Eye Injuries: The Hidden Costs Revealed

Today, many of your patients will be going about their daily activities assuming their spectacles or sunglasses are providing all they need to protect themselves from an eye injury. Yet in reality, those spectacles or sunglasses could exacerbate the damage caused by an accident, resulting in a devastating penetrating eye injury.

In Australia the medical cost of hospital admitted eye injuries alone sits in the realm of approximately AU$1,885 million every year – a massive hit to the economy. But that’s just the tip of the iceberg. When patients are left with permanent damage to their vision, they can suffer lifelong social and economic consequences.

Isn’t it time we paid more attention to educating patients about minimising or even eliminating hazards, engineering controls, and wearing personal eye protection?

Our ability to see and interpret the world contributes to more than 90% of the information we process.¹ Impairment to our vision can have consequences on many aspects of our life with health^2,3 economic,⁴ education,⁵ and psychological well-being^6,7 for individuals, families and the broader community. Eye injuries are responsible for 10–27% of operating department, 38–65% of emergency department and 5–16% of all eye hospital patient admissions.⁸ An important contributor to vision loss, trauma is estimated to be responsible for 5% of blindness⁹ and can have a devastating impact for all ages.⁸ Up to 90% of eye injuries however are preventable¹⁰ and the first step in implementing strategies for prevention is knowing who’s at risk (see breakout box).

trauma is estimated to be responsible for 5% of blindness and can have a devastating impact for all ages

Figure 1. Hierarchy of controls for hazards.

THE COST OF EYE INJURIES

The most comprehensive data on the impact of eye injuries was published by the World Health Organization in 1998,⁸ which estimated that every year around the world, 55 million eye injuries restrict activity by more than one day. An estimated 13/100,000 population suffer an eye injury requiring hospitalisation, resulting in 19 million people with unilateral blindness or low vision from trauma annually. In Australia, more than 20 years on, the incidence of eye injuries has been estimated at between 11.9 and 25.5/100,000 people.^11,12 The number of hospitalised eye injuries in the five years to 2015 was 52,000¹¹ at an average cost of AU$181,322 per injury.¹² The direct medical cost of admitted eye injuries per year in Australia could therefore be extrapolated to almost $1,885 million.

Figure 2. Age-specific rates of hospitalised eye injuries by gender, Australia 2010–2011 and 2014–2015.¹¹

INJURY PREVENTION: WHAT’S THE STRATEGY?

Effective management of ocular trauma is one thing, however, the most effective strategy is prevention. The aim should be to avoid exposure to hazards by eliminating or substituting hazards, as well as engineering and administrative controls. When these steps cannot be taken, personal protective equipment is the last line of defence in the hierarchy of hazard controls (Figure 1).

Successful interventions to prevent eye injuries fall broadly into four key areas:

Education and awareness,
Legislation,
Standards, and
Eye protection.¹³

A wide range of eye and face protection is available and your recommendation, in terms of size and style, should be made based on the patient’s individual needs and a risk analysis. Compliance with eye protection programs is a key factor in effectiveness of injury prevention strategies, and is influenced by factors including fit and comfort of eye protection.¹⁴

MEETING EYE PROTECTION STANDARDS

Standards are essential because they ensure products are made without qualities that would lead to injury or harm during use, and they provide important guidance on the labelling and handling of products. While standards can be voluntary, many are adopted into legislation and are, therefore, mandatory.

Standards organisations, including the International Organization for Standardization (ISO), the American National Standards Institute (ANSI) and the American Society for Testing and Materials (ASTM), facilitate the development of standards through committees of industry, consumer and academic experts. The standards relevant to eye injury prevention include occupational,¹⁵ sports,¹⁶ and sunglass standards.¹⁷ Standards for occupational eye protection provide minimum performance criteria and an appropriate level of protection to avoid or minimise exposure to hazards. In the United States, ANSI and ASTM,^18-20 and in Europe EN and ISO standards,^21,22 are referred to for eye and face protection.

CORRECT USE OF EYE PROTECTION

Mandatory occupational health and safety requirements, and the successful deployment of eye injury prevention strategies, have reduced the number of occupational eye injuries. However there is still more to be done.

Compliance continues to be an issue, with patients with eye injuries usually reporting not wearing eye protection due to problems with comfort, fogging or as a result of poor fit.²³ It was estimated that the correct use of eye protection for work-related and ‘do it yourself ’ type home projects involved ocular hazards in Australia would have saved $59 million in the period November 1989 to April 1991.

Lack of education is another continuing issue, with many patients under the false impression that regular spectacle lenses provide eye protection. In fact, regular spectacles or sunglasses have been known to convert blunt trauma into a more devastating penetrating eye injury from lens fragments.²⁴

Improvements in technology and design, as well as legislation and public advocacy programs, have and will continue to improve compliance, facilitating a reduction in occupational eye injuries.

YOUR ROLE IN INJURY PREVENTION

A patient’s vision impacts on their ability to navigate their daily lives, with vision loss and blindness having a significant impact on health and quality of life.^3,7,25-27

The direct economic cost of an eye injury should be viewed as the ‘tip of the iceberg’ as patients may be left with lifelong social and economic consequences. The cost and time invested in wearing correct eye protection far outweighs these consequences.

Eye health professionals can play a key role in the prevention of ocular trauma by informing patients of the hazards commonly associated with ocular trauma and the consequences, and advising them on appropriate prevention measures, including the use of eye protection.

Emphasis should be given to people who have had prior intraocular surgery, an eye injury or live with conditions such as keratoconus. Additionally, prioritise those undertaking ‘high risk’ activities both at work and outside work.

The cost and implications of an eye injury extend far beyond the immediate medical cost, making the need for prevention of eye injuries an important priority.

Annette Hoskin is a research fellow focusing on eye injuries and their prevention. She holds positions at the Save Sight Institute, University of Sydney and Lions Eye Institute, University of Western Australia. She is a committee member for Standards Australia and International Organization for Standardization committees for eye protection, sunglasses, spectacle lenses and frames and Global Standardization Manager for Essilor International.

References

Who's At Risk?

Patterns of ocular trauma vary internationally with a wide range of products, environments and ages implicated. A bi-modal peak is commonly reported with higher injury rates among the very young and middle-aged patients.¹¹

Almost universally, males have higher eye injury rates than females, with the exception being elderly patients, where fall-related injuries see a slight reversal of this trend (Figure 2).

WORKERS

Eye hazards associated with work environments are as significant and numerous as the injuries that can result. Industrial environments often associated with eye injuries include forestry, fishing, farming, construction and mining.²⁸ Working with metal, whether hammering, grinding or cutting, is one of the most significant sources of work-related eye injuries. Other common work hazards which result in eye injuries include artificial radiation²⁹, such as when welding, and chemicals.³⁰

Advances in eye protection design, as well as work health and safety regulations have helped reduce work-related eye injuries, however developing countries continue to have high rates.³¹ As vision plays an important role at work³², employers should ensure visual needs are met with appropriate visual correction incorporated into safety eyewear.

SPORT

Sporting activities contribute to eye injuries among both children³³ and adults.³⁴ Common eye injuries in sport include lid lacerations, orbital fractures, retinal detachment and closed globe injuries.

Australian football,³³ basketball in the United States,³⁴ floorball in Switzerland and Sweden,³⁵ and camogie and hurling in Ireland,³⁶ are sports that significantly contribute to the number of eye injuries sustained each year. The presence of a bat, ball, collision or contact with other players, is an undeniable contributor.

However, changes to rules and equipment, alongside mandated eye protection are contributing to reduced eye injuries in sports including field hockey,³⁷ ice-hockey,³⁸ squash,³⁹ and women’s la-crosse.⁴⁰

Many sports now have voluntary standards for eye protection,⁴¹ and recent surveys have shown compliance rates for eye protection are increasing in the United States.⁴²

Introducing eye protection for junior sports players can be an effective way to condition players to make protective equipment a necessary part of their kit.

HOME

An absence of education regarding hazards and appropriate eye protection has resulted in eye injuries at home representing an increasing proportion of all eye injuries.⁴³

Studies from the United States have shown that children, in particular those aged 0–4 years, are most represented in consumer product-related eye injuries.⁴⁴Products including toys, air soft and non-powdered guns,⁴⁵ yo-yos,⁴⁶and remote control helicopters,⁴⁷ are just some of the causes reported in the literature. Household products such as cleaning chemicals,⁴⁸carbonated drink bottles,⁴⁹ and elastic luggage straps⁵⁰ have also been implicated. Additionally, interaction with animals including dogs, cats and birds, both domestic and wild, can result in eye injuries, with children at particular risk due to their size and inexperience interacting with them.^51,52

Given the lifelong implications of ocular injury on a child’s social, health, developmental and economic prospects,^13,53,54 awareness and injury prevention strategies are particularly important.

Falls are a particular risk factor for young pre-ambulant children as well as the elderly, resulting in severe eye injuries.⁵⁵

Among adults, hammering and grinding metal,⁵⁵ as well as falls are common causes of eye injury.

FESTIVALS

Fireworks are often used at festivals to celebrate cultural, religious, national and regional events and milestones, and are a significant contributor to ophthalmic trauma.⁵⁶Almost half of all fireworks-related injuries result in eye injuries, with one in six leading to permanent vision loss.⁵⁸ Thermal burns are usually associated with fireworks affecting the hands (38%) and eyes.⁴Young males are most commonly affected.^58,59

ROAD

Although road traffic related ophthalmic trauma has been reported as a significant source of eye injuries,⁶⁰ improvements in motor vehicle design and regulations, including laminated windscreens, seatbelts and airbags are reducing motor vehicle related eye injuries in developed countries.⁶¹ However, developing countries such as India, continue to report high numbers of road traffic related ocular trauma.⁶²

References

Koch K, McLean J, Segev R, Freed MA, Berry MJ, 2nd, Balasubramanian V, et al. How much the eye tells the brain. Curr Biol. 2006;16(14):1428-34.
Crewe JM, Spilsbury K, Morlet N, Morgan WH, Mukhtar A, Clark A, et al. Health Service Use and Mortality of the Elderly Blind. Ophthalmology. 2015;122(11):2344-50.
Crewe JM, Morlet N, Morgan WH, Spilsbury K, Mukhtar AS, Clark A, et al. Mortality and hospital morbidity of working-age blind. Br J Ophthalmol. 2013;97(12):1579-85.
Davie G, Lilley R. Financial impact of injury in older workers: use of a national retrospective e-cohort to compare income patterns over 3 years in a universal injury compensation scheme. BMJ Open. 2018;8(4):e018995.
Morgan-Warren PJ, Mehta P, Ahluwalia HS. Visual function and quality of life in patients who had undergone eye removal surgery: a patient survey. Orbit. 2013;32(5):285-93.
Frank CR, Xiang X, Stagg BC, Ehrlich JR. Longitudinal Associations of Self-reported Vision Impairment With Symptoms of Anxiety and Depression Among Older Adults in the United States. JAMA Ophthalmol. 2019;137(7):793-800.
Karaman S, Ozkan B, Gok M, Karakaya I, Kara O, Altintas O, et al. Effect of eye trauma on mental health and quality of life in children and adolescents. Int Ophthalmol. 2017;37(3):539-44.
Negrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol. 1998;5(3):143-69.
Thylefors B. Epidemiological patterns of ocular trauma. Aust N Z J Ophthalmol. 1992;20(2):95-8.
Pizzarello LD. Ocular trauma: time for action. Ophthalmic Epidemiol. 1998;5(3):115-6.
Tovell A, McKenna K. Eye injuries in Australia, 2010–11 to 2014–15. Injury research and statistics series no. 194. . Canberra: AIHW; 2018. Contract No.: Cat. no. INJCAT 114.
Hoskin AK, Philip SS, Yardley AM, Mackey DA. Eye Injury Prevention for the Pediatric Population. Asia Pac J Ophthalmol (Phila). 2016;5(3):202-11.
Philip SS, Hoskin AK. Children’s protective eyewear: the challenges and the way forward. Med J Aust. 2014;201(2):87-8.
Solomon A. State of the World’s Sight. Vision 2020: the Right to Sight 1999–2005. . Geneva: WHO; 2005.
Garrow A. A Statistical Enquiry into 1000 Cases of Eye Injuries. Br J Ophthalmol. 1923;7(2):65-80.
Forrest KY, Cali JM. Epidemiology of lifetime work-related eye injuries in the U.S. population associated with one or more lost days of work. Ophthalmic Epidemiol. 2009;16(3):156-62.
Northey LC, Bhardwaj G, Curran S, McGirr J. Eye trauma epidemiology in regional Australia. Ophthalmic Epidemiol. 2014;21(4):237-46.
Bizrah M, Yusuf A, Ahmad S. An update on chemical eye burns. Eye (Lond). 2019.
Jovanovic N, Peek-Asa C, Swanton A, Young T, Alajbegovic-Halimic J, Cavaljuga S, et al. Prevalence and risk factors associated with work-related eye injuries in Bosnia and Herzegovina. Int J Occup Environ Health. 2016;22(4):325-32.
Legood R, Scuffham P, Cryer C. Are we blind to injuries in the visually impaired? A review of the literature. Inj Prev. 2002;8(2):155-60.
Hoskin AK, Yardley AM, Hanman K, Lam G, Mackey DA. Sports-related eye and adnexal injuries in the Western Australian paediatric population. Acta Ophthalmol. 2016;94(6):e407-10.
Haring RS, Sheffield ID, Canner JK, Schneider EB. Epidemiology of Sports-Related Eye Injuries in the United States. JAMA Ophthalmol. 2016;134(12):1382-90.
Maxen M, Kuhl S, Krastl G, Filippi A. Eye injuries and orofacial traumas in floorball–a survey in Switzerland and Sweden. Dent Traumatol. 2011;27(2):95-101.
Crowley PJ, Condon KC. Analysis of hurling and camogie injuries. Br J Sports Med. 1989;23(3):183-5.
Wisse RP, Bijlsma WR, Stilma JS. Ocular firework trauma: a systematic review on incidence, severity, outcome and prevention. Br J Ophthalmol. 2010;94(12):1586-91.
Jeyabal P, Davies L, Rousselot A, Agrawal R. Fireworks: boon or bane to our eyes? Int Ophthalmol. 2019.
Bagri N, Saha A, Chandelia S, Dubey NK, Bhatt A, Rai A, et al. Fireworks injuries in children: A prospective study during the festival of lights. Emerg Med Australas. 2013;25(5):452-6.
Bull N. Legislation as a tool to prevent firework-related eye injuries. Acta Ophthalmol. 2011;89(8):e654-5.
John D, Philip SS, Mittal R, John SS, Paul P. Spectrum of ocular firework injuries in children: A 5-year retrospective study during a festive season in Southern India. Indian J Ophthalmol. 2015;63(11):843-6.
Frimmel S, de Faber JT, Wubbels RJ, Kniestedt C, Paridaens D. Type, severity, management and outcome of ocular and adnexal firework-related injuries: the Rotterdam experience. Acta Ophthalmol. 2018;96(6):607-15.
Jing Y, Yi-qiao X, Yan-ning Y, Ming A, An-huai Y, Lian-hong Z. Clinical analysis of firework-related ocular injuries during Spring Festival 2009. Graefes Arch Clin Exp Ophthalmol. 2010;248(3):333-8.
Kong Y, Tang X, Kong B, Jiang H, Chen Y. Six-year clinical study of firework-related eye injuries in North China. Postgrad Med J. 2015;91(1071):26-9.
Chang IT, Prendes MA, Tarbet KJ, Amadi AJ, Chang SH, Shaftel SS. Ocular injuries from fireworks: the 11-year experience of a US level I trauma center. Eye (Lond). 2016;30(10):1324-30.
Saadat S, Naseripour M, Smith GA. The health and economic impact of fireworks-related injuries in Iran: a household survey following the New Year’s Festival in Tehran. Injury. 2010;41(7):e28-33.
Yardley AE, Hoskin AK, Hanman K, Sanfilippo PG, Lam GC, Mackey DA. Paediatric ocular and adnexal injuries requiring hospitalisation in Western Australia. Clin Exp Optom. 2017;100(3):227-33.
Chen AJ, Chan JJ, Linakis JG, Mello MJ, Greenberg PB. Age and consumer product-related eye injuries in the United States. Rhode Island medical journal. 2014;97(1):44-8.
Laraque D, American Academy of Pediatrics Committee on Injury V, Poison P. Injury risk of nonpowder guns. Pediatrics. 2004;114(5):1357-61.
Brown L. Yo-yo injuries. Pediatric emergency care. 2004;20(6):379-81.
Alphonse VD, Kemper AR, Rowson S, Duma SM. Eye injury risk associated with remote control toy helicopter blades. Biomedical sciences instrumentation. 2012;48:20-6.
Vajpayee RB, Shekhar H, Sharma N, Jhanji V. Demographic and clinical profile of ocular chemical injuries in the pediatric age group. Ophthalmology. 2014;121(1):377-80.
Kuhn F, Mester V, Morris R, Dalma J. Serious eye injuries caused by bottles containing carbonated drinks. Br J Ophthalmol. 2004;88(1):69-71.
Da Pozzo S, Pensiero S, Perissutti P. Ocular injuries by elastic cords in children. Pediatrics. 2000;106(5):E65.
Yardley AM, Hoskin AK, Hanman K, Wan SL, Mackey DA. Animal-inflicted ocular and adnexal injuries in children: A systematic review. Surv Ophthalmol. 2015;60(6):536-46.
Matsa E, Shi J, Wheeler KK, McCarthy T, McGregor ML, Leonard JC. Trends in US Emergency Department Visits for Pediatric Acute Ocular Injury. JAMA Ophthalmol. 2018;136(8):895-903.
Beshay N, Keay L, Dunn H, Kamalden TA, Hoskin AK, Watson SL. The epidemiology of Open Globe Injuries presenting to a tertiary referral eye hospital in Australia. Injury. 2017;48(7):1348-54.
Glynn RJ, Seddon JM, Berlin BM. The incidence of eye injuries in New England adults. Arch Ophthalmol. 1988;106(6):785-9.
Leonard JC. National Trends in Ocular Injury: Differing Studies, Common Call to Action. JAMA Ophthalmol. 2019;137(1):56-7.
Swathi A, Matheen A, Charanya C, Sudhaker S. Prospective Study of Ocular Manifestation of Road Traffic Accidents on East Coast Road Presenting to Tertiary Care Centre in Tamilnadu. International Journal of Health Sciences and Research. 2016;6(8):84-8.
Long J, Mitchell R. Hospitalised Eye Injuries in New South Wales, Australia. The Open Epidemiology Journal. 2009;2:1-7.
Tielsch JM, Parver LM. Determinants of hospital charges and length of stay for ocular trauma. Ophthalmology. 1990;97(2):231-7.
Fong LP. Eye injuries in Victoria, Australia. Med J Aust. 1995;162(2):64-8.
Akbar-Khanzadeh F, Bisesi MS, Rivas RD. Comfort of personal protective equipment. Appl Ergon. 1995;26(3):195-8.
Kriz PK, Comstock RD, Zurakowski D, Almquist JL, Collins CL, d’Hemecourt PA. Effectiveness of protective eyewear in reducing eye injuries among high school field hockey players. Pediatrics. 2012;130(6):1069-75.
Pashby T. Eye injuries in Canadian amateur hockey. Can J Ophthalmol. 1985;20(1):2-4.
Finch C, Vear P. What do adult squash players think about protective eyewear? Br J Sports Med. 1998;32(2):155-61.
Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Clough MV, Dick RW, et al. Effectiveness of the women’s lacrosse protective eyewear mandate in the reduction of eye injuries. Am J Sports Med. 2012;40(3):611-4.
Dain SJ. Sports eyewear protective standards. Clin Exp Optom. 2016;99:4-23.
Leisy HB, Coritsidis AL. Use of Protective Eyewear During Recreational Activities in Adults of the United States: Analysis from the 2016 National Health Interview Survey. Ophthalmic Epidemiol. 2019;26(3):216-22.
AS/NZS 1337.1 Personal eye protection Part 1: Eye and face protectors for occupational applications. Sydney: Standards Australia/ Standards New Zealand, 2010.
AS/NZS 4066 Eye protectors for racquet sports. Sydney: Standards Australia/ Standards New Zealand, 1992.
AS/NZS 1067.1 Eye and face protection- Sunglasses. Part 1: Requirements. Sydney: Standards Australia/ Standards New Zealand, 2016.
ANSI Z87.1 American National Standard for Occupational and Educational Personal Eye and Face Protection Devices. American National Standards Institute, Inc. 2010.
ASTM F803-11 Standard Specification for eye Protectors for Selected Sports. ASTM International. 2011.
ASTM F1776-12 Standard Specification for Eye Protective Devices for Paintball Sports. ASTM International. 2012.
ISO 12312-1 Eye and face protection- Sunglasses and related eyewear- Part 1: Sunglasses for general use. Internationa Organization for Standardization. 2013.
EN 166 Personal eye protection. Specifications. European Committee for Standardization. 2002.
Fong LP, Taouk Y. The role of eye protection in work-related eye injuries. Aust N Z J Ophthalmol. 1995;23(2):101-6.
Zakrzewski H, Chung H, Sanders E, Hanson C, Ford B. Evaluation of occupational ocular trauma: are we doing enough to promite eye safety in the workplace? Can J Ophthalmol. 2017;52(4).
Crewe JM, Lam G, Clark A, Spilsbury K, Mukhtar AS, Morlet N, et al. Hospitalization rates of children who are blind. Clin Exp Ophthalmol. 2013;41(8):773-8.
Frank CR, Xiang X, Stagg BC, Ehrlich JR. Longitudinal Associations of Self-reported Vision Impairment With Symptoms of Anxiety and Depression Among Older Adults in the United States. JAMA Ophthalmol. 2019.
Frost A, Eachus J, Sparrow J, Peters TJ, Hopper C, Davey-Smith G, et al. Vision-related quality of life impairment in an elderly UK population: associations with age, sex, social class and material deprivation. Eye (Lond). 2001;15(Pt 6):739-44.

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