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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. Eye Examination
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- Medications
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) Materials
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, 2007 Eye 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 blunT TrauMa
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 7 American Family Physician  1019
Eye injuries and illnesses
is similar to other chemical Patients with acute bacterial conjunctivitis Work-related allergic 
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- agricultural workers.
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 conjuncTiviTis
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, 2007 Eye 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 The author
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 7 American 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

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