Ocular Injury – 5 brief points for optometrists

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Ocular injury is an interesting area of eye-care, and perhaps one that we don’t encounter quite as often in modern optometry due to improved safety standards and awareness, but in this post I wanted to highlight a few aspects of this whole subject of ocular injury that we as optometrists should be mindful of.

  1. Risk of injury in one-eyed or amblyopic patients.

The old adage of ‘In the Land of the Blind, the one-eyed man is King, is often heard. We collectively see a lot of patients who rely solely on one good eye, whether that is through pathology to one eye, a severe injury or dense amblyopia. There was always the thought that when it comes to ocular injury, the good eye is at higher risk of being injured than the poor eye. This may be related to the fixation of the good eye, making it more prone. I have looked to try to find evidence to support this notion and struggled. However whether this is the case or not, at best the risk of injury to the good eye over the bad is 50%, which is unacceptably high in any case, considering that the patients’ eyesight is at stake.

In terms of my own clinical practice, when I see patients who are one eyed, I ask about their work, hobbies, and sporting activities and try to identify if they are doing anything which might carry risk of ocular injury. It is good practice to stress to them the importance of using the appropriate eye safety wear and precautions, and emphasise to them the potential implications of an injury to the good eye. When I am discharging children from the clinic who are amblyopic, I give the parents a little chat about the importance of protecting the good eye, and maybe to be mindful of the type of sporting activities they are involved in and career choices later in life, and to be very protective of their good eye.

2. Sports injuries 

A range of ocular injuries can occur in sport, most of which tend to be some form of blunt trauma. These can result in number of changes in the eye such as hyphema, Commotio retinae, blowout fracture, angle recession, or cataract to name a few.

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Protective goggles for squash

A review by North in 1986 found that the most common sports where injuries occurred were squash, soccer, badminton, tennis and rugby. In doing a lot of work with glaucoma, I see patients who have angle recession and of those squash, badminton and cricket often come to mind. These injuries may not always involved an object hitting the eye such as a squash ball, rather an elbow from an opponent or a clash of heads etc can be the cause of injury.
The total eradication of sporting ocular injuries is likely to be impossible, however in sports with clear risks such as squash, badminton and cricket, the use of appropriate eye safety devices is advised.

3. Alkali chemical injuries

This is one area of ocular injury which everyone working with eyes should be alert to. Anyone suffering a chemical injury to the eye should be examined as a matter of urgency. If there is a possibility that the substance involved was alkali in nature, the patient needs immediate first aid rinsing of the eye with saline, or water.

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Example of an emergency saline eye-wash

Alkali substances are lipophilic which leads them to penetrate the ocular tissues more quickly than acid substances. If they penetrate into the anterior segment they can damage other tissues such as the lens and the ciliary body. They are also very damaging to the limbal stem cells, leaving the cornea prone to long term severe damage, and visual loss.
Copious irrigation with saline for a period of 30minutes is usually recommended as the immediate response. If a pH strip is available, this can be very helpful to check the pH of the ocular surface and check that this is coming back to normal with irrigation. A drop of local anaesthetic may help with this process. Irrigating under the lids to get rid of any particulates is also vital.
Once sufficient irrigation has been administered then the patient should be got into the secondary care setting for an ophthalmologist to take over their care as quickly as possible.
Acid injuries will essentially require the same prompt treatment, however the alkali injuries are potentially more damaging to the eye.

4. Ocular injuries in children

A paper in 1999 by MacEwen et al aimed to build up a picture of the causes and outcomes of ocular injury in children at that time. The findings indicated that overall the incidence of childhood ocular injury was reducing and that visual outcomes were improving, with 88% of the 93 eyes reviewed achieving a VA of >6/12.
In terms of the dynamics of the cohort, 70% were male and 84% were aged between 5 and 14. Most injuries took place either at home or at school, with blunt traumas accounting for 65% of these, followed by penetrating injury in 24%. The actual cause of injury in the 0 to 4year age group tended to relate mainly to toys and implements within the home, which is probably what you would expect with developing motor skills and understanding of risks. In the 4 to 15 year olds there was more of a spread of causes, including sports, assault, toys and tools.
This paper reiterates the importance of awareness of risks within the home environment for younger children or in sports and other activities for older children and taking the right measures to minimise these risks.
More recently there are other risks for the older age group of children in the form of laser pointers bought over the internet. An ophthalmology colleague recently presented a case series of around 6 children in one Scottish health board area who had suffered varying degrees of macular damage through misadventure with these devices.

 

5. Occupational ocular injuries

Again this in an area in which it is difficult to obtain detailed statistics, however one American Study indicated that the most common industries where eye injuries occurred were mining, construction and other manufacturing sectors. The incidence in 2013 was 109 cases in 10,000 full-time employees in these sectors. The annual cost of eye injuries in the US is estimated to be about $300million through lost productivity, health care costs and compensation.

(https://www.totalsafety.com/insights/eye-injuries-still-major-cause-of-workplace-injuries-lost-productivity/)

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Typical metallic foreign body

From what I see in clinical practice mechanics and anyone working with metal I can be prone to ocular injury, though these can often be fairly minor superficial foreign bodies. Builders working with brick and stone can also get corneal foreign bodies, as well as the risks of working with lime plaster in some cases. Joiners are another group in which I have seen penetrating injuries through a shard of wood, or tools such as nail guns.
Even everyday activities as mowing the grass – I remember a patient who was cutting their grass and got a piece of stone whipped up into the eye, and this is an activity where I suspect the vast majority of people don’t put on a pair of safety specs.

In summary ocular injuries occur in a whole variety of settings and situations, ranging fairly from fairly minor to sight-threatening cases. In our role as optometrists we can at least try to be aware of the higher risk areas and give our patients the best warnings and advice we can to minimise these risks.

Thanks again for reading this article and I am always glad to receive any comments or feedback.
Stan

 

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