Table Of Content1
Epidemiology and economic
impact of ocular trauma
James T. Banta
EPIDEMIOLOGY OF OCULAR TRAUMA
3. 200 000 open globe injuries occur annually
Make no mistake, ocular trauma is a disease. It 4. 19 million people are unilaterally blind, 2.3
has a well-established natural history, modifi able million have bilateral low vision, and 1.6
risk factors, and distinct prevention, classifi ca- million are bilaterally blind due to eye
tion, and treatment schemes. The literature is injuries.
replete with reports of ocular trauma, both visu- The lifetime prevalence of eye injury in three
ally signifi cant and insignifi cant. Unfortunately, large epidemiologic studies was approximately
the vast majority of these studies are hampered 20%.4,15,16 Interestingly, a person with an eye
by their retrospective nature and extrapolation to injury is three times more likely to have a second
larger, often very different populations. However, eye injury.4 After spending 5 years in an eye
when the ocular trauma literature is viewed as a emergency room, I can defi nitively say that
whole, multiple aspects are incredibly consistent: ocular trauma is a recurrent disease. It is remark-
1. Ocular trauma is a disease with a bimodal age able how often a patient with a metallic corneal
distribution, the fi rst in the years of late ado- foreign body has multiple corneal scars from pre-
lescence and early adulthood and the second vious foreign body removals. Similarly, assault-
in those older than 70.1–3 related trauma, particularly fi st-fi ghting, has a
2. Ocular trauma, particularly severe, vision- distinct pattern of recurrence.
threatening eye injuries, affects men three to Severe eye trauma may slowly be decreasing in
fi ve times as frequently as women.1,3–8 incidence in large part due to improved safety
3. Ocular trauma is a signifi cant cause of visual standards in the workplace. However, it is clear
loss, especially in lower socioeconomic strata that current prevention strategies are woefully inad-
and underdeveloped countries.5,9,10 equate. Studies have shown that appropriate eye
4. Ocular trauma is largely preventable, espe- protection is rarely in place at the time of a
cially in the workplace.6,11–13 severe eye injury.6,11–13 A study in Singapore
5. Ocular trauma is a recurrent disease.4 revealed a troubling trend.13 Of a cohort of eye
A large worldwide meta-analysis of eye injury injuries seen in an emergency department, 71.4%
epidemiology was performed by the World were work-related. Of these work-related cases,
Health Organization and published in 1998.14 21.7% wore eye protection, 43.7% were given eye
The analysis compiled information from various protection but did not use it, and 34.6% were
studies performed between 1971 and 1995. not provided eye protection. A study in the
Several salient points emerged: United States of open globe injuries suffered at
1. 55 million eye injuries which restrict activities work discovered a mere 6% wore eye protection
for ≥ 1 day occur annually at the time of injury.11
2. 750 000 eye injuries require hospitalization Cases of eye injuries requiring hospitalization
annually have also declined in the last decade, not because
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Ocular trauma
Table 1.1 Physical characteristics of various sporting balls commonly encountered in
ocular trauma
Ball type Diameter Max velocity Weight Distensibility
Baseball 7.62 cm >150 kph 145 g Minimal
Tennis ball 6.5 cm >150 kph 57 g Moderate
Racquetball 5 cm >150 kph 40 g Signifi cant
Hockey puck 2.54 cm vertical >150 kph 160 g None
7.62 cm horizontal
Paintball pellet 1.72 cm 90–150 mps 3.2 g Signifi cant
cm = centimeter, kph = kilometers per hour, mps = meters per second, g = grams.
of a major decrease in the number of severe eye 3.5 × 4.0 cm. Use of a ball, projectile, or playing
injuries, but because of changing indications object (e.g. stick, bat, racket) small enough to fi t
for hospitalization.2 Patients with a traumatic within the orbit greatly increases the risk of
hyphema, now typically observed on an outpa- severe eye injury (Table 1.1). Eye injuries have
tient basis, were routinely hospitalized for 5–7 been described in virtually every major and
days in years past. Likewise, the frequency and minor sport. The most common and devastating
duration of hospitalization for open globe inju- offenders are hockey, racket sports, baseball, and
ries has decreased. more recently, paintball (often referred to as
Ocular trauma in children has been exten- ‘war games’). In our recent experience, paintball
sively studied. During the fi rst few years of life, injuries are rapidly becoming the most common
the incidence of ocular injury is essentially equal and severe of the sports-related ocular injuries
in males and females, but changes quickly to the encountered (Figure 1.1). The number of patients
male preponderance seen in adults.10 The major- and severity of injury encountered with this
ity of injuries occur at home or school.17–19 Lower activity is rapidly moving into the realm of a
socioeconomic and educational standing seem to public health crisis. As will be discussed in the
increase the risk of injury.10 Adult supervision following chapter, certain sports have shown a
clearly decreases the incidence of eye injuries in dramatic reduction in the number of eye injuries
children.10,18 Scissors and furniture were found when the proper eye protection is utilized.
to be frequent causes of severe eye injuries in Motor vehicle accidents (MVA) are another
children less than 6 years old, while toys, balls, source of eye injury that has been individually
and stones were more frequently implicated in examined. The question has arisen, ‘Do airbags
children 6 years of age or older.17 Following increase the rate of ocular injury during a motor
ocular injury in children, the rate of blindness vehicle accident?’ Confl icting results are found
(visual acuity <20/200) ranges from 1% to in the literature. A large study that reviewed
34%.10,19–21 22 236 MVA with frontal airbag deployment
Sports activities are a signifi cant cause of ocular found an increase in minor eye injuries (specifi -
trauma. The protective bony orbit measures cally corneal abrasions) and a decrease in severe
2
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Epidemiology and economic impact of ocular trauma
in 1985 and published in 1988.26 The direct cost,
excluding physician fees and laboratory exams,
was $2400 for a traumatic hyphema and $6300
for an open globe injury. A conservative estimate
of total direct and indirect cost of all ocular
injuries in this eye emergency department for
1 year was $5 million and a loss of 60 work
years. Taking into account infl ation and the small
population studied, the overall costs when
considered on a global scale are staggering. An
estimate of the national total for direct hospital
costs, extrapolated from information obtained
Figure 1.1 An 11-year-old boy was struck with a from California hospitals during a 1-year period,
paintball pellet leading to hyphema and extensive iris was $99.7 million for the year 2000.27 As large
disruption.
as this number is, it only represents a small frac-
tion of the cost when physician fees, laboratory
and radiologic exams, drugs, rehabilitation, and
eye injuries.22 A study out of Henry Ford Hospi- particularly lost work days are taken into
tal found the rate of MVA-related ocular injuries account.
was reduced by the use of airbags, as was the It is clear that prevention of severe eye injuries
death rate.23 A large meta-analysis published in is an accomplishable goal and one that demands
2003 found the risk of a severe eye injury due to attention given its far-reaching societal and eco-
airbag deployment to be 0.4%.24 The most recent nomic impact. Ocular trauma is a public health
epidemiologic study showed a two-fold increase problem with identifi able prevention strategies.
in eye injuries with airbags and a two-fold The following chapter will review these preven-
decrease in eye injuries with seatbelt use.25 In tion strategies in detail.
short, it appears that although airbags may
increase the overall rate of eye injuries, the
protective effect against severe eye injuries, and FUTURE DIRECTIONS
particularly death, outweighs the small risk.
Compiling epidemiologic data on ocular trauma
ECONOMIC IMPACT OF is a vital part of defi ning populations, risk factors,
OCULAR TRAUMA and trends in this disease state. The World
Eye Injury Registry (WEIR) was established to
What is the economic impact of ocular trauma? collect information from ophthalmologists on
Simply put, immense. It is diffi cult to quantify severe, vision-threatening eye injuries. Standard-
precisely because of the signifi cant impact of ized reporting forms are used to capture data at
indirect costs, particularly lost work days. Only the initial visit (Figure 1.2) and 6 months after
a few studies looking at the economic impact of the initial injury. The standardized nature of the
ocular trauma have been published. information gathered allows accurate compari-
An epidemiologic study of eye trauma at an sons to be made. Further information is available
urban eye emergency department was conducted online at www.WEIRonline.org.
3
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WORLD EYE INJURY REGISTRY
INITIAL REPORT
1 )Check appropriate responses 2 )Fill out comments 3 )File bilateral injury re p o rts seperately
4 )Submit Data via WEIRONLINE.org 5 )Write Down Record ID _________________________
A I D E N T I F I C AT I O N : I S O U R C E : M INITIAL DIAGNOSES:
OPEN GLOBE INJURY: Yes(cid:2) 18.5 Postequatorial Extension No
Patient’s Initials:__________________ 0100 HShamarmp Oerb ojenc tM*etal LACERATION: 00.0 Perioc. 02.0 Lacrim. 08.1 Contusion
Patient’s Home ZIP: _______________ 11 Nail PARTIAL THICKNESS WOUND: 09.1 Corneal 09.2 Scleral
Medical Rec. #____________________ 25 Fall CORNEAL BURN: 12.0 Thermal 12.1 Alkal. 12.2 Acid
Age: _________ Sex: M F 20 Blunt Object* RUPTURE: 10.3 Corneal ______ mm 18.3 Scleral ______ mm
Injury Date: ______/_______/_______ 30 Gunshot 13.3 Corneoscleral ______ mm
Eye: Right Left 31 BB/Pellet Gun PENETRATING INJURY:
40 Motor Vehicle Crash
10.4 Corneal _____mm 18.4 Scleral _____mm 13.4 Corneoscleral _____mm
Race:___________________________ 50 Fireworks*
IOFB: 90.0 Magnetic 90.1 Ant. Segment 90.2 Post. Segment
Initial Rx MD: ____________________ 60 Burn 91.0 Nonmagnetic 91.1 Ant. Segment 91.2 Post. Segment
70 Explosion
Initially Treated At:_________________ 90 Lawn Equipment* PERFORATING INJURY: 18.2 Perforating Injury 18.21 Corneoscleral
Reporting MD: ___________________ 98 Unknown 18.22 Scleroscleral
Exam Date for Report: 99 Other* UVEA IN WOUND: 18.1 Scleral 10.1 Cornea 11.1 In Visual Axis
_______/________/________ *Description of Source:___________ WOUND DEHISCENCE: 19.0 HYPHEMA: 20.0 _______%
Report Filer’s Name:_______________ ______________________________ IRIS PUPIL: 22.0 Iris Laceration/Dialysis 22.3 Afferent Pupil Defect
_____________________________ J TISSUES INVOLV E D : IOP: 24.0 Angle Recession 26.0 Glaucoma, Secondary 28.0 Hypotony
00 Lids LENS: 30.0 Cataract (Traumatic) 32.0 Subluxed Lens 32.1 Dislocated Lens
Contact for 6 mo F/U: ______________
09 Lacrimal System VITREOUS: 40.0 Hemorrhage 42.0 Penetration
AAB I L A__T_E_R_A_L_ _IN_J_U__R_Y_:____Y_e_s_______N_o_ 1109 CSoclrenreaa RETINA: 50.0 Retinal Hemorrhage 55.5 Macular Hemorrhage
51.0 Retinal Edema 55.2 Macular Edema 52.0 Retinal Defect
B EYE PROTECTION: 20 Iris 52.1 Tear 52.2 Giant Tear 52.3 Laceration 52.4 Dialysis
Yes No Unknown 22 Anterior Chamber 53.0 Retinal Detachment(cid:2)Number of Quadrants? 1 2 3 4
Regular Safety Sun 30 Lens RD TYPE: 53.1 Hemorrhagic 53.2 Tract. 53.3 Rhegm. 53.5 Macular
Glass Shattered? Yes No 4500 VRietrteinoaus CHOROID: 58.0 Hemorrhage 58.1 Rupture
C PATIENT A BYSTANDEURn:k nown 55 Macula OPTIC NERVE INJURY: 82.0 Optic Nerve
Yes No Unknown 58 Choroid ORBITAL: 70.0 Fracture 71.0 Foreign Body 73.0 Hemorrhage
D W O R K - R E L ATED: 60 Extraocular Muscle INFLAMMATION: 95.0 Uveitis 92.0 Endophthalmitis(cid:2)Organism:_________________
Yes(cid:2)List Occupation below 70 Orbit 99.0 Other or comments: ______________________________________________
80 Optic Nerve
No Unknown _____________________________________________________________________
99 Other*
Occupation: ___________________ *Describe:_____________________ N INITIAL OPERAT I O N : Date: ______/______/______
E P L A C E : ______________________________ REPAIR EYELID WOUND: 00.0 Full-thickness 00.1 Partial-thickness
01 Industrial Premises
K VISION (OF BOTH EYES): REPAIRLACRIMAL: 02.0 GLOBE: 18.0 Exploration of Globe
05 Farm
10 Home DATE:______/______/______ REPAIR CORNEAL: 10.4 Laceration 10.3 Rupture
20 School RE LE REPAIR SCLERAL: 18.4 Laceration 18.3 Rupture
30 Place for Recreation & Sport* 00- - - - - - NLP - - - - - 00 REPAIR CORNEOSCLERAL: 13.4 Laceration 13.3 Rupture
40 Street and Highway* 10- - - - - - LP - - - - - - 10 IOFB: 90.1 IOFB Removal by Magnet from Anterior Segment
60 Public Building* 20- - - - - - HM - - - - - - 20 90.2 IOFB Removal by Magnet from Posterior Segment
98 Unknown 30 1/200 to 4/200 (CF) 30 91.1 IOFB Removal by Forceps from Anterior Segment
99 Other* 40- - 5/200 to 19/200 - - 40 91.2 IOFB Removal by Forceps from Posterior Segment
*Specify: _____________________ ____If>19/200 Specify Accuity____ CORNEA: 19.2 Corneal Transplant 19.3 Temporary Keratoprosthesis (TKP)
F I N J U RY’S ZIP: __________________ 91 - - - Not Tested - - - 91 REPAIR WOUND DEHIS: 19.0 Dehiscence HYPHEMA: 20.0 Removal
G I N T E N T: 52 Unintentional 98- - - - Unknown - - - - 98 IRIS: 22.0 Iridectomy 22.1 Iridoplasty 22.2 Iridotomy
50 Assault 98 Unknown 99- - - - - Other - - - - - 99 LENS: 30.0 ECCE 30.2 Phaco 30.3 Pars Plana Lensectomy
51 Self-inflicted (intentional) KK EYE NORMAL PRIOR TO INJURY? IOL: 36.1 AC 36.2 PC
H DRUG USE: Y N Unknown Yes Unknown VITRECTOMY MECHANICAL: 44.0 Anterior 44.1 Posterior
Describe:______________________ No(Explain)_________________ VITRECTOMY OPEN-SKY: 44.2
ALCOHOL USE: Yes No ______________________________ ANTIBIOTICS: 45.0 Intravitreal 45.1 Intracameral
Unknown L C O M M E N T S :(Please describe the injury RD PROPHYLAXIS: 53.0 Cryopexy 53.1 Laser 53.2 Buckle
as much as possible):
RD REPAIR: 53.01 Cryopexy 53.11 Laser 53.5 Buckle 53.3 Vitrectomy
______________________________________________________________________ 53.7 Air 53.4 Gas 53.6 Silicone Oil 53.8 Pneumatic Retinopexy
______________________________________________________________________ REPAIR EXTRAOCULAR MUSCLE: 60.0
ORBIT: 70.0 Fract. Repair 71.0 FB Removal 75.0 Decomp.
______________________________________________________________________
93.0 Evisceration 94.0 Enucleation 97.0 None 98.0 Unknown
______________________________________________________________________ OTHER: 99.0 Other or Comments:_________________________________________
R_e_v_._10_/_3_/2_0_0_0____________________________________________________________ _____________________________________________________________________
Figure 1.2 World Eye Injury Registry (WEIR) standardized reporting form for severe ocular trauma. (Data provided
by the United States Eye Injury Registry of the American Society of Ocular Trauma, through funding by the Helen
Keller Foundation, Birmingham, Alabama, USA.)
4
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Epidemiology and economic impact of ocular trauma
REFERENCES 14. Négrel AD, Thylefors B. The global impact of eye injuries.
Ophthalmic Epidemiol 1998;5:143–169.
15. McCarty CA, Fu CLH, Taylor HR. Epidemiology of ocular
1. Klopfer J, Tielsch JM, Vitale S, et al. Ocular trauma in the
trauma in Australia. Ophthalmology 1999;106:1847–1852.
United States: eye injuries resulting in hospitalization,
16. Katz J, Tielsch JM. Lifetime prevalence of ocular injuries
1984 through 1987. Arch Ophthalmol 1992;110:838–842.
from the Baltimore Eye Study. Arch Ophthalmol 1993;111:
2. Tielsch JM, Parver L, Shankar B. Time trends in the incidence
1564–1568.
of hospitalized ocular trauma. Arch Ophthalmol 1989;107:
17. Tomazzoli L, Renzi G, Mansoldo C. Eye injuries in childhood:
519–523.
a retrospective investigation of 88 cases from 1988 to 2000.
3. Wong TY, Tielsch JM. A population-based study on the
Eur J Ophthalmol 2003;13:710–713.
incidence of severe ocular trauma in Singapore. Am J
18. Serrano JC, Chalela P, Arias JD. Epidemiology of childhood
Ophthalmol 1999;128:345–351.
ocular trauma in a northeastern Columbian region. Arch
4. Wong TY, Klein BEK, Klein R. The prevalence and 5-year
Ophthalmol 2003;121:1439–1445.
incidence of ocular trauma, the Beaver Dam Eye Study.
19. MacEwen CJ, Baines PS, Desai P. Eye injuries in children: the
Ophthalmology 2000;107:2196–2202.
current picture. Br J Ophthalmol 1999;83:933–936.
5. Abraham D, Vitale S, West S, Isseme I. Epidemiology of eye
20. Mela EK, Georgakopoulos CD, Georgalis A, et al. Severe ocular
injuries in rural Tanzania. Ophthalmic Epidemiol 1999;2:85–94.
injuries in Greek children. Ophthalmic Epidemiol
6. May DR, Kuhn FP, Morris RE, et al. The epidemiology of
2003;10:23–29.
serious eye injuries from the United States Eye Injury Registry.
21. Vasnaik A, Battu RR, Kurian M, George S. Mechanical eye
Graefe’s Arch Clin Exp Ophthalmol 2000:238:153–157.
(globe) injuries in children. J Ped Ophthalmol Strab
7. Glynn RJ, Seddon JM, Berlin BM. The incidence of eye injuries
2002;39:5–10.
in New England adults. Arch Ophthalmol 1998;106:785–789.
22. Duma SM, Jernigan MV, Stitzel JD, et al. The effect of frontal
8. Koval R, Teller J, Belkin M, et al. The Israeli ocular injuries
airbags on eye injury patterns in automobile crashes. Arch
study, a nationwide collaborative study. Arch Ophthalmol
Ophthalmol 2002;120:1517–1522.
1988;106:776–780.
23. Anderson SK, Desai UR, Raman SV. Incidence of ocular injuries
9. Dandona L, Dandona R, Srinivas M, et al. Ocular trauma in an
in motor vehicle crash victims with concomitant air bag
urban population in southern India: the Andhra Pradesh Eye
deployment. Ophthalmology 2002;109:2356–2358.
Disease Study. Clin Exp Ophthalmol 2000;28:350–356.
24. Lehto KS, Sulander PO, Tervo TM. Do motor vehicle airbags
10. Moreira CA, Debert-Ribeiro M, Belfort R. Epidemiological
increase risk of ocular injuries in adults? Ophthalmology
study of eye injuries in Brazilian children. Arch Ophthalmol
2003;110:1082–1088.
1988;106:781–784.
25. McGwin G, Owsley C. Risk factors for motor vehicle collision-
11. Dannenberg AL, Parver LM, Brechner RJ, Khoo L. Penetrating
related eye injuries. Arch Ophthalmol 2005;123:89–95.
eye injuries in the workplace, the national eye trauma system
26. Schein OD, Hibberd PL, Shingleton BJ, et al. The spectrum
registry. Arch Ophthalmol 1992;110:843–848.
and burden of ocular injury. Ophthalmology
12. Yu TSI, Liu H, Hui K. A case-control study of eye injuries in the
1988;95:300–305.
workplace in Hong Kong. Ophthalmology 2004;111:70–74.
27. Baker RS, Wilson MR, Flowers CW, et al. A population-based
13. Voon LW, See J, Wong TY. The epidemiology of ocular trauma
survey of hospitalized work-related ocular injury: diagnoses,
in Singapore: perspective from the emergency service of a
cause of injury, resource utilization, and hospitalization
large tertiary hospital. Eye 2001;15:75–81.
outcome. Ophthalmic Epidemiol 1999;6:159–169.
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2
Prevention of eye injuries
Paul M. Gallogly, Stephanie L. Vanderveldt, James T. Banta
INTRODUCTION A number of professional organizations are
involved in the standards of eye protection
The vast majority of eye injuries are preventable manufacturing, testing of eyewear to conform
with currently available protective devices. to safety standards, and dissemination of safety
Nevertheless, nearly 55 million eye injuries that information to educate the public. They
restrict activities for more than 1 day occur each include:
year.1 As eye care professionals we must identify 1. ANSI: The American National Standards
and educate those individuals at risk for ocular Institute is an organization which facilitates
injury. voluntary consensus standards in the US and
The initial step in preventing ocular injury is abroad. ANSI is a private, nonprofi t organiza-
identifying patients at risk. One may argue that tion that promotes voluntary consensus stan-
the entire population carries some inherent risk. dards including standards for eye protection,
This of course is true, but identifi cation of both personal and occupational. ANSI pro-
patients with high-risk jobs or activities may vides standards for the strength of polycar-
help limit preventable ocular trauma. A simple bonate lenses and the manufacture and design
history of daily activities and hobbies obtained of safety spectacle frames and chemical
by the ophthalmologist or technician can quickly eyewash stations, among many other safety
and easily identify these patients. Brief questions standards. More information is available at
may include: ‘What are your hobbies?’ ‘Are you www.ANSI.org.
involved in sports activities?’ ‘What is your 2. ASTM: ASTM International, formerly the
occupation?’ A previous history of ocular trauma American Society for Testing and Materials,
is equally important, as studies have shown that is a voluntary standards development organi-
ocular trauma is a recurrent disease.2 zation generating standards for the manufac-
Another important population that must be turing of a wide variety of materials including
identifi ed is the patient with one functional eye. sports eye protectors. ASTM International
The functionally one-eyed patient is an individ- certifi es racket sport eye protectors as well as
ual who would have a signifi cant change in life- those for paintball, baseball, downhill skiing,
style if the better-seeing eye was damaged or and ice hockey. The ASTM standards for
lost. Some common examples include patients racket sport wear are signifi cantly more strin-
with amblyopia, decreased vision due to a prior gent than those of ANSI. More information is
traumatic event, or decreased vision due to a available at www.ASTM.org.
chronic but asymmetric ocular condition (e.g. 3. PECC: The Protective Eyewear Certifi cation
glaucoma). After the ophthalmologist has appro- Council independently tests and certifi es
priately identifi ed those individuals with preven- eyewear in hopes of reducing eye injuries.
tative needs, recommendations must be given in Manufacturers that produce products passing
a simple and directed manner. their standards bear the seal of the
7
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Ocular trauma
organization. More information is available at organization works to educate the public
www.PROTECTEYES.com. about ocular public health issues, including
4. CSA: The Canadian Standards Association prevention of ocular injuries. More informa-
works to develop standards for a multitude of tion is available at www.AAO.org.
items, particularly items meant to enhance Given the sheer number of high-risk activities,
public safety. They also work to educate the the scope of this chapter does not allow the
public about these standards. More informa- authors to cover each activity in detail. Special
tion is available at www.CSA.ca. mention will be given to a few high-risk situa-
5. HECC: The Hockey Equipment Certifi cation tions that are most frequently associated with
Council independently reviews the recom- eye injuries, namely: work, sport, driving, and
mendations of various hockey organizations assault.
with regard to safety equipment and certifi es
specifi c safety products by validating the LENS MATERIALS
testing performed by the manufacturer. This
organization is supported by USA Hockey Glass or allyl resin plastic (CR-39) lenses, present
who require the use of HECC-certifi ed equip- in nearly 90% of all dispensed spectacles, have
ment in offi cial play. HECC refers to ASTM little impact resistance, are prone to shatter, and
F513 guidelines in certifi cation testing of all have caused eye injury as a result of this shatter-
eye and face protectors. More information is ing. The material of choice for all protective
available at www.HECC.net. lenses, both street-wear and active-wear, is poly-
6. NOCSAE: The National Operating Commit- carbonate. Polycarbonate lenses have excellent
tee on Standards for Athletic Equipment is impact resistance, good optical properties, and
involved in testing and implementing test acceptable UV absorption. They are thinner,
standards for various sports in a concerted lighter, equally scratch resistant, and signifi cantly
effort to reduce injuries. More information is safer than glass or CR-39 plastic lenses.
available at www.NOCSAE.org. Polycarbonate lenses are not without limita-
7. OSHA: The Occupational Safety and Health tions, however. First, there is a cost differential
Administration is a component of the US of approximately $25 for polycarbonate lenses
Department of Labor that establishes stan- vs. CR-39. Additionally, there is a limitation in
dards to ensure the safety and well-being of the range of refractive errors that can be accom-
American workers. In particular, OSHA modated. Most companies can accommodate
governs the requirements for use and mainte- refractive errors of 12–14 diopters of myopia.
nance of occupational eye protection in various Recently, with refi nements of high-index poly-
industrial settings. The organization also pro- carbonate, prescriptions can be fi lled up to 20
vides employee training requirements for the diopters of myopia, albeit at a premium cost.
use of protective equipment and the care, Chromatic aberration at the lens periphery of
maintenance, and inspection of such equip- high minus polycarbonate lenses is also encoun-
ment. More information is available at www. tered. Athletes or workers with a large refractive
OSHA.gov. error that precludes the use of polycarbonate
8. AAO: The American Academy of Ophth- should wear contact lenses with the appro-
almology is the professional society of priate non-prescription polycarbonate protective
ophthalmologists in the United States. The device.
8
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Prevention of eye injuries
WORK-RELATED INJURIES
In industrialized countries, approximately 14%
of all ocular injuries take place within the work-
place. The direct cost of these ocular injuries is
estimated to be more than $500 million annu-
ally.3 In many instances, ‘safety’ eyewear is inade-
quate or simply not worn. A study of open globe
injuries in workers in the United States showed
that only 6% of workers were wearing eye pro-
tection at the time of injury.4 These numbers
leave tremendous room for improvement, as the
use of appropriate protective devices can prevent
most, if not all of these injuries.
Specifi c occupations inherently carry more
risk. As elicited in the 1994 Bureau of Labor
Statistics,5 the risk of ocular injury is as
follows:
1. Construction: 29 per 10 000 Figure 2.1 Industrial eye protectors should meet or
exceed ANSI Z87.1 and when feasible should include
2. Agriculture, fi shing, and forestry: 25 per
side shields. Protectors are available that fi t over
10 000
prescription eyewear. (Photo courtesy of Miller Electric
3. Manufacturing: 17 per 10 000
Manufacturing Company.)
4. Mining: 13 per 10 000.
In the case of work-related injuries, the eye care
professional must go beyond the injured employee
and involve company management in prevention falling objects smaller than the head of a pin. In
strategies. Appropriate eyewear must be made general, ANSI Z87.1 is the standard to which
available, and consequences for not wearing industrial eye protectors should be held. Safety
appropriate eye protection must be instituted. spectacles with side shields are the minimum
This multilevel approach provides the greatest protective equipment required when working in
potential for improved eye safety in the an area with a potential impact hazard (Figure
workplace. 2.1). Clinically, many injuries are seen from
objects fl ying under the rim of safety spectacles,
Industrial eye protectors particular with grinding and hammering. There-
Industrial eye injuries are responsible for the vast fore, polycarbonate goggles should be considered
majority of metallic corneal foreign bodies, and standard protection for workers exposed to high
more seriously, intraocular foreign bodies. In velocity or large fragments (Figure 2.2). If the
particular, hammering metal on metal and grind- occupation poses additional hazard to the face,
ing are two common causes of injury. According a face shield should be employed. Since face
to the US Department of Labor Occupational shields are often lifted in the midst of work
Safety and Health Administration (OSHA), the activities, it is recommended that safety glasses
majority of impact injuries result from fl ying or with side shields be worn under the shield.
9
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Ocular trauma
Figure 2.3 Welding masks that meet or exceed ANSI
Z49.1 should be used over goggles or safety spectacles
with side shields. (Photo courtesy of Miller Electric
Manufacturing Company.)
splash, irritating mists, vapors, and fumes. OSHA
Figure 2.2 Polycarbonate goggles should be recommends that face shields should be used as
considered standard protection when high-velocity secondary protectors to shield the entire face
impact potential exists. (Photo courtesy of Miller from exposure to chemical hazards. For work-
Electric Manufacturing Company.)
places that pose a dust hazard, safety goggles are
recommended and the use of contact lenses is
OSHA requires workers who are exposed to discouraged.
high temperatures, splashes from molten metal, Finally, optical radiation is a risk in work
or sparks (those involved in pouring, casting, hot environments with exposure to intense heat,
dipping, furnace operations, or welding) to use ultraviolet, infrared, or refl ected light radiation.
goggles or special-purpose lenses in appropriate Welders and workers exposed to lasers fall into
safety spectacles with side shields. Protective this category. The lens and glare requirements
devices for welding are held to the higher ANSI for adequate protection in these scenarios are
Z49.1 standard which requires the use of safety based on the maximum power density that the
spectacles with side shields or goggles to be worn lasers produce.
underneath a facemask fi tted with a fi ltered
safety lens (Figure 2.3). Chemical eyewash stations
With regard to chemical hazards, goggles are Eyewash stations are required by OSHA to be
the primary means of protection against liquid placed in any location where there is a reasonable
10
Ch002-X2559.indd 10 1/24/2007 11:22:29 AM
Prevention of eye injuries
probability of injury that may require treatment.
Table 2.1 Risk categories for sports-related
Laboratories in which corrosive or biohazardous eye injury for the unprotected player.
chemicals are present are a common example.
OSHA requires that these chemical eyewash sta- High risk
tions follow ANSI Z358.1 standards. In general, Small, fast projectiles
–Air rifl e/BB gun
eyewash stations are designed to provide a steady
–Paintball
soft stream of water (15–35° Celsius) not less
Hard projectiles, fi ngers, ‘sticks,’ close contact
than 11.4 L per minute for at least 15 minutes.
–Baseball/softball/cricket
The station is manufactured to provide continu- –Basketball
ous irrigation simultaneously to both eyes while –Fencing
the user manually opens and holds the eyelids. –Field hockey
–Ice hockey
On–off valves on eyewash stations must be acti-
–Lacrosse, men’s and women’s
vated in 1 second or less and must remain on
–Squash/racquetball
without the use of the operator’s hands until
–Street hockey
intentionally discontinued. The eyewash stations Intentional injury
are to be inspected monthly to assure that they –Boxing
are in proper working order and are freely –Full-contact martial arts
accessible. Moderate risk
Fishing
SPORTS INJURIES Football
Soccer/volleyball
Tennis/badminton
Almost every type of sport has been associated
Water polo
with eye injury. In the United States alone, an
Low risk
estimated 40 000 sports- and recreation-related
Bicycling
eye injuries were reported in 2000. The eye
Noncontact martial arts
injury risk of a sport is proportional to the likeli-
Skiing
hood of the eye being impacted with suffi cient Swimming/diving/water-skiing
energy to cause harm. Vinger et al categorized Wrestling
common sports into four types: high risk,
Eye safe
moderate risk, low risk, and eye safe (Table 2.1).6 Gymnastics
Among individuals older than 5 years of age, the Track and fi eld*
two sports most commonly associated with eye
*Javelin and discus have a small but defi nite
injuries were basketball and baseball. potential for injury that is preventable with good
The sport of hockey is a good example of posi- fi eld supervision.
tive results from preventative measures. In the (From Vinger PF. A practical guide for sports eye
protection. Physician and Sports Medicine
1977–78 season, the National Collegiate Athletic
2000;28(6):49–69, with permission.)
Association (NCAA) required full facemasks to
be worn in all college hockey games in the United
States.7 As seen in Figure 2.4, eye injuries have
fallen sharply since the introduction of new rules
and use of facemasks. A study of junior hockey
11
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