea or a purulent con- junctivitis, effective eye protection is mandatory.

In my opinion. the use of clear CR 39 plastic lenses, at least 58 mm in diameter, set in a solid aluminium frame or a moulded plastic frame will provide all dental personnel with efficient eye protection.

It is vitally important that all of these safety items used for the protection of the patient, dentist, and dental assistant, meet the safety standards as laid down by the Australian Safety Standards for both lenses and frames. All spectacles worn for dentistry must be fitted and continue to remain comfortably fitted by an expert spectacle-maker who completely under- stands design necessary for dental spectacles. H e must be competent t o modify the basic lens shape as required for the individual wearer’s facial features and magnifying combination, if worn. In expert fitting hands, the modified Mark III design is the best dental spectacle currently available, in

mention a s they should be cleaned under running cold water and dried off with a tissue*. When not in use, spectacles should always be kept in the case provided.

Among the total causes of blindness in Australia, eye injury or trauma accounts for 5 per cent. Most regrettably, at least 95 per cent of all eye injuries could have been prevented if efficient eye protection had only been worn at the time of injury.

A relatively common eye injury that I see is caused by being hit by a squash racquet or ball. This usually caused internal bleeding and hospitalization results. Last year the Royal Vic- torian Eye & Ear Hospital admitted 387 patients who required emergency eye treatment. Of these, 140 patients were injured as a result of ball games and, in particular, 61 persons were admitted from squash accidents. Being hit by the ball was the cause of 54, whilst the racquet made up the final 7. It would be my recommendation that all persons playing this game wear efficient eye protection.

For those persons who do not wear glasses then a n eye guard’:’* designed for eye protection in handball, squash, tennis, and other sports is excellent. It is also applicable to those wearing contact lenses.

If correction spectacles are worn, then the best frame is the type? made of nylon using a large rubber-moulded nose-piece and attached by adjust- able elastic strap to prevent slipping. It is used by parachutists and body contact sportsmen and is unbreakable and will not degrade and become brittle as does the normal plastic (cellulose nitrate or acetate) frames after two years of constant use.

Eye protection is mandatory when engaged in home-hobbies, in particular home-carpentry and other do-it-yourself building and repair pursuits, especially using high speed power tools. Also when using either hand or power lawnmowers, as energy released by flying particles often causes serious eye injury which could easily have been avoided by the wearing of eye protection. When exploding fireworks and removing champagne corks and the like, great care should be taken as the eyes are very susceptible to injury. A champagne cork remover is commercially available. Remem- ber, eye injuries are the cause of 5 per cent of blindness in Australia.

In my opinion, the use of clear plastic lenses, 58 mm in diameter, set in a moulded plastic frame, or solid aluminium will provide adequate indus- trial eye protection for dentists during their off- duty pursuits. Their cost is less than $20.00.

my opinion, for all dentists using either corrected or uncorrected lenses. * Kleenex.

The care of CR 39 lenses deserves special * ~ ~ ~ ~ ~ ~ & ~ EyeGuard‘

45 6 Australian Dental Journal, December, 1978

Remember you are only one eye injury away from being effectively unemployed.

Since the compulsory use of effective seat-belts has been introduced in Victoria, I have been impressed. ;IS an eye-surgeon, with the greatly re- duced numbers of persons receiving multiple facial and eye lacerations as ;I result of being ejected through the car windscreen or windows. I t would therefore be most prudent for all dentists to fasten their effective seat belts at all times when travelling in ii car ;IS either driver or passenger, and so ni i n ini ize mu t i lat ing eye damage.

Utilization The only limiting factor to one’s efficiency and

competence a s ;I surgical operator is vision. The hest way to improve the quality of vision is mag- nification. It is desirable t o use only the amount o f magnification required to ensure accurate and comfortable work and this can be achieved by simple magnifying devices initially.

Currently, it is found that excellent dental re- sults are being obtained from ;I magnification of

$ Telescopic. Carl Zeiss.

2 x. Such units: have the advantage of being able to be fixed to the front surface of the dentist’s spectacles. Thus, if the dentist normally wears a prescription lens, the advantage of this prescription can still be used.

The Oculus spectacle-frame mounted device also provides a magnification of 2 x, and should be compared to the Carl Zeiss lens mounted device.

All dentists will need magnification eventually, so my advice would be to start using its undoubted benefits at an early age so that procedures can be more accurately performed, resulting in a higher standard of dental care.

Acknowledgements The assistance and encouragement of David M.

Casey of Amherst, New York; Peter J . Cunning- ham of Melbourne; and the technical contributions made to the development of the spectacles by Martin X. Hogan of Melbourne, is recognized and deeply appreciated.

The Clinical School, Royal Victorian Eye & Ear Hospital,

126 Victoria Parade, Melbourne, Vic., 3002.