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  Table of Contents 
Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 111-113

Ocular injury due to arecanut: A unique occupational hazard in Central Karnataka

Department of Vitreo-Retina, Sankara Eye Hospital, Shimoga, Karnataka, India

Date of Submission15-May-2020
Date of Decision29-May-2020
Date of Acceptance13-Jun-2020
Date of Web Publication9-Jul-2021

Correspondence Address:
Dr. H N Ravishankar
Sankara Eye Hospital, Harakere, Shimoga, Karnataka - 577202
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijoem.IJOEM_174_20

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Purpose: To evaluate the ocular manifestations and visual outcomes of ocular injury by arecanut. Methods: We analysed cases with ocular injury by arecanut from August 2018 to December 2019, retrospectively. Mode of injury, visual acuity and ocular manifestations of trauma were recorded. Results: Out of the 40 cases, closed globe injuries were seen in 97.5% of cases. All the injuries were due to the direct impact of arecanut during harvesting. The mean age was 45.15 ± 12.84 years. The mean best-corrected visual acuity (BCVA) at presentation was 20/40. A significant number of cases (35%) required surgical intervention. Mean BCVA at final follow-up was 20/30 but 16.66% of cases had BCVA of <20/60 even after definitive therapy. Conclusion: Ocular trauma due to arecanut is an important and preventable cause of visual impairment in central Karnataka. Modifications in harvesting technique would prevent ocular injuries.

Keywords: Arecanut; close globe injury, occupational hazard, open globe injury

How to cite this article:
Gondchawar A, Ravishankar H N, Sagar P, Tekade P, Biswal SK, Mahesha S. Ocular injury due to arecanut: A unique occupational hazard in Central Karnataka. Indian J Occup Environ Med 2021;25:111-3

How to cite this URL:
Gondchawar A, Ravishankar H N, Sagar P, Tekade P, Biswal SK, Mahesha S. Ocular injury due to arecanut: A unique occupational hazard in Central Karnataka. Indian J Occup Environ Med [serial online] 2021 [cited 2021 Dec 4];25:111-3. Available from:

  Introduction Top

Arecanut (areca catechu) is a tropical crop cultivated commonly in the coastal areas of India. According to food and agriculture organization (FAO) reports 2013, India is the largest (49.74%) producer of arecanut in the world.[1] In India, Karnataka produces 62.69% of arecanut crops followed by Kerala and Assam. Arecanut is popularly known as “betel nut” or “supari”.[2]

Arecanut is commonly used as a masticator with or without betel leaves.[3] Arecanut harvesting is carried out from August to December in the Mediterranean belt and from October to January in Malnad and coastal areas.[4] A group of skilled people would be necessary to accomplish the work. The method of harvesting varies from region to region. The workers are at risk of ocular injury during the process of the harvesting the crop. In this retrospective study, we describe the ocular manifestations and visual outcomes of ocular injury by arecanut.

  Methods Top

This is a retrospective analysis of cases with ocular injury by arecanut treated at a tertiary eye care centre in central Karnataka from August 2018 to December 2019. Institute ethical committee approval was not required as it was a retrospective review of past medical records. The study adhered to the tenets of the Declaration of Helsinki.

A detailed history including the mode of injury and symptoms were recorded. Best-corrected visual acuity (BCVA) was recorded with the Snellen's chart. Intraocular pressure (IOP) was recorded by Goldmann Applanation Tonometer. A comprehensive ocular examination was performed. Injuries were classified according to Birmingham eye trauma terminology system (BETTS)[5] and ocular trauma classification group (OTGS).[6] Cases were treated medically or surgically based on the type of injury and ocular complications. The patients were followed up regularly and outcomes were assessed.

  Results Top

Forty patients with ocular injury by arecanut were recruited in the study. All the cases were unilateral. Most of the cases were men (97.5%). The mean age at presentation was 45.15 ± 12.84 years (range 18-67 years). The mean BCVA at the presentation in decimal notation was 0.45 ± 0.34 (Snellen equivalent: 20/25 to no perception of light). The mean IOP in cases with close globe injury was 14.67 ± 4.33 mm Hg (range: 9-30 mm Hg). The injury was confined to the anterior segment in 40% of the cases and posterior segment in 20% of the cases. Both anterior and posterior segments were affected in 40% of the cases. Thirty-nine eyes (97.5%) had closed globe injury. Out of the 39 cases with closed globe injuries, zone I, zone II and zone III injuries were noted in 15.38%, 25.64% and 58.97% of the cases, respectively [Table 1]. One case of open globe injury had corneal laceration (zone I). The majority of the cases were managed with topical medications. A retinal laser barrage was performed in 7.5%. Fourteen cases (35%) required surgical intervention.
Table 1: Ocular manifestations of arecanut injury

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Out of 40 cases, 12 patients were lost to follow-up after the first visit. Out of the 28 cases, the mean follow-up duration was 13.87 weeks (range: 1-184 weeks). Four cases with a dislocated lens did not undergo surgery. Details regarding indication for intervention, surgical procedure and outcomes are summarized in [Table 2]. Three cases developed secondary glaucoma during follow-up. One case was managed with anti glaucoma medications and one case underwent trabeculectomy. One case ended up in no perception of light due to glaucomatous optic atrophy.
Table 2: Surgical outcome for cases with ocular injuries

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Final BCVA of patients who required medical management was 0.75 ± 0.33 (Snellen equivalent 20/25) and those who required surgical intervention was 0.41 ± 0.33 (Snellen equivalent 20/50). Four cases had permanent visual impairment (BCVA < 20/60) in spite of management (excluding the cases, who did not undergo surgery).

  Discussion Top

The arecanut tree ranges from 10 to 30 m in height. Arecanut is ovoid with an average width of 2.25 cm. The length varies from 3.79 to 6 cm.[7] Human orbit ranges from 3 to 3.9 cm in height and from 3.5 to 5.2 cm in breadth.[8] As the dimensions of arecanut is lesser than the human orbit, the risk of the direct impact on the globe is high.

In Malnad area, 'nut plucker' will stand on the ground or climb the tree to a certain height and will pluck the arecanut bunch with a sickle connected to a long bamboo stick. 'Nut collector' will be standing on the ground and will catch the bunch with a rubber sheet. The collector has to keep an eye on the bunch that falls on the ground from a significant height. So 'nut collector' is at risk of injury to the eye by arecanut. The nut can fall directly on the eye while plucked or it can bounce back from the ground and injure the eye [Figure 1].
Figure 1: (a) Arecanut tree with arecanut bunches. (b) Arecanut dimensions. (c) ‘Nut plucker’ climbing the tree. (d) ‘Nut collector’ keeping an eye on the plucked arecanut bunch

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Most of the ocular injuries were due to the direct fall of arecanut over the collector's eye. A wide spectrum of ocular injuries was recorded from trivial sub-conjunctival hemorrhage to retinal detachment. Though visual improvement was seen in the majority of the cases after medical management, a significant number of cases required surgical intervention. Visual impairment (< 20/60) was seen in four cases in spite of management. Twelve patients (30%) did not come for follow-up after the first visit and four patients (28.58% of the cases requiring surgical intervention) did not undergo surgery. This highlights the lack of awareness among the workers. Ocular injury due to arecanut mainly affects the working age group. It results in financial burden as the patient has to stay away from work for longer duration.

Considering the magnitude of the problem, measures should be taken to prevent this workplace injury. Awareness programmes should be conducted to make the workers aware of the ocular morbidity due to injury. Personal protective equipment such as protective goggles should be provided to the workers. The workers particularly the 'nut collector' should be counselled to use the goggles regularly during working hours. Innovative techniques that involve lesser risk of injury such as the commercially available arecanut plucking machine can be used to minimize the risk of ocular injury.[9]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Commodity: Areca Retrieved 31 May 2016.  Back to cited text no. 1
Tejwani KG. Agro Forestry in India. Concept Publishing Company; 2002. ISBN 978-81-7022-918-6.  Back to cited text no. 2
Giriappa S. Arecanut production and marketing in India.M.D. Publications Pvt. Ltd.; 1994. ISBN 978-81-85880-45-7.  Back to cited text no. 3
Ramappa BT. Economics of areca nut cultivation in Karnataka, a case study of Shivamogga district. IOSR J Agric Vet Sci 2013;3:50-9.  Back to cited text no. 4
Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham eye trauma terminology system (BETT). J Fr Ophthalmol 2004;27:206-10.  Back to cited text no. 5
Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, Bridges WZ Jr, Capone A Jr, Cardillo JA, et al. A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group. Am J Ophthalmol 1997;123:820-31.  Back to cited text no. 6
Sheshagiri KS, Narayanaswamy H, Shivanna BK. Methods of Agriculture Cultivation. Arecanut Research Centre. Navile, Shimoga: AgricultureCollege.  Back to cited text no. 7
Bekerman I, Gottlieb P, Vaiman M. Variations in eyeball diameters of the healthy adults. J Ophthalmol 2014;2014:503645.  Back to cited text no. 8
Tony M, Johny C, Savooj S, Yatish K, Vas JP. Design and fabrication of arecanut tree climbing and spraying machine. J Mech Eng Autom 2016;6:93-6.  Back to cited text no. 9


  [Figure 1]

  [Table 1], [Table 2]


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