Injury to the cornea due to fish bile

OLSEN E. Injury to the cornea due to fish bile. Scand J Work Environ Health 1993;19:358-9. A retrospective study of 207 patients with chemical eye injuries in northern Norway revealed that fish bile was the causal agent in 14%. Fish bile caused superficial cor neal erosions in 28 of 29 cases. All but one of the patients were professional fishermen or fish indus try workers. In one case delayed medical care led to serious corneal opacity. Provided that there was immediate and abundant rinsing of the affected eye and good medical care, the prognosis of fish bile injuries was fairly good. The mechanisms for corneal damage due to fish bile are not clear.

In a costal region of Norway physicians are regularly consulted by fishermen and workers in the fish indu stry because of fish bile spurt into their eyes. Few reports exist on eye injuries caused by bile (1 , 2). To ou r knowledge, serious dam age to the cornea caused by fish bile has not yet been reported. This study was done to estimate the size of the problem and to evaluate the severity of these injuries .

Subjects and methods
The file s of all 207 patients (259 eyes) treated for chemical eye trauma during 1980-1989 at the Department of Ophthalmology, Univer sity Hospit al of Tromse, were examined retro spectively. The following information was recorded: gender, age, profession, type of chemical agent cau sin g the trauma, immed iate action taken by the patient to minimize the injury, the state of the eye on arriva l at the hospital, hospital treatment, and duration of hospitalization. The final outcome concerning corneal opacity and visual acuity was assessed.

Results
In 29 patients (28 males and 36 eye s) the traumas were caused by fish bile. Of the se patients 28 were exposed to fish bile during occupational work , one was a leisure-time fisherman. Fish bile cau sed 56 % of all occupational eye traumas due to chemicals among fishermen and workers in the fish indu str y. Twenty-three patients rin sed their eyes with water immed iately after the accident. All of the patients attended medical care because of di scom fort or pain 358 in the injured eye. All of them showed some degree of chemosis and blepharospasm. In 28 patients (32 eyes) the affected cornea showed t1uorescein staining. On arrival at the hospital all of the eyes were treated by continuous irrigation by at least 4 I of sterile 0.9% saline solution through an irrigation len s system, followed by chloramphenicol ointm ent and an occluding eye pad. The median dur ation of hospitali zation was 3 (range 0-60) d.
A summary of the findings is shown in table I . One patient suffered severe corn eal opacit y. The remaining 28 patient s (35 eyes) avoided seque la.
The patient who suffered severe cornea l opa cit y was a male fisherman who was 44 yea rs of age at the time of the accident. He had had no previou s eye disorder. Fish bile spurted into his right eye as he rinsed a codfish. He attempted to rinse the eye with water. Due to increasing pain he consulted a phy sician II h after the accident. The eye was treated with chloramphenicol ointment. The symptoms per sisted, and he was admitted to the Department of Ophthalmology 3 d later. The right eye was markedly congested . Large parts of the corneal surface showed fluorescein staining. There was slight edema of the cornea. Th e visual acuity of the affected eye was 0.7. The eye was irrigated with 6 I of 0.9 % saline solution and treated with chloramphenicol ointment and topical atropine. A bandage len s wa s applied 4 d after his admittance. The cornea was completely covered by epithelium after 14 d in the hospital. There was stromal edema and opacity causing a decrea se in visual acuit y so that he could count fing ers no farther away than 2 m. Chloramphenicol and atropine was continued and supplemented with topical prednisolon e. The stromal edema and opa city persisted. Five week s after the injury his visual acuity had deteriorated to the point that he could count finger s no farther away than 30 em. The pat ient subsequently underwent two penetrating keratoplasties. Twentythree months postoperatively his visual acuity in the affec ted eye was 0.95 .

Discussion
All serious corneal injuries in the two northern counties in Norway are referre d to the University Hospital of Tromse . Durin g the period 1980-1989 all referred patients with chemical traumas to the eye were hospitalized. The prim ary treatment of such patient s was kept unchanged in the period studied. A significantl y different occurrence of sequel a betw een fish bile injuries and other chemical injuries would therefore reflect different severity. No such difference was found . Another indicator of sev erity is duration of hospitalization. The fish bile pati ent s stayed longer in the hospital than the rest of the patients, eve n if the patient with sequela is excl uded (table 1). However , this difference was not statistically significant.
To our knowl edge one case of corneal opacity in a human eye exposed to fish bile has earlier been reported (1) . However, this corneal opacity was probably caused by the weak solution of lead acetate used for rinsing .
In the case presented in our Results section, proper irriga tion of the eye was delayed . In addition to epithelial erosion stromal edema was observed. The epitheli al wound grew slowl y. No sign s of corneal infection were found. The eye was treated only with topical medication commonly used in eyes with similar trauma s. No other reason th an the fish bile has been found for the corneal opacity. Fish bile produces ero sion s in the corneal epithelium. The prognosis is fairly good. Except for one patient , the cornea healed without any permanent change. However, this was the case also for all but one of the patients with corneal trauma cau sed by othe r chemical agent s in the same period. The fact that approxi mately 80% of the patients rinsed their eyes immediately after the inju ry may have contributed to the good prognosis.
The fish bile tested had a neutral pH. Bile contains bile salts which are highly effective detergents (3,4). Thus bile salts may attack the hydrophobic surface layer of the cornea. The bile salt sodium tauodeoxycholate enhances the permeability of hydrophilic compounds through rabbit corneas in vitro (5) . Bile produces temporary damage to the corneal epithelium ( I, 6). It facilitates mechanic al remo val of corneal epithelium and causes a temporary superficial acellular band in the corn eal stroma (7).
In conclusion, fish bile trauma s accounted for 14% of all chemical corneal traumas and one of the two serious complications in our material. It seems to be an important cause of occupatio nal eye trau mas of persons rinsing fish . It causes superficial corneal erosion. Pro vided that the affected eye receives immediate and abundant washing and good medical care, the progn osis is mostly good. However, the present study show s that fish bile injuries can cau se serious sequela.