Is a Dry Eye Disorder in Firefighters an Occupational Disease?

Main Article Content

İbrahim Ethem Ay
Yiğit Şenol
Hamidu Hamisi Gobeka
Mustafa Doğan


Dry eye disorder, Firefighters, Fire smoke, Occupational disease, Ocular surface disease index, Tear break-up time, Schirmer test


Background: To examine firefighters (FFs) exposed to high levels of fire smoke and, as a result, to uncover risk factors for dry eye disorder (DED) compared to age-and gender-matched healthy individuals.

Methods: In this cross-sectional study, 51 FFs from the Afyonkarahisar Municipality Fire Department were chosen at random (group 1). A control group (group 2) included 51 age- and gender-matched healthy individuals. The Ocular Surface Disease Index (OSDI) questionnaire was administered after all participants were thoroughly explained the study's objectives and procedures. Then, using a portable hand biomicroscope, an ocular exam was performed on-site. DED was defined as a non-anesthetic Schirmer test result of <10 mm and/or a tear film break-up time (TBUT) of <5 seconds.

Results: Groups 1 and 2 had mean ages of 44.82±7.29 and 44.73±7.41 years, respectively (p=0.946). The median work duration in group 1 was 14 years (min-max: 1-27 years). TBUT test revealed a significantly increased DED prevalence in group 1 than group 2 (p=0.046). Despite the non-significant difference (p=0.276), Schirmer test revealed that group 1 had a higher DED prevalence than group 2. The OSDI score revealed that group 1 had more mild, moderate, and severe DED than group 2 (p=0.359). Longer work duration was associated with a higher DED prevalence (p=0.179).

Conclusions: Given the high prevalence of fire smoke-induced DED in FFs, preventive measures such as regular ocular exams, encouraging personal protective equipment usage, and health education programs can assist in avoiding complications and reducing the burden of ocular diseases.

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1. Lee JH, Lee W, Yoon JH, Seok H, Roh J, Won JU. Relationship between symptoms of dry eye syndrome and oc-cupational characteristics: the Korean National Health and Nutrition Examination Survey 2010-2012. BMC Ophthalmol. 2015;15:147. Doi: 10.1186/s12886-015-0147-3.
2. The Health and Safety Executive. A Recipe for Safety: Occupational Health and Safety in Food and Drink Manu-facture. 2nd ed. 2015, ISBN: 978 0 7176 6646 1; Series code: HSG252.
3. Khurana A. Diseases of the Lens. Comprehensive Ophthalmology 4th ed. New Delhi: New Age International (p) Limited. 2007:170.
4. Pflugfelder SC. Prevalence, burden, and pharmacoeconomics of dry eye disease. Am J Manag Care. 2008;14(3 Suppl):S102-S106.
5. Kawashima M, Sano K, Takechi S, Tsubota K. Impact of lifestyle intervention on dry eye disease in office work-ers: a randomized controlled trial. J Occup Health. 2018;60(4):281-88. Doi:10.1539/joh.2017-0191-OA.
6. Zhou Y, Murrough J, Yu Y, et al. Association Between Depression and Severity of Dry Eye Symptoms, Signs, and Inflammatory Markers in the DREAM Study. JAMA Ophthalmol. 2022;140(4):392-399. Doi:10.1001/jamaophthalmol.2022.0140
7. Nichols KK, Bacharach J, Holland E, et al. Impact of Dry Eye Disease on Work Productivity, and Patients’ Satis-faction With Over-the-Counter Dry Eye Treatments. Invest Ophthalmol Vis Sci. 2016;57:2975-2982. Doi: 10.1167/iovs.16-19419
8. Miljanović B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol. 2007;143(3):409-415. Doi:10.1016/j.ajo.2006.11.060
9. Guo ODLW, Akpek E. The negative effects of dry eye disease on quality of life and visual function. Turk J Med Sci. 2020;50(SI-2):1611-1615. Doi:10.3906/sag-2002-143
10. Song G, Wang F. Firefighters’ Protective Clothing and Equipment. In Firefighter’s Clothing and Equipment: Per-formance, Protection, and Comfort; CRC Press: Boca Raton, FL, USA; Taylor & Francis Group: Abingdon, UK, 2019; pp. 26-60.
11. Kahn SA, Patel JH, Lentz CW, Bell DE. Firefighter burn injuries: predictable patterns influenced by turnout gear. J Burn Care Res. 2012;33(1):152-156. Doi: 10.1097/BCR.0b013e318234d8d9
12. Demers PA, DeMarini DM, Fent KW, et al. Carcinogenicity of occupational exposure as a firefighter. Lancet On-col. 2022;23(8):985-986. Doi: 10.1016/S1470-2045(22)00390-4
13. Gilman WD, Davis PO. Fire fighting demands aerobic fitness. NFPA Journal. 1993;87:68–73.
14. Austin CC, Dussault G, Ecobichon DJ. Municipal firefighter exposure groups, time spent at fires and use of self-contained-breathing-apparatus. Am J Ind Med. 2001;40(6):683-692. Doi: 10.1002/ajim.10023.
15. Gledhill N, Jamnik VK. Characterization of the physical demands of firefighting. Can J Sport Sci. 1992;17(3):207-213.
16. Oliveira M, Slezakova K, Alves MJ, et al. Firefighters’ exposure biomonitoring: Impact of firefighting activities on levels of urinary monohydroxyl metabolites. Int J Hyg Environ Health. 2016;219(8):857-866. Doi:10.1016/j.ijheh.2016.07.011
17. Griffith GA, Jones NP. Eye injury and eye protection: a survey of the chemical industry. Occup Med (Lond). 1994;44(1):37-40. Doi:10.1093/occmed/44.1.37.
18. Bhutia P, Sen S, Nath T, Shamshad MA. The effect of smoking on ocular surface and tear film based on clinical examination and optical coherence tomography. Indian J Ophthalmol. 2021;69(7):1693-1696. Doi:10.4103/ijo.IJO_2840_20
19. Li J, Zhang G, Nian S, et al. Dry eye induced by exposure to cigarette smoke pollution: An in vivo and in vitro study. Free Radic Biol Med. 2020;153:187-201. Doi:10.1016/j.freeradbiomed.2020.04.007
20. Soteriades ES, Smith DL, Tsismenakis AJ, Baur DM, Kales SN. Cardiovascular disease in US firefighters: a sys-tematic review. Cardiol Rev. 2011;19(4):202-215. Doi:10.1097/CRD.0b013e318215c105
21. Dobson M, Choi B, Schnall PL, et al. Exploring occupational and health behavioral causes of firefighter obesity: a qualitative study. Am J Ind Med. 2013;56:776-790. Doi: 10.1002/ajim.22151
23. Walt J. Ocular Surface Disease Index (OSDI). Administration and Scoring Manual. Irvine, CA Allergan, Inc 2004.
24. Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol. 2000;118(5):615-621. Doi:10.1001/archopht.118.5.615
25. Pflugfelder SC, Tseng SC, Sanabria O, et al. Evaluation of subjective assessments and objective diagnostic tests for diagnosing tear-film disorders known to cause ocular irritation. Cornea. 1998;17(1):38-56. Doi:10.1097/00003226-199801000-00007.
26. Paugh JR, Tse J, Nguyen T, et al. Efficacy of the Fluorescein Tear Breakup Time Test in Dry Eye. Cornea. 2020;39(1):92-98. Doi:10.1097/ICO.0000000000002148.
27. Cook B, Mitchell W. Occupational health effects for firefighters: The extent and implications of physical and psychological injuries. Report prepared for the United Firefighters Union of Australia, Victorian Branch. Center of full Employment and Equity. 2013.
28. Kim YT, Kim WJ, Choi JE, et al. Cohort Profile: Firefighter Research on the Enhancement of Safety and Health (FRESH), a Prospective Cohort Study on Korean Firefighters. Yonsei Med J. 2020;61:103-109. doi: 10.3349/ymj.2020.61.1.103.
29. Ângelo RP, Chambel MJ. The reciprocal relationship between work characteristics and employee burnout and engagement: a longitudinal study of firefighters. Stress Health. 2015;31:106-114. doi: 10.1002/smi.2532.
30. Li K, Lipsey T, Leach HJ, Nelson TL. Cardiac health and fitness of Colorado male/female firefighters. Occup Med (Lond). 2017;67(4):268-273. doi:10.1093/occmed/kqx033
31. Tavares Fde P, Fernandes RS, Bernardes TF, Bonfioli AA, Soares EJ. Dry eye disease. Semin Ophthalmol. 2010;25(3):84-93. Doi:10.3109/08820538.2010.488568
32. Okumura Y, Inomata T, Iwata N, et al. A Review of Dry Eye Questionnaires: Measuring Patient-Reported Outcomes and Health-Related Quality of Life. Diagnostics (Basel). 2020;10:559. Doi: 10.3390/diagnostics10080559
33. Islam SS, Doyle EJ, Velilla A, Martin CJ, Ducatman AM. Epidemiology of compensable work-related ocular injuries and illnesses: incidence and risk factors. J Occup Environ Med 2000;42:575-581. Doi: 10.1097/00043764-200006000-00004
34. Guidotti T. Health risks and occupation as a firefighter. Adelaide SA: Medical Advisory Services. 2014.
35. International Dry Eye WorkShop Definition and Classification Subcommittee. The definition and classification of dry eye disease. Ocul Surf. 2007;5(2):75-92. Doi: 10.1016/s1542-0124(12)70081-2.
36. Bazeer S, Jansonius N, Snieder H, Hammond C, Vehof J. The relationship between occupation and dry eye. Ocul Surf. 2019;17(3):484-490. Doi: 10.1016/j.jtos.2019.04.004.
37. Kumah DB, Mohammed AK, Ablordeppey RK, et al. Eye Conditions among Fire Officers in the Brong Ahafo Region, Ghana. Int J Open Access Ophthal. 2017;2(1):5. Doi: 10.15226/2474-9249/2/1/00118
38. International Agency for Research on Cancer. Volume 132: Occupational exposure as a firefighter. Lyon, France; June 7-14, 2022. IARC Monogr Identif Carcinog Hazards Hum (in press).
39. Fabian TZGP. Smoke Characterization Project: Technical Report. Northbrook IL: Underwriters Laboratories, Inc.; April 2007
40. Song G, Mandal S, Rossi R. Thermal protective clothing: A critical review. United Kingdom: Woodhead Pub-lishing. 2016.
41. Rossi R. Fire fighting and its influence on the body. Ergonomics. 2003;46(10):1017-1033. Doi:10.1080/0014013031000121968
42. JOIFF Handbook on Personal Protective Equipment (PPE) to protect against Heat and Flame. 2007 JOIFF Ltd. Ireland.
43. Harris CR, Jenkins M, Glaser D. Gender Differences in Risk Assessment: Why do Women Take Fewer Risks than Men? Judgm Decisi Mak. 2006;1(1):48-63.
44. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017 Jul;15(3):334-365. Doi: 10.1016/j.jtos.2017.05.003.
45. Vehof J, Wang B, Kozareva D, Hysi PG, Snieder H, Hammond CJ. The heritability of dry eye disease in a female twin cohort. Invest Ophthalmol Vis Sci. 2014;55(11):7278-7283. Doi:10.1167/iovs.14-15200
46. Wolkoff P, Nøjgaard JK, Troiano P, Piccoli B. Eye complaints in the office environment: precorneal tear film integrity influenced by eye blinking efficiency. Occup Environ Med. 2005;62(1):4-12. Doi:10.1136/oem.2004.016030
47. Courtin R, Pereira B, Naughton G, et al. Prevalence of dry eye disease in visual display terminal workers: a systematic review and meta-analysis. BMJ Open. 2016;6(1):e009675. Doi:10.1136/bmjopen-2015-009675
48. Cho HA, Cheon JJ, Lee JS, Kim SY, Chang SS. Prevalence of dry eye syndrome after a three-year ex-posure to a clean room. Ann Occup Environ Med. 2014;26:26. Doi:10.1186/s40557-014-0026-z
49. Beaumont JJ, Chu GS, Jones JR, et al. An epidemiologic study of cancer and other causes of mortality in San Francisco firefighters. Am J Ind Med. 1991;19(3):357-372. Doi:10.1002/ajim.4700190309
50. Bacharach SB, Bamberger PA, Doveh E. Firefighters, critical incidents, and drinking to cope: the adequacy of unit-level performance resources as a source of vulnerability and protection. J Appl Psychol. 2008;93(1):155-169. Doi:10.1037/0021-9010.93.1.155
51. Chowdhury R, Shah D, Payal AR. Healthy Worker Effect Phenomenon: Revisited with Emphasis on Statistical Methods - A Review. Indian J Occup Environ Med. 2017;21(1):2-8. Doi:10.4103/ijoem.IJOEM_53_16.