More than 65,000 work-related eye injuries and illnesses cause job absenteeism in the United States every year.¹ Workers who have the highest risk of eye injuries include fabricators, laborers, equipment operators, repair workers, and production and precision workers. More than one half of work-related eye injuries occur in the manufacturing, service, and construction industries. Most chemical and thermal eye injuries occur when persons are at work.² Eighty-one percent of work-related eye injuries occur in men, and most occur in workers 25 to 44 years of age.¹

Eye Examination

The visual acuity of a patient with an eye injury should always be tested because vision changes provide objective tools to monitor clinical improvement or deterioration. Prepare an eye tray (Table 1) in advance, and perform irrigation in the event of a chemical burn. Use fluorescein dye and a cobalt-blue filtered light to detect corneal abrasions. After the assessment, gently irrigate the eye to diminish the risk of an adverse reaction to the dye, such as burning.³

Only a short-acting mydriatic agent (e.g., tropicamide [Mydriacyl]) should be used to dilate the pupil. The effects of longer-duration agents (e.g., atropine, homatropine hydrobromide [Isopto Homatropine]) may last for days, impairing vision and preventing patients from driving. To reduce injury and discomfort, instill a topical anesthetic (e.g., tetracaine [Pontocaine], proparacaine [Ophthetic]) before using fluorescein or removing a foreign body. Only use anesthetics in the office; if a patient uses the medication at home, it can delay healing and mask complications.

Check the expiration dates of all medications and the batteries of handheld ophthalmoscopes. A slit lamp is useful, but a thorough examination with a handheld ophthalmoscope is adequate for most patients. Evert the eyelids by placing a cotton-tipped swab on top of the upper eyelid and rolling the lid over the swab; carefully inspect the eye for foreign bodies.

Diagnosis and Management

CORNEAL ABRASIONS

Eye pain after a trauma caused by a foreign body, rubbing, or a scratch suggests a corneal abrasion. Associated symptoms may include blinking, tearing, pain with eye movement, headache, blurry vision, and foreign body sensation. Some physicians treat noninfected corneal abrasions prophylactically with topical antibiotics, although the evidence supporting this practice is limited. Ointments are more soothing and persist on the cornea longer than eyedrops. Erythromycin and bacitracin (AK-tracin) are preferred over gentamicin (which may be toxic to corneal epithelium) and Neosporin (which has a relatively high allergic reaction rate).⁴

Studies have shown that eye patching does not improve corneal reepithelialization or discomfort and increases pain in one half of patients.^5–7 The addition of a topical nonsteroidal anti-inflammatory drug (NSAID; e.g., ketorolac [Acular], diclofenac [Voltaren]) has been shown to be somewhat beneficial for symptom relief⁷ and for decreasing narcotic use and time off work; however, NSAIDs may delay healing.⁸ Mydriatic agents are no longer recommended to treat corneal abrasions because they offer no additional benefit.⁹ Regardless of the ocular agents used, always offer oral analgesics because pain may be severe. Advise the patient to avoid wearing contact lenses until the abrasion is healed and symptoms are resolved.

If symptoms and the abrasion improve after one day, reevaluate in two or three days. Refer the patient to an ophthalmologist for any of the following scenarios: a small- to moderate-sized abrasion has not resolved by the third day; the cornea has not improved at any of the follow-up examinations; symptoms do not decrease each day; or the edge of the abrasion is white or gray, which may indicate infection.⁷

Progression to recurrent corneal erosion (i.e., breakdown of the corneal epithelium) may occur years after a corneal abrasion. Symptoms of corneal erosion mimic the initial corneal abrasion, and tearing on awakening is common. Refer patients with recurrent corneal erosion to an ophthalmologist.

FOREIGN BODIES

Foreign bodies are common with corneal abrasions. After instilling topical anesthesia, remove superficial foreign bodies using a cotton-tipped swab soaked in saline. Remove minor irritants by irrigating the eye with eyewash solution. Soot from fires can contain toxic and allergenic particles that can further irritate the eye. For example, a firefighter can be exposed to rhus (e.g., poison ivy, sumac, and oak) from a brush fire. Foreign bodies embedded deeper into the cornea require removal with a hypodermic needle and using a slit lamp. If a foreign body is not easily removed, refer the patient to an ophthalmologist.

Oxidation of a ferrous foreign body in the eye can leave rust residue (“rust rings”). Remove rust rings to decrease inflammation and scarring.¹⁰ Before removal, instill a topical anesthetic. Place an 18-gauge needle on the end of a cotton-tipped swab or rotary drill. Hold the needle at 90 degrees to the affected surface of the eye, and gently scrape the ring until it is removed. Refer the patient to an ophthalmologist if you are uncomfortable performing the procedure, if the ring cannot be removed completely, if the ring has been present for one week or more, or if you suspect recurrent corneal erosion. Offer the patient an oral analgesic for pain relief.

BLUNT TRAUMA

Bleeding into the anterior chamber of the eye (hyphema), retina, or vitreous may suggest blunt trauma. Retinal detachment may present as a dark curtain covering part of the visual field. Advise the patient to remove contact lenses because swelling may prevent removal later, and refer him or her to an ophthalmologist.

Eyelid lacerations should be treated by a specialist, unless it is a small or partial-thickness laceration. Larger and deeper lacerations and those involving the lateral and medial edges of the eyelid or the eyelid margin can cause scarring, retraction, and the inability to close the eyelid if they are not repaired properly. Lacerations involving the nasal portion of the upper or lower eyelids may damage the lacrimal drainage apparatus.

Penetrating injuries are caused by high-velocity impacts and should be suspected if sudden eye pain presents in patients who have used a chisel, hammer, grinding wheel, or saw. Pupil or lens changes (e.g., cataract, dark surface uveal tissue, vitreous hemorrhage) also are suggestive of a penetrating injury. Head injuries can dislocate the lens. A dilated pupil indicates a possible cerebral injury.¹¹

To evaluate the orbit for an intraocular fragment, dilate the pupil (unless intracerebral bleeding or swelling is suspected) and obtain an orbital computed tomography (CT) scan (axial and coronal views; thin cuts of 1 to 1.5 mm). If CT is not available, radiographs (up and down gaze views) are useful.¹¹ Use an ocular shield (a hard, protective cover) to avoid pressure on the orbit, and refer the patient to an ophthalmologist immediately if a fragment is detected.

CHEMICAL BURN

Ocular chemical burns make up a significant percentage of work-related eye injuries¹² and require rapid treatment. Alkalis (pH greater than 10) are more dangerous than acids (pH less than 4), with the exception of hydrofluoric acid,¹³ because they may penetrate the cornea for an extended period. Litmus or pH paper can assist in determining alkalinity or acidity. Although most chemical burns are mild and without residual effects, patients with severe burns have a poor prognosis.²

For a chemical eye burn, immediately begin copious irrigation with one liter of physiologic saline over one to two hours using intravenous drip tubing.^2,13,14 Promptly refer the patient to an ophthalmologist¹⁴; irrigation can be continued during transportation for definitive treatment.¹⁵ Use litmus or pH paper to judge the response to irrigation. When the pH level is near neutral (6 to 8 pH), discontinue irrigation. Hydrofluoric acid burns are common in the semiconductor industry, and treatment is similar to other chemical burns using isotonic saline, isotonic magnesium chloride solution, or Hexaf luorine (a hypertonic, amphoteric, chelating solution).¹⁶ Instill a topical anesthetic before irrigation to diminish pain.

The composition of a chemical can be obtained from Material Safety Data Sheets, which are required at some workplaces, or by contacting the Agency for Toxic Substances and Disease Registry (http://www.atsdr.cdc.gov).

CONJUNCTIVITIS

Work-related allergic conjunctivitis increasingly has been reported among food handlers and agriculture workers exposed to common spices, fruits, and vegetables. Workers may be unaware that a work-related allergen is causing recurrent conjunctival symptoms, often including rhinitis and asthma. Improvement in symptoms when the patient is not at work is suggestive of work-related allergic conjunctivitis, and a family history of allergic conjunctivitis often is present. Percutaneous skin tests can reveal reactions to allergens, and cross-reactivity is common.^4,17,18 Outdoor workers are at increased risk of allergic reactions to grass, ragweed, and rhus.¹⁹ Allergic conjunctivitis is characterized by red, itchy eyes; serous or ropy secretions; bulbar conjunctiva swelling; and red, hypertrophic papillae under the upper eyelid.²⁰

Treatment of allergic conjunctivitis includes avoidance of the allergen and the use of topical mast cell stabilizers (e.g., lodoxamide [Alomide], cromolyn [Crolom]). Topical corticosteroids are helpful but increase the risk of glaucoma and cataracts, and long-term use is associated with systemic adverse effects. Antihistamine eye-drops (e.g., ketotifen fumarate [Zaditor], olopatadine [Patanol]) are alternatives to topical corticosteroids.²¹

Bacterial conjunctivitis generally presents as copious discharge and puffy eyelids. Most bacterial conjunctivitis cases are self-limited to five to seven days, although topical antibiotics can reduce recovery time.²² Patients with acute bacterial conjunctivitis should not return to work until the discharge clears.

Viral conjunctivitis often is associated with an upper respiratory infection and is characterized by diffuse conjunctival injection, a serous discharge, and excessive eye watering. An education program and infection control policy for viral conjunctivitis would be helpful in the workplace. The risk of spreading the disease is reduced with frequent handwashing and by not sharing towels. Adenovirus can 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 who present with viral conjunctivitis symptoms should not go to work for seven to 10 days after the onset of symptoms (the most infectious period),²³ although this may not be practical for many patients.

Prevention

Ninety percent of work-related eye injuries are preventable with adequate eye protection.²⁴ Educate your patients about the benefits of eye protection and proper maintenance of equipment.²⁵ Easy access to an eyewash method also is important.

The Occupational Safety and Health Administration (OSHA) mandates that employers provide workers with adequate eye protection.²⁶ Safety goggles should have proper vents (indirect), and side shields are particularly important in an industrial setting where f lying dust and other particles are often present. However, goggles with side shields do not offer sufficient protection against dust, fumes, and vapors for persons who wear contacts.²⁶ Cleaning solution for contact lenses and storage for eye protection equipment should be available in the workplace.²⁶

Because laser use has increased in industrial and medical settings, adequate personal protection is needed to prevent cataracts. Welding causes 1,200 eye injuries annually in the United States.¹ Optical radiation from welding can affect the eyes and skin, and protective equipment, including a welder's helmet and safety goggles, are essential.²⁷

For outdoor workers, significant exposure to ultraviolet rays has been associated with age-related macular degeneration. These workers should receive counseling about sun protection.²⁸ The preventive benefits of antioxidants (e.g., from dark-green, leafy vegetables) against age-related macular degeneration require further investigation.²⁹

Contact Lens Use

Over 24 million working adults in the United States wear contact lenses, which offer no eye protection.³⁰ The OSHA guideline (Table 2²⁶ ) recommends that workers who wear contact lenses wear appropriate safety eyewear (i.e., impact-resistant polycarbonate safety glasses),²⁶ that they remove contact lenses (with clean hands if possible) when eye irritation occurs, and that they avoid wearing lenses when working with certain chemicals.²⁶

Previously, workers who used respirators were advised to avoid wearing contact lenses.³¹ It has been shown, however, that wearing glasses with a respirator decreases the visual field, and that wearing contact lenses is safer than glasses.⁶

Police officers often are at risk of head trauma during an altercation. Those with distant vision worse than 20/80 should use soft contact lenses rather than hard or conventional lenses because soft lenses are less likely to fall out and compromise the officer's ability to act in self-defense.