Work-Related Eye Injuries and Illnesses W.F. PEATE, M.D., M.P.H., University of Arizona Colleges of Medicine and Public Health, Tucson, Arizona More than 65,000 work-related eye injuries and illnesses, causing significant morbidity and disability, are reported in the United States annually. A well-equipped eye tray includes fluorescein dye, materials for irrigation and foreign body removal, a short-acting mydriatic agent, and topical anesthetics and antibiotics. The tray should be prepared in advance in case of an eye injury. Eye patching does not improve cornea reepithelialization or discomfort from corneal abrasions. Blunt trauma to the eye from a heavy object can cause a blow-out fracture. Sudden eye pain after working with a chisel, hammer, grinding wheel, or saw suggests a penetrating globe injury. Chemical eye burns require immediate copious irrigation. Nontraumatic causes of ocular illness are underreported; work-related allergic conjunctivitis increasingly has been recognized among food handlers and agriculture workers who are exposed to common spices, fruits, and veg- etables. The patient’s history of eye injury guides the diagnosis. Primary prevention and patient counseling on proper eye protection is essential because over 90 percent of injuries can be avoided with the use of eye protection. As laser use increases in industry and medical settings, adequate personal protection is needed to prevent cataracts. Outdoor workers exposed to significant ultraviolet rays need sun protection and safety counseling to prevent age-related macular degeneration. Contact lenses do not provide eye protection, and physicians should be familiar with guidelines for the use of contacts in the workplace. (Am Fam Physician 2007;75:1017-22, 1024. Copyright 2007 American Academy of Family Physicians.)
▲ Patient information:
A handout on work-related eye injuries and il nesses, written by the author of this article, is provided on page 1024.
More than 65,000 work-related dilate the pupil. The effects of longer-duration
eye injuries and illnesses cause agents (e.g., atropine, homatropine hydro-job absenteeism in the United bromide [Isopto Homatropine]) may last for States every year.1 Workers days, impairing vision and preventing patients
who have the highest risk of eye injuries from driving. To reduce injury and discom-include fabricators, laborers, equipment fort, instill a topical anesthetic (e.g., tetracaine operators, repair workers, and production [Pontocaine], proparacaine [Ophthetic]) and precision workers. More than one half of before using fluorescein or removing a for-work-related eye injuries occur in the manu-
eign body. Only use anesthetics in the office;
facturing, service, and construction indus-
if a patient uses the medication at home, it can
tries. Most chemical and thermal eye injuries delay healing and mask complications. occur when persons are at work.2 Eighty-one
Check the expiration dates of all medica-
percent of work-related eye injuries occur tions and the batteries of handheld oph-in men, and most occur in workers 25 to thalmoscopes. A slit lamp is useful, but a 44 years of age.1
thorough examination with a handheld oph-thalmoscope is adequate for most patients.
Evert the eyelids by placing a cotton-tipped
The visual acuity of a patient with an eye swab on top of the upper eyelid and rolling injury should always be tested because vision the lid over the swab; carefully inspect the changes provide objective tools to monitor eye for foreign bodies. clinical improvement or deterioration. Pre- pare an eye tray (Table 1) in advance, and Diagnosis and Management perform irrigation in the event of a chemical cornEal abrasions burn. Use fluorescein dye and a cobalt-blue Eye pain after a trauma caused by a foreign filtered light to detect corneal abrasions. body, rubbing, or a scratch suggests a corneal After the assessment, gently irrigate the eye abrasion. Associated symptoms may include to diminish the risk of an adverse reaction to blinking, tearing, pain with eye movement, the dye, such as burning.3
headache, blurry vision, and foreign body
Only a short-acting mydriatic agent (e.g., sensation. Some physicians treat noninfected
tropicamide [Mydriacyl]) should be used to corneal abrasions prophylactically with topical
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2007 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. sorT: KEY rEcoMMEnDaTions For PracTicE
Patching is ineffective for corneal abrasions and is not
randomized control ed trials and good-quality patient-oriented evidence
Topical nonsteroidal anti-inflammatory drugs are only
somewhat beneficial for symptom relief in patients
with corneal abrasions and may delay healing.
Mydriatic agents are ineffective for corneal abrasions
control ed trials and good-quality patient-oriented evidence
Persons with a chemical eye burn should receive
Percutaneous skin tests should be used to assess a
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 957 or http://www.aafp.org/afpsort.xml.
antibiotics, although the evidence supporting
this practice is limited. Ointments are more does not improve corneal reepithelializa-soothing and persist on the cornea longer tion or discomfort and increases pain in one than eyedrops. Erythromycin and bacitracin half of patients.5-7 The addition of a topi-(AK-tracin) are preferred over gentamicin cal nonsteroidal anti-inflammatory drug (which may be toxic to corneal epithelium) (NSAID; e.g., ketorolac [Acular], diclofenac and Neosporin (which has a relatively high [Voltaren]) has been shown to be some-allergic reaction rate).4
what beneficial for symptom relief7 and for decreasing narcotic use and time off work; however, NSAIDs may delay healing.8 Myd-riatic agents are no longer recommended to
Table 1. suggested Eye Tray contents for the Treatment
treat corneal abrasions because they offer
of Eye injuries
no additional benefit.9 Regardless of the ocular agents used, always offer oral anal-
gesics because pain may be severe. Advise
Short-acting mydriatic agent (e.g., tropicamide [Mydriacyl])
the patient to avoid wearing contact lenses
Topical anesthetic (e.g., proparacaine [Ophthetic], tetracaine
until the abrasion is healed and symptoms
Topical antibiotics (e.g., bacitracin [AK-tracin], erythromycin)
after one day, reevaluate in two or three
Basin to catch water during eye irrigation
days. Refer the patient to an ophthalmolo-
Cobalt-blue filtered light and fluorescein dye to detect corneal abrasions
gist for any of the following scenarios: a
Cotton-tipped swabs to facilitate examination and foreign body removal
small- to moderate-sized abrasion has not
Diluted sodium hypochlorite spray to disinfect work surfaces
resolved by the third day; the cornea has not
For chemical burns: intravenous drip tubing, one liter of isotonic saline,
improved at any of the follow-up examina-
tions; symptoms do not decrease each day;
or the edge of the abrasion is white or gray,
Hypodermic needle (18 gauge) for removal of foreign bodies and rust rings
Progression to recurrent corneal erosion
(i.e., breakdown of the corneal epithelium)
NOTE: An eye tray should be prepared in advance in case of an eye injury.
may occur years after a corneal abrasion. Symptoms of corneal erosion mimic the
1018 American Family Physician Volume 75, Number 7 ◆ April 1, 2007Eye injuries and illnesses
initial corneal abrasion, and tearing on awak-
close the eyelid if they are not repaired prop-
ening is common. Refer patients with recur-
erly. Lacerations involving the nasal portion
rent corneal erosion to an ophthalmologist.
of the upper or lower eyelids may damage the lacrimal drainage apparatus. ForEign boDiEs
Foreign bodies are common with corneal velocity impacts and should be suspected if abrasions. After instilling topical anesthesia, sudden eye pain presents in patients who have remove superficial foreign bodies using a used a chisel, hammer, grinding wheel, or cotton-tipped swab soaked in saline. Remove saw. Pupil or lens changes (e.g., cataract, dark minor irritants by irrigating the eye with surface uveal tissue, vitreous hemorrhage) eyewash solution. Soot from fires can contain also are suggestive of a penetrating injury. toxic and allergenic particles that can further Head injuries can dislocate the lens. A dilated irritate the eye. For example, a firefighter pupil indicates a possible cerebral injury.11can be exposed to rhus (e.g., poison ivy,
To evaluate the orbit for an intraocular
sumac, and oak) from a brush fire. Foreign fragment, dilate the pupil (unless intracere-bodies embedded deeper into the cornea bral bleeding or swelling is suspected) and require removal with a hypodermic needle obtain an orbital computed and using a slit lamp. If a foreign body is tomography (CT) scan (axial not easily removed, refer the patient to an and coronal views; thin cuts of
recurrent corneal erosion may occur years after a
Oxidation of a ferrous foreign body in able, radiographs (up and down
corneal abrasion injury.
the eye can leave rust residue (“rust rings”). gaze views) are useful.11 Use an Remove rust rings to decrease inflamma-
tion and scarring.10 Before removal, instill a tive cover) to avoid pressure on the orbit, topical anesthetic. Place an 18-gauge needle and refer the patient to an ophthalmologist on the end of a cotton-tipped swab or rotary immediately if a fragment is detected. drill. Hold the needle at 90 degrees to the affected surface of the eye, and gently scrape chEMical burn the ring until it is removed. Refer the patient Ocular chemical burns make up a significant to an ophthalmologist if you are uncomfort-
percentage of work-related eye injuries12 and
able performing the procedure, if the ring require rapid treatment. Alkalis (pH greater cannot be removed completely, if the ring than 10) are more dangerous than acids (pH has been present for one week or more, or if less than 4), with the exception of hydroflu-you suspect recurrent corneal erosion. Offer oric acid,13 because they may penetrate the the patient an oral analgesic for pain relief.
cornea for an extended period. Litmus or pH paper can assist in determining alkalinity or
acidity. Although most chemical burns are
Bleeding into the anterior chamber of the mild and without residual effects, patients eye (hyphema), retina, or vitreous may sug-
with severe burns have a poor prognosis.2
gest blunt trauma. Retinal detachment may
present as a dark curtain covering part of begin copious irrigation with one liter of the visual field. Advise the patient to remove physiologic saline over one to two hours contact lenses because swelling may prevent using intravenous drip tubing.2,13,14 Promptly removal later, and refer him or her to an refer the patient to an ophthalmologist14; ophthalmologist.
irrigation can be continued during trans-
Eyelid lacerations should be treated by a portation for definitive treatment.15 Use
specialist, unless it is a small or partial-thick-
litmus or pH paper to judge the response
ness laceration. Larger and deeper lacerations to irrigation. When the pH level is near and those involving the lateral and medial neutral (6 to 8 pH), discontinue irrigation. edges of the eyelid or the eyelid margin can Hydrofluoric acid burns are common in cause scarring, retraction, and the inability to the semiconductor industry, and treatment
April 1, 2007 ◆ Volume 75, Number 7American Family Physician 1019 Eye injuries and illnesses
is similar to other chemical Patients with acute bacterial conjunctivitis
burns using isotonic saline, should not return to work until the dis-
conjunctivitis has been
isotonic magnesium chloride charge clears. increasingly reported
Viral conjunctivitis often is associated with
among food handlers and
an upper respiratory infection and is char-
acterized by diffuse conjunctival injection, a
cal anesthetic before irrigation serous discharge, and excessive eye watering. to diminish pain.
An education program and infection control
The composition of a chemical can be policy for viral conjunctivitis would be help-
obtained from Material Safety Data Sheets, ful in the workplace. The risk of spreading the which are required at some workplaces, or disease is reduced with frequent handwashing by contacting the Agency for Toxic Sub-
and by not sharing towels. Adenovirus can
stances and Disease Registry (http://www.
remain viable for 72 hours on work surfaces
such as counters and doorknobs; therefore, a diluted sodium hypochlorite spray should
be used to disinfect work surfaces. Workers
Work-related allergic conjunctivitis increas-
who present with viral conjunctivitis symp-
ingly has been reported among food handlers toms should not go to work for seven to 10 and agriculture workers exposed to common days after the onset of symptoms (the most spices, fruits, and vegetables. Workers may be infectious period),23 although this may not be unaware that a work-related allergen is caus-
ing recurrent conjunctival symptoms, often including rhinitis and asthma. Improvement Prevention in symptoms when the patient is not at work Ninety percent of work-related eye inju- is suggestive of work-related allergic con-
ries are preventable with adequate eye pro-
junctivitis, and a family history of allergic tection.24 Educate your patients about the conjunctivitis often is present. Percutaneous benefits of eye protection and proper main-skin tests can reveal reactions to allergens, tenance of equipment.25 Easy access to an and cross-reactivity is common.4,17,18 Out-
door workers are at increased risk of aller-
gic reactions to grass, ragweed, and rhus.19 Administration (OSHA) mandates that Allergic conjunctivitis is characterized by red, employers provide workers with adequate itchy eyes; serous or ropy secretions; bulbar eye protection.26 Safety goggles should have conjunctiva swelling; and red, hypertrophic proper vents (indirect), and side shields are papillae under the upper eyelid.20
particularly important in an industrial set-
Treatment of allergic conjunctivitis ting where flying dust and other particles
includes avoidance of the allergen and the are often present. However, goggles with use of topical mast cell stabilizers (e.g., side shields do not offer sufficient protec-lodoxamide [Alomide], cromolyn [Cro-
tion against dust, fumes, and vapors for
lom]). Topical corticosteroids are helpful persons who wear contacts.26 Cleaning solu-but increase the risk of glaucoma and cata-
tion for contact lenses and storage for eye
racts, and long-term use is associated with protection equipment should be available in systemic adverse effects. Antihistamine eye-
drops (e.g., ketotifen fumarate [Zaditor],
Because laser use has increased in indus-
olopatadine [Patanol]) are alternatives to trial and medical settings, adequate personal topical corticosteroids.21
protection is needed to prevent cataracts.
Welding causes 1,200 eye injuries annually
ents as copious discharge and puffy eyelids. in the United States.1 Optical radiation from Most bacterial conjunctivitis cases are self-
welding can affect the eyes and skin, and
limited to five to seven days, although topi-
protective equipment, including a welder’s
cal antibiotics can reduce recovery time.22 helmet and safety goggles, are essential.27
1020 American Family Physician Volume 75, Number 7 ◆ April 1, 2007Eye injuries and illnesses
Police officers often are at risk of head
Table 2. osha safety
trauma during an altercation. Those with
recommendations for Workers
distant vision worse than 20/80 should use
Who Wear contact lenses
soft contact lenses rather than hard or con-ventional lenses because soft lenses are less
Avoid the fol owing chemicals when wearing
likely to fall out and compromise the offi-
chloropropane; ethylene oxide; methylene chloride; 4,4’ methylenedianiline
The author thanks Robin Braun for help with the prepara-
Wear wel -fitting, indirectly vented goggles or
a ful -face respirator to prevent exposure to chemical and caustic hazards (close-fitting safety goggles with side shields do not
W.F. PEATE, M.D., M.P.H., is an associate professor of fam-
Use a wetting agent or artificial tears to
ily and community medicine at the University of Arizona
Col ege of Medicine, Tucson, and is an associate professor
at the university’s Col ege of Public Health. He received his
irrigation to remove contact lenses; if the
medical degree from Dartmouth Medical School, Hanover,
lenses are not flushed out with irrigation,
N.H., and his master’s degree in public health at Harvard
University, Boston, Mass. He completed an occupational medicine residency at the University of Arizona Col ege
OSHA = Occupational Safety and Health Address correspondence to W.F. Peate, M.D., M.P.H, University of Arizona College of Public Health, 1295 N. Martin Ave., P.O. Box 245210, Tucson, AZ 85724-5210 (e-mail: [email protected]). Reprints are not available from the author.
Author disclosure: Nothing to disclose.
sure to ultraviolet rays has been associ- ated with age-related macular degeneration. These workers should receive counseling rEFErEncEs about sun protection.28 The preventive 1. Harris PM. Bureau of Labor Statistics. Nonfatal occu-
benefits of antioxidants (e.g., from dark-
pational injuries involving the eyes, 2002. Accessed
green, leafy vegetables) against age-related
November 3, 2006, at: http://www.bls.gov/opub/cwc/
2. Kuckelkorn R, Kottek A, Schrage N, Reim M. Poor prog-
nosis of severe chemical and thermal eye burns: the need for adequate emergency care and primary preven-
contact lens use
tion. Int Arch Occup Environ Health 1995;67:281-4.
Over 24 million working adults in the United 3. Anderson EL. Systemic adverse reaction to topical
fluorescein dye: a previously unreported event. Mil Med
States wear contact lenses, which offer no eye
protection.30 The OSHA guideline (Table 226) 4. Bielory L. Ocular al ergy guidelines: a practical treat-recommends that workers who wear con-
ment algorithm. Drugs 2002;62:1611-34.
5. Arbour JD, Brunette I, Boisjoly HM, Shi ZH, Dumas J,
tact lenses wear appropriate safety eyewear
Guertin MC. Should we patch corneal erosions? Arch
(i.e., impact-resistant polycarbonate safety
glasses),26 that they remove contact lenses 6. Zelnick SD, McKay RT, Lockey JE. Visual field loss while (with clean hands if possible) when eye irrita-
wearing ful -face respiratory protection. Am Ind Hyg Assoc J 1994;55:315-21.
tion occurs, and that they avoid wearing lenses 7. Kaiser PK, Pineda R II, for the Corneal Abrasion Patch-when working with certain chemicals.26
ing Study Group. A study of topical nonsteroidal
anti-inflammatory drops and no pressure patching in the treatment of corneal abrasions. Ophthalmology
tors were advised to avoid wearing contact
lenses.31 It has been shown, however, that 8. Weaver CS, Terrell KM. Evidence-based emergency wearing glasses with a respirator decreases
medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with
the visual field, and that wearing contact
simple corneal abrasion without delaying healing? Ann
April 1, 2007 ◆ Volume 75, Number 7American Family Physician 1021 Eye injuries and illnesses
9. Carley F, Carley S. Towards evidence based emer-
A comparison of the relative efficacy and clinical perfor-
gency medicine: best BETs from the Manchester Royal
mance of olopatadine hydrochloride 0.1% ophthalmic
Infirmary. Mydriatics in corneal abrasion. Emerg Med
solution and ketotifen fumarate 0.025% ophthalmic
solution in the conjunctival antigen chal enge model.
10. Liston RL, Olson RJ, Mamalis N. A comparison of rust-
ring removal methods in a rabbit model: smal -gauge
22. Sheikh A, Hurwitz B. Antibiotics versus placebo for
hypodermic needle versus electric dril . Ann Ophthal-
acute bacterial conjunctivitis. Cochrane Database Syst
11. Khaw PT, Shah P, Elkington AR. Injury to the eye. BMJ
23. Azar MJ, Dhaliwal DK, Bower KS, Kowalski RP, Gordon
YJ. Possible consequences of shaking hands with your
12. McGwin G Jr, Xie A, Owsley C. Rate of eye injury in
patients with epidemic keratoconjunctivitis. Am J Oph-
the United States [Published correction appears in
Arch Ophthalmol 2005;123:1285]. Arch Ophthalmol
24. Bureau of Labor Statistics. Workplace injuries and il -
nesses in 2003 [Press release]. June 14, 2005. Accessed
13. Blais BR. Treating chemical eye injuries. Occup Health
November 3, 2006, at: http://stats.bls.gov/news.
14. Lusk PG. Chemical eye injuries in the workplace. Pre-
25. Yu TS, Liu H, Hui K. A case-control study of eye inju-
vention and management. AAOHN J 1999;47:80-7.
ries in the workplace in Hong Kong. Ophthalmology
15. Boyd-Monk H. Eye trauma in the workplace. AAOHN J
26. U.S. Department of Labor Occupational Safety and
16. Soderberg K, Kuusinen P, Mathieu L, Hall AH. An
Health Administration. Title 29-Labor. Part 1910-Occu-
improved method for emergent decontamination of
pational safety and health standards. Sec. 1910.132.
ocular and dermal hydrofluoric acid splashes. Vet Hum
Subpart I. Personal Protective Equipment. Revised 2004.
27. Tenkate TD. Optical radiation hazards of welding arcs.
17. Brito FF, Mur P, Barber D, Lombardero M, Galindo PA,
Gomez E, et al. Occupational rhinoconjunctivitis and
28. Tomany SC, Cruickshanks KJ, Klein R, Klein BE,
asthma in a wool worker caused by Dermestidae spp.
Knudtson MD. Sunlight and the 10-year incidence of
age-related maculopathy: the Beaver Dam Eye Study
18. Gall H, Kalveram KJ, Forck G, Sterry W. Kiwi fruit
[Published correction appears in Arch Ophthalmol
al ergy: a new birch pol en-associated food al ergy.
2005;123:362]. Arch Ophthalmol 2004;122:750-7.
J Al ergy Clin Immunol 1994;94:70-6.
29. Mozaffarieh M, Sacu S, Wedrich A. The role of carot-
19. Schwartz HJ, Jones RT, Rojas AR, Squil ace DL, Yung-
enoids, lutein and zeaxanthin, in protecting against
inger JW. Occupational al ergic rhinoconjunctivitis and
age-related macular degeneration: a review based on
asthma due to fennel seed. Ann Al ergy Asthma Immu-
controversial evidence. Nutr J 2003;2:20.
30. Blais BR. Discrimination against contact lens wearers.
20. Ono SJ, Abelson MB. Al ergic conjunctivitis: update on
pathophysiology and prospects for future treatment.
31. Blais BR. Does wearing of contact lenses in the work-
J Al ergy Clin Immunol 2005;115:118-22.
place pose a direct threat? Occup Environ Med Rep
21. Berdy GJ, Spangler DL, Bensch G, Berdy SS, Brusatti RC.
1022 American Family Physician Volume 75, Number 7 ◆ April 1, 2007
Warning Letters > Novartis International AG 11/18/11http://www.fda.gov/ICECI/EnforcementActions/Warn. Inspections, Compliance, Enforcement, and Criminal Investigations Home Inspections, Compliance, Enforcement, and Criminal Investigations Enforcement Actions Warning Letters Novartis International AG 11/18/11 Department of Health and Human Services WARNING LETTER Novembe
Rechargeable lithium-ion (Li-Ion) and lithium polymer (Li-Poly) batteries deliver high energy density at low weight and volume, making them the ideal choice for portable handheld applications. Battery management devices ensure optimal energy utilization while protecting lithium batteries against potentially hazardous conditions related to current, voltage and temperature. Atmel® addresses the