Eye Injury Prevention
Eye injuries: introduction and overview of their impact
Our eyes naturally defend themselves against a broad range of hazards. Innate defences include the eyelids, eyelashes and blink reflex, which provide a mechanical barrier, as well as the iris’s ability to contract in response to bright visible light. The bony cavity containing the eyeball itself, as well as the brow and forehead, provide further protection as they protrude beyond the eye, particularly in children. The eyes innate mechanisms alone however are insufficient to prevent many injuries and our insights into the types of eye injuries that have occurred provides a basis for our understanding why and when they occur and how to prevent them.
Negrel & Thylefors estimated that world-wide approximately 55 million eye injuries, restricting activity by more than one day, occur every year. WHO data indicates that an estimated 19 million people worldwide are affected with unilateral blindness or low vision from trauma in 1998. The WHO data estimated 13 per 100, 000 population suffer an eye injury requiring hospitalization. More than 20 years on, the incidence of eye injuries has been estimated at between 11.9 and 25.5/ 100,000 population in Australia. 
The indirect cost includes economic social and psychosocial effects on the patients and their families. Vision loss and blindness can impact on children’s hospitalization rates mental health and quality of life, mortality and morbidity, anxiety and depression and quality of life in the elderly. One centre in the United States in 1982 estimated direct medical costs of $5M and another study estimated the total cost of eye injuries in the US in 1990 at $200m. In Australia, the average medical cost of a hospitalized eye injury was calculated at $23,717 with a total annual cost of approximately $155M in 1995. The number of hospitalized eye injuries in the 5 years to 2015 in Australia was 52,000 at an average cost of $181,322 per injury. The direct medical cost of admitted eye injuries per year in Australia could therefore be extrapolated to $2,357 M.
After suffering an eye injury with severe vision loss, workers report difficulty reading and doing their usual job, and up to 40% are unable to return to their previous job. The direct economic cost of an eye injury should be viewed as the ‘tip of the iceberg’ given a patient may be left with lifelong social and economic consequences following the injury. The cost and time invested in wearing the correct eye protection far outweighs these consequences. A number of societies have been established to develop forums for knowledge transfer on the treatment and management of ophthalmic trauma as well as to support advocacy efforts to reduce vision loss from trauma. Globally these currently include APOTS, ASOT, COTS, AAO , ISOT (perhaps include links to their website) as well as a number of national Ophthalmic & Ophthalmic Trauma Societies. Health care professional play an important role in preventing eye injuries by promoting and following eye injury prevention measures at work and at home.
Classification, measurement and prognostication of ophthalmic trauma
A universal system of unambiguous communication is key to clear and effective reporting both in clinical practice and research as categorising trauma is essential for prognostication, management and to develop prevention strategies. Globe injuries have been categorised as open or closed globe based on whether they are with or without a full thickness wound to the eye wall, respectively. (Figure 4) Initiated by Ferenc Kuhn and members of the International Society of Ocular Trauma, a set of standardized terminology  and a system for classifying, measuring and prognosticating mechanical injuries called the OTS was developed in 1997.
The OTS was developed based on an assessment of more than 2,500 open globe injuries (OGI) and provided a method for predicting visual outcomes for ocular trauma based on simple clinical data.  Points were allocated based on six parameters measured at presentation including initial visual acuity, rupture, endophthalmitis, perforating injury, retinal detachment and afferent pupillary defect which are defined in Table 1. The raw points provided a category from 1 to 5 which translated to a likely visual outcome ranging from ≥ 20/40 to no light perception. A low raw score of 0-44 correlated with a 74% chance of final visual acuity of no light perception and a high raw score of 92-100 correlated with a 94% likelihood of final VA of ≥ 20/40.
OGI’s include globe ruptures, penetrating eye injuries, perforating injuries and intraocular foreign bodies and are often associated with presenting vision of < 6/60 with young age and distress often contributing to difficulties in measuring VA. The zone of an OGI is defined as the location of the most posterior full-thickness aspect of the globe opening, Zone I isolated to the cornea or corneoscleral limbus; Zone II involves anterior 5mm of the sclera and Zone III injuries extend into the sclera more than 5mm posterior to the corneoscleral limbus.
Closed globe injuries (CGI) are characterised as an eye injury without a full thickness wound to the eye wall, they include contusions and lamellar lacerations. CGI’s are defined based on the tissues injured, Zone 1 superficial injuries involving conjunctiva, sclera and cornea; Zone II involve structures in the anterior segment and Zone III injuries involve the posterior segment. An important element of injuries to the eye is to incorporate both injuries to the globe and adnexa which is known as Ophthalmic Trauma.
The OTS has been validated as predictive of visual outcome in mechanical ocular injury with different zones of injury  and in the case of concomitant facial fractures as well as for pediatric patients.  The OTS was published in 1996, almost 25 years ago, and should be reconfirmed and updated as necessary. The OTS is currently the most widely used and accepted method of measurement for ocular trauma however limitations have been identified for its application and prognostication of ophthalmic trauma. Controversies remain with respect to its’ application, including the appropriate demarcation of Zone II and III as well as the lack of inclusion of adnexal and non–mechanical injuries, such as thermal and chemical eye injuries. 
Ocular trauma in children presents specific difficulties in prognostication due to the challenges associated with examination, evolving anatomy, different healing patterns and complications arising from amblyopia. Alternate scoring systems have been proposed specifically for children  but without the validation of a much larger data set are not as predictive for visual acuity.
Due to the limitations of the OTS and lack of validation of other trauma scores, a systematic and easily applied clinical and research tool for ophthalmic trauma needs to be developed and validated. This updated tool would ensure all types of trauma related to the eye and adnexa, for all ages, can be appropriately measured and reported to improve prognostication, management and outcomes from ocular trauma.
Epidemiology of eye injuries: including key risk factors
Our capacity to prevent trauma is linked to developing a clear understanding of when and where it occurs. Ophthalmic trauma is usually reported based on either the demography of the injured or the associated environment or activity. Activity based categories for ophthalmic trauma include occupational, sports and combat-related trauma. Categorisation of trauma has also been based on the type of hazard causing it such as those associated with public events and festivals, around the home and in road-traffic related incidents. A summary of ophthalmic trauma related to these broad categories is discussed in the sections below.
Patterns of ocular trauma vary regionally, nationally and globally partially due to variations in work and lifestyle patterns along with culture and regulation. For example, in the US, a developed country, household cleaning chemicals and toys are important causes of ocular trauma. Common household items such as glass bottles and photo frames (25%) and toy guns and fireworks (17%) were reported as leading contributors to eye injuries in one study from Hong Kong. Firework related eye injuries have been frequently reported in India , the US  and parts of South America including Columbia.  Fireworks in such settings have a key role in celebrations and their use may not be effectively regulated. Stationery items, such as scissors and pens and pencils have been reported as important contributors to penetrating eye injuries in children in Taiwan  and Australia . Increasing rates of myopia have contributed to an increase in spectacle-related ocular trauma in Taiwan . Ocular trauma in Indian children is often associated with exposure to lime found in “chuna”, an additive in chewing tobacco which is still a common habit in India.
A bi-modal peak is often reported with young and old patients commonly reported with higher ocular trauma rates. Almost universally in the literature males have a higher eye injury rate than females. However in very young pre-ambulant children and the elderly, where fall-related ocular trauma contributes to a reversal of this trend, females were slightly more represented than males. In Australia, the number of eye injuries per 100,000 population remains higher for males except in the elderly, from approximately 75 years- of age, where the female rate exceeds males. (Figure 6)
Eye hazards associated with work environments are significant and numerous. Industrial environments commonly associated with eye injuries include forestry, fishing, farming, construction and mining. Working with metal, whether hammering, grinding or cutting, has been reported as one of the most significant sources of work-related open globe injuries. The hazards associated with welding and other sources of artificial radiation  are well documented, however these injuries still occur .
The rapid development of chemical industries in industrialized countries has resulted in higher incidences of injuries caused by chemicals. Chemical eye injuries most commonly occur in males exposed to alkalis at work. A large proportion of work-related chemical eye injuries are bilateral (12.3%) and they are a significant contributor to subsequent bilateral vision loss . An increasing number of chemical-related eye injuries have been reported in the United Kingdom in association with assault .
Industrial environments often associated with eye injuries include forestry, fishing, farming, construction and mining. Working with metal, eg when hammering, grinding or cutting, is one of the most common sources of work-related eye injuries. Other work hazards which frequently result in eye injuries include chemicals eg acids, alkalis, cleaning solutions, and artificial radiation, such as when welding.
Occupational-related ophthalmic trauma has decreased in developed countries with changes to work health and safety regulations. A paucity of data on occupational-related eye injuries from developing countries means the picture is less clear. Prevention measures, including eye protection, for work-related ophthalmic trauma has seen a reduction of vision loss from these causes in developed countries.
Advances in eye protection design as well as work health and safety regulations have helped reduce work-related eye injuries. With more than 50,000 admitted to hospital in 2 years (2010-11, 2015-15) in Australia, we are still far from solving this problem. Because vision plays an important role at work, employers should ensure visual needs are met with appropriate visual correction incorporated into safety eyewear to ensure good vision in maintained.
Sport-related eye injuries represent a significant proportion of eye injuries in children  and adults . Injuries commonly sustained during sport to the eye and adnexa include lid lacerations, orbital fractures and closed globe injuries. The incidence of sports-related eye injuries by country is dependent on the type of sports played and their hazards as well sports participation rates. For instance, sports related eye injuries are more common in Australian Football League in Australia, basketball in the United States, Floorball in Switzerland and Sweden and Camogie and Hurling in Ireland. Hazards associated with sports include the bat, ball, chances of collision or contact with other players for example basketball and rugby and football codes have had high eye injury rates reported.  Players should be encouraged to appropriate protective eye wear and seek early medical attention for any eye injuries.
Festivals associated with cultural, religious, national and regional events are used to bring communities together and celebrate milestones and are often related to the use of fireworks. Fireworks are a contributor to ophthalmic trauma worldwide. Festivals including New Year’s Eve, Deepvali, Chinese New Year and 4th of July are associated with extensive use of fireworks and commonly ocular trauma.
The profile and incidence of eye injuries associated with combat has changed over the last century as a result of a range of factors, including the increased use of improvised explosive devices (IED’s). With large numbers of small high energy particles deployed, IED’s are used to disable soldiers and have been associated with an increase in ocular morbidity . Eye injuries represented 13% of hospitalised casualties in the 1990’s, a significant increase on 2% during World War 1  Many military services internationally now recognize the benefit of eye protection not only to protect soldiers during combat but also to maintain good vision during military exercises and prevent soldiers being disabled by vision loss. 
Eye injuries around the home
Eye injuries outside work represent an increasing proportion of ocular trauma. Activities including hammering and grinding metal introduce hazards and are significant contributors to open globe injuries around the home. Falls around the home, in particular onto hard surfaces or sharp corners, are common and a risk factor for young pre-ambulant children and the elderly; resulting in OGI’s and CGI’s.
Easily accessed hazardous consumer products around the home have been reported to result in eye injuries, most commonly in young children (0-4 years-old)  from cleaning chemicals but also in primary school aged children (5- 9 years) from pens, pencils, knives, forks and toys. Eye injuries in children have been reported to occur from products such as toys, air soft and non-powdered guns , yo-yos  and remote control helicopters as well as with household products such as cleaning chemicals, carbonated drink bottles and elastic luggage straps.
Road traffic-related ophthalmic trauma was widely reported in the literature last century.   Developments and regulations in motor vehicle design including laminated windscreen, seatbelts and airbags are thought to have contributed to a reduction in eye injuries associated with motor vehicle crashes in developed countries. However, developing countries such as India, continue to report high numbers of road traffic-related ocular trauma. Further, in countries where motorbikes predominate as the main transport and appropriate helmets are not typically worn, e.g. Malaysia and India, conjunctival (42.4%), lid (33.0%) and posterior segment trauma (8.8%) are significant contributors to eye injuries.
Eye injury prevention
Ocular trauma is an important and developing sub-specialty in ophthalmology, focusing on reducing vision loss through improved treatment. However, 90% of ocular trauma is preventable with strategies for prevention playing a key role in reducing the burden of vision loss from ocular trauma. The application of the hierarchy of control (HOC) (Figure 1) is an established approach to hazard reduction. A hazard is defined as ‘an injury producing agent’ and the first priority is the elimination of danger - a combination of hazard and risk. Where elimination is not possible then substitution, engineering and administrative controls are progressively applied, with personal protection representing the last line of defence in prevention. 
Gaps remain in our ability to systematically collect data on eye injuries, with accepted terminology, measurement systems and evidence base some of the current limitations. In particular, data from developing countries on the circumstances, including preventive measures such as eye protection and visual outcomes, are lacking. Without a systematic method to collect data internationally on the circumstances and outcomes from ophthalmic trauma, our capacity to develop effective evidence-based prevention strategies is limited. Collaborative research provides an opportunity to gather data globally, previously the United States Eye Injury Registry (USEIR) provided very useful data on eye injuries in the US.  More recently the International Globe and Adnexal Trauma Epidemiology Study (IGATES) as part of the Asia Pacific Ocular Trauma Society (APOTS) has begun collecting data on ophthalmic trauma from a number of countries using an online platform.
Legislation, statutory laws which are enacted by a governing body, may play a role in reducing exposure to hazards in occupational, public and home environments by:
- Eliminating products from sale
- Ensuring minimum standards are applied to product safety and/or
- Providing appropriate labelling and instructions.
Legislation has been used to reduce ocular trauma by eliminating or controlling hazardous substances or activities e.g. laws relating to the restricted sale of airsoft guns in Australia , product warning labels on toys advising of age restrictions (ref EN 71-1), and luggage straps warning of the hazards, and legislation banning the import of bb-guns; commonly associated with eye injuries in the US; into Australian.
Regulations are used to prescribe or proscribe conduct and may or may not be government mandated. One prominent example is motor vehicle design, which regulates many features including those relating to safety. The mandated use of seatbelts, airbags and laminated windscreens has contributed to reduced mortality in motor vehicle crashes in Australia. Although the introduction of air bags in motor vehicles was associated with reduced mortality, they were initially associated with an increase in eye injuries associated with chemical and thermal burns from chemicals used in deployment. Upgraded designs, including smart sensors which use the passenger’s weight to refine the amount of chemical and therefore impact energy, have reduced ophthalmic trauma associated with airbag deployment. This injury mechanism is however still reported in the literature, particularly in countries with reduced motor vehicle regulation and for children.
The implementation of safety features in motor vehicles and subsequent ophthalmic trauma highlights the importance of monitoring the effects of new legislation on ocular injury circumstances and rates. It is important to note that legislation is not a panacea for injury prevention with eye protection and standard providing an integral and supporting roles.
Education can effectively support all levels of the HOC’s eg if the aim is to eliminate children’s exposure to dangerous chemicals around the home, educating parents about these chemicals out of reach will help to reduce children’s exposure to these chemicals. Educational interventions that aim to bring about behavioral change can be effective in reducing the incidence of eye injuries. Interventions have included the use of warnings and education on the risks associated with use of products and appropriate precautions. Dishwashing detergent pods which combine caustic detergent with attractive colourful packaging, have been reported to cause eye injuries in children, labelling was successfully used to educate carer’s about the need to remove these products from the reach of children.  The use, labelling and storage of household cleaning products should be regularly reviewed. Child protection agencies, such as Kidsafe, The Child Accident Prevention Authority and Children’s Health and Safety Association, have previously educated and informed parents about hazards, such as children’s access to detergent pods.
National and international standards are in place in many countries for sports, military and occupational eye protection. Whilst they are generally not mandatory, standards provide a basis to ensure products promoted as eye protection provide an appropriate level of mechanical impact protection. It is also important to ensure that there is no visual impairment introduced through the optical, transmittance and colouration limitations. Initial eye protection standards focused on lens performance and were material-specific. As knowledge of the nature of eye injuries and frame and lens technology evolved, standards incorporated impact performance and coverage requirements for the complete product, rather than being material- or design-specific. With the long-term effects of environmental ultraviolet (UV) radiation apparent, UV requirements are also incorporated in eye-protection standards, with many lens materials providing adequate protection when outdoors. Another requirement in current eye protection standards is ensuring no secondary hazards are introduced by the inappropriate use of frame or lens materials that are harmful to the wearer. In Australia, the first prescription eye protection standard (AS1337.6) included requirements for the complete spectacle-type eye protector, tested with a range of prescription powers to ensure compliance across a specified power range. Figure12 summarises some of the key changes in the 19th and 20th century aimed to reduce eye injuries including policies, standards and material innovation.
When substitution or elimination of eye hazards is not possible, eye protection provides the last line of defense. A wide range of eye and face protection styles and sizes are available. It is important to ensure that selection of eye protection is based on a thorough risk analysis as well as a clear understanding of the morphology and individual needs of the wearer to maximize compliance. Compliance with personal protective equipment wear, including eye protection, is a key factor in effectiveness of injury prevention programs and is influenced by human factors including fit and comfort.
Hierarchy of controls
Eye injury prevention strategies should apply the HOC with elimination of hazards the first priority, as this is the most effective means of prevention, i.e. elimination or substitution eg using an effective non-toxic alternative to cleaning acids, providing engineering controls eg guards on a metal lathes to prevent exposure to high speed particles. Administrative controls are the next most effective injury prevention measure e.g working indoors at peak periods of ultraviolet exposure to avoid sunburn. Personal protection equipment, in the form of eye protection, provides the last available option in eye injury prevention. The hierarchy of controls can be supported by a number of strategies including education, legislation and product standards.
Eye injuries are the leading cause of vision loss in one eye and often affect young working age males. It is particularly important to take care of high risk individuals. At particular risk are those who have had a previous eye injury, surgery or who are one-eyed (amblyopic). The risks and consequences of vision loss for these high individuals is even higher.
Why regular spectacles and sunglasses are not eye protection? A common misconception is that regular spectacles can be used as eye protection. Regular spectacles and sunglasses should not be used as eye protection. The plastic or glass material used in regular spectacles may dislodge from the frame and fracture, penetrating the eye and potentially resulting in severe eye injuries and vision loss. Regular prescription spectacles are also unlikely to offer protection from the sides, providing more opportunity for objects to enter the eye from the side. Regular prescription spectacles should always be replaced with custom-made prescription safety eye protection, complying with AS/ NZS 1337.6 or ANSI Z87.1 , when exposed to eye hazards.
Ocular trauma & posttraumatic blindness is largely preventable. Working together to gather data to understand when and why injuries occur is the first step in prevention. A clear consistent message through advocacy, education and product standards will help support prevention strategies.
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