Characteristics and Outcomes of Work-Related Open Globe Injuries
To evaluate the characteristics and outcomes of patients treated for open globe injuries sustained at work and to compare these results to patients injured outside of work. Retrospective chart review of 812 consecutive patients with open globe injuries treated at the Massachusetts Eye and Ear Infirmary between 1999 and 2008. A total of 146 patients with open globe injuries sustained at work were identified and their characteristics and outcomes were compared with the rest of the patients in the database. Of the patients injured at work, 98% were men, and the average age of the patients was 35.8 years (17-72 years). The most common mechanism of injury was penetrating trauma (56%); 38 patients examined had intraocular foreign bodies (IOFB). Nine work-related open globe injuries resulted in enucleation. There was a higher incidence of IOFBs (P = .0001) and penetrating injuries (P = .0005) in patients injured at work. Both the preoperative (P = .0001) and final best-corrected visual acuity (P = .0001) was better in the work-related group. The final visual acuity was better than 20/200 in 74.1% of cases of work-related open globe injuries. However, there was no difference observed in the rate of enucleations (P = .4). Work-related injuries can cause significant morbidity in a young population of patients. Based on average patient follow-up and final visual acuity, those injured at work do at least as well as, if not potentially better than, those with open globe injuries sustained outside of work. While the statistically higher rate of IOFB in the work population is not surprising, it does emphasize the importance of strict adherence to the use of eye protection in the workplace.
Characteristics and Outcomes of Work-Related Open
JUSTIN M. KANOFF, ANGELA V. TURALBA, MICHAEL T. ANDREOLI, AND CHRISTOPHER M. ANDREOLI
PURPOSE: To evaluate the characteristics and out-
comes of patients treated for open globe injuries sus-
tained at work and to compare these results to patients
injured outside of work.
DESIGN: Retrospective chart review of 812 consecu-
tive patients with open globe injuries treated at the
Massachusetts Eye and Ear Inﬁrmary between 1999 and
METHODS: A total of 146 patients with open globe
injuries sustained at work were identiﬁed and their
characteristics and outcomes were compared with the
rest of the patients in the database.
RESULTS: Of the patients injured at work, 98% were
men, and the average age of the patients was 35.8 years
(17–72 years). The most common mechanism of injury
was penetrating trauma (56%); 38 patients examined had
intraocular foreign bodies (IOFB). Nine work-related
open globe injuries resulted in enucleation. There was a
higher incidence of IOFBs (P ⴝ .0001) and penetrating
injuries (P ⴝ .0005) in patients injured at work. Both
the preoperative (P ⴝ .0001) and ﬁnal best-corrected
visual acuity (P ⴝ .0001) was better in the work-related
group. The ﬁnal visual acuity was better than 20/200 in
74.1% of cases of work-related open globe injuries.
However, there was no difference observed in the rate of
enucleations (P ⴝ .4).
CONCLUSIONS: Work-related injuries can cause signif-
icant morbidity in a young population of patients. Based
on average patient follow-up and ﬁnal visual acuity, those
injured at work do at least as well as, if not potentially
better than, those with open globe injuries sustained
outside of work. While the statistically higher rate of
IOFB in the work population is not surprising, it does
emphasize the importance of strict adherence to the use
of eye protection in the workplace. (Am J Ophthalmol
2010;150:265–269. © 2010 by Elsevier Inc. All rights
CCUPATIONAL INJURIES ARE COMMON IN THE
United States. In 2004 there were 1.3 million
injuries that resulted in at least 1 day of missed
work. Of these work-related injuries, 36 680 involved the
eye, with one quarter of the accidents occurring in the
manufacturing sector. Over 24% of the ocular injuries in
the workplace involved either a projectile or other object
contacting the eye, which can lead to a ruptured globe.
The lifetime prevalence of work-related eye injuries among
US workers is 4.4%. Accidents are signiﬁcantly more
common among men, self-employed individuals, and workers
with no college education.
Through lost productivity,
medical expenses, and workers’ compensation, eye injuries
cost over $300 million per year in the United States. The
Department of Labor’s Bureau of Labor and Statistics
estimates that over 90% of these injuries could be pre-
vented by the proper use of eye safety glasses.
Ruptured globe injuries can have severe morbidity
associated with loss of vision, infections, and multiple
surgical procedures. Of 2939 cases of open globe trauma
reported to the National Eye Trauma System Registry,
22% occurred in an occupational setting.
In India, a
developing nation, 33% of open globe injuries presenting
to a major medical center were occupational-related trauma.
All too commonly in these injuries the patients were not
using proper eye protection; in one series only 5.5% of
patients reported the use of safety glasses
and in another
only 25% of workers were using proper protective equip-
It is important to clearly delineate the characteristics of
patients who sustain open globe injuries at work in an
effort to better understand the associated risk factors and to
ensure that proper care is rendered. This study aims to
compare open globe injures that occur in the workplace
with those that occur in the greater community.
A RETROSPECTIVE CHART REVIEW WAS CONDUCTED ON 812
patients treated for open globe injuries at the Massachu-
setts Eye and Ear Inﬁrmary between 1999 and 2008. An
open globe injury was deﬁned as a break in the structural
integrity of either the cornea or sclera creating a connec-
tion between the intraocular contents and the external
environment. The Massachusetts Eye and Ear Inﬁrmary is
a specialty eye hospital; the patients in this cohort repre-
Accepted for publication Feb 19, 2010.
From Harvard Medical School (J.M.K., A.V.T., C.M.A.), Massachu-
setts Eye and Ear Inﬁrmary (J.M.K., A.V.T.), Boston University School of
Medicine (M.T.A.), and Harvard Vanguard Medical Associates (C.M.A.),
Inquiries to Justin M. Kanoff, Department of Ophthalmology, 243
Charles St, Boston, MA 02114; e-mail: Justin_Kanoff@meei.harvard.edu
© 2010 BY ELSEVIER INC.ALL RIGHTS RESERVED.0002-9394/$36.00 265
sent consecutive patients treated by the ocular trauma
service either with isolated open globe injuries or with an
open globe injury as part of a multisystem trauma. Demo-
graphic and clinical data from all patients were entered
into a computerized database and made available for later
review. The data included age; sex; information about the
time and place of injury, mechanism of injury, initial
examination, and follow-up examinations; surgical proce-
dures; and outcomes. If a speciﬁc data ﬁeld was not
available for a patient then the patient was excluded from
that particular analysis.
Patients are evaluated and treated for open globe inju-
ries at the Massachusetts Eye and Ear Inﬁrmary according
to a previously published standardized protocol.
arrival to the emergency room a standard history and
ocular physical examination is completed. A noncontrast
computed tomography scan of the orbits with thin cuts is
obtained, the patient’s tetanus is updated, and intravenous
antibiotics (IV) are started. Repair of the open globe is
completed within 24 hours when not prohibited by a late
presentation or other active medical issues. After surgery,
the patients are observed on an inpatient basis and
continued on IV antibiotics for 48 hours.
The demographic and clinical information of the pop-
ulation identiﬁed as having an occupational open globe
injury was analyzed and compared to a control group
(patients with non-occupational open globe injuries in the
database). Occupational open globe injuries were identi-
ﬁed based on patients’ self-reported history at the time of
initial presentation. Statistical analysis was performed
using either a 2-tailed t test to compare means or a 2-tailed
Fisher exact test to compare categorical data.
AMONG THE 812 PATIENTS WITH OPEN GLOBE INJURIES
seen at the Massachusetts Eye and Ear Inﬁrmary between
1999 and 2008 there were 146 (18.0%) with occupational-
related eye trauma (Table 1). One hundred forty-three
(98.0%) of the patients injured at work were men and their
mean age was 35.8 years (range 17-72 years). Compared
with the control population, the patients injured at work
were signiﬁcantly more likely to be male (98.0% vs 94.0%,
P ⫽ .0001) and represented a younger group (mean age
35.8 vs 42.4, P ⫽ .0016).
There were a wide variety of mechanisms of injury in the
occupational group (Table 1). They included nails in 36
patients (24.8%), projectiles other than nails in 41 pa-
tients (28.3%), dull objects in 18 patients (12.4%), wood
in 13 patients (9.0%), wire in 9 patients (6.2%), knives in
6 patients (4.1%), and glass in 5 patients (3.4%). The open
globes were also classiﬁed according to the BETT system
(Birmingham Eye Trauma Terminology system) as blunt
ruptures (14.4%), penetrating injuries (56.8%), perforating
injuries (1.4%), and eyes with intraocular foreign bodies
(27.3%). When compared to the control population those
patients with occupational injuries were more likely to
have penetrating injuries (57% vs 41%, P ⫽ .0005) and
less likely to have blunt ocular trauma (14% vs 47%, P ⫽
.0001). Thirty-eight patients injured at work had intraoc-
ular foreign bodies, which was signiﬁcantly greater (P ⫽
.0001) than the proportion of patients in the control
There was variability in the time it took patients to
present to the emergency room after an ocular trauma had
occurred at work. Seventy-eight patients (60.0%) pre-
sented to the emergency room less than 6 hours after the
injury occurred, 30 (23.1%) presented 6 to 12 hours after
the injury, 9 (6.9%) presented 12 to 24 hours after the
injury, and 13 (10.0%) presented more than 1 day after the
injury. Stated another way, 16.9% of patients took greater
than 12 hours to seek medical care after an injury at work.
There was no signiﬁcant difference between the occupa-
tional group and the control group in the proportion of
patients seeking medical attention less than 6 hours after
injury (60.0% vs 54.3%, P ⫽ .24) or greater than 12 hours
after the injury (16.9% vs 22.0%, P ⫽ .23). The time of
injury occurrence was spread throughout the day and night
with peaks occurring at 10:00 to 11:00 and 15:00 to 16:00
(Figure). After the initial evaluation and surgical repair,
the average follow-up of the occupational injuries was 281
days (range 1–2681 days), which did not differ from the
control group (281 vs 247, P ⫽ .35).
All of the patients underwent primary repair of the
ruptured globe except 1 who had a primary enucleation. In
TABLE 1. Occupational Open Globe Injury Baseline Data
Total Occupational Injuries (N ⫽ 146)
Male, n (%) 143 (98.0%)
Average age, years (range) 35.8 (17 to 72)
Initial vision, n (%)
20/40 or better 38 (26.8%)
20/50 to 20/200 34 (23.9%)
20/200 or worse 70 (49.3%)
No light perception 6 (4.2%)
BETT system classiﬁcation, n (%)
Penetrating injuries 79 (56.8%)
Intraocular foreign bodies 38 (27.3%)
Blunt injuries 20 (14.4%)
Perforating injuries 2 (1.4%)
Mechanism of injury, n (%)
Nails 36 (28.1%)
Other projectiles 41 (32.0%)
Dull objects 18 (14.1%)
Wood 13 (10.2%)
Wire 9 (7.0%)
Knives 6 (4.7%)
Glass 5 (3.9%)
BETT ⫽ Birmingham Eye Trauma Terminology.
AMERICAN JOURNAL OF OPHTHALMOLOGY266 AUGUST 2010
addition to the repair of the ruptured globe, the patients
needed many additional surgeries during their ocular reha-
bilitation (Table 2). Nine patients (6.2%) underwent
penetrating keratoplasty, 1 patient (0.7%) underwent glau-
coma surgery, 48 patients (32.9%) underwent a vitrec-
tomy, 11 patients (7.5%) had a scleral buckle placed, 57
patients (39.0%) underwent a lensectomy, 9 patients
(6.2%) had an anterior chamber washout, and 9 patients
(6.2%) needed enucleation. There was no difference be-
tween the work group and the control group in the
proportion of patients needing enucleation (6.2% vs 8.6%,
P ⫽ .4). At the time of initial presentation the visual
acuity was 20/40 or better in 38 patients (26.8%), between
20/50 and 20/200 in 34 patients (23.9%), and 20/200 or
worse in 70 patients (49.3%). Six patients (4.2%) were no
light perception on initial presentation. At the time of the
last recorded follow-up (Table 2), the visual acuity was
20/40 or better in 69 patients (63.9%), 20/50 to 20/200 in
11 patients (10.2%), and 20/200 or worse in 28 patients
(25.9%). Besides the 9 patients who underwent enucle-
ation, 3 additional patients had a ﬁnal visual acuity of no
light perception. The occupational open globe injuries had
better visual acuities both at initial presentation (50.7% vs
22.8% with better than 20/200, P ⫽ .0001) and at the last
recorded follow-up (74.1% vs 43.6%, P ⫽ .0001) compared
to the control group. Three patients (2.1%) developed
endophthalmitis, which was not statistically different from
the non-work-related injury group (2.1% vs 0.45%, P ⫽
.75). Thirteen patients (8.9%) had a retinal detachment
during the course of their treatment, which was signiﬁ-
cantly lower than the number of retinal detachments in
the control group (8.9% vs 16.4%, P ⫽ .02).
WORK-RELATED OPEN GLOBE INJURIES ARE A SIGNIFICANT
cause of morbidity among young, otherwise healthy indi-
viduals. This study demonstrates that occupational injuries
occur in a younger, male-dominated population. This age
cohort represents workers’ prime productive years, a time
when injury can cause signiﬁcant loss of wages and earning
FIGURE. Incidence of occupational open globe injuries plotted as a function of hour of the day.
TABLE 2. Outcomes for Work-Related Open Globe
Injuries (N ⫽ 146)
Final vision, n (%)
20/40 or better 69 (63.9%)
20/50–20/200 11 (10.2%)
20/200 or worse 28 (25.9%)
No light perception 7 (6.5%)
Average follow-up, days (range) 281 (1–2681)
Additional surgeries needed, n
Scleral buckle 11
Penetrating keratoplasty 9
Anterior chamber washout 9
Glaucoma surgery 1
WORK-RELATED OPEN GLOBE INJURIESVOL. 150,NO. 2 267
potential. These injuries also cause a signiﬁcant ﬁnancial
toll on society as a whole. Many of the injuries that occur
at work are preventable; prevention rather than treatment
would save lost productivity and health care dollars.
Lowering health care costs is an especially important goal
for the country at this point in time.
This study demonstrates that occupational open globe
injuries have a better prognosis than other ruptured globes;
workers are signiﬁcantly more likely to have “useful vision”
(20/200 or better) after surgical repair and postoperative
medical management. The mechanism of injury is likely a
factor in this better overall prognosis. Occupational inju-
ries were signiﬁcantly more likely to be of a sharp, or
penetrating, mechanism versus the more common blunt
rupture in non-work-related open globes. Blunt rupture has
been previously demonstrated to be a poor prognostic
factor in open globe injuries.
The occupational injuries
were also less likely to be associated with a retinal
detachment. This statistical information can be helpful
when counseling patients during their initial presentation
and providing accurate prognostic data.
An important part of this study was evaluating injured
workers’ access to initial medical and follow-up care. This
study uses initial time to presentation and length of
follow-up as a proxy for these indicators. There was no
signiﬁcant difference in the initial time to presentation
between the occupational injuries and the control group.
However, it is important to note that 17% of workers took
greater than 12 hours to present for medical evaluation and
10% presented more than 24 hours after injury, placing
them outside the ideal window of time for primary repair of
In addition, a number of patients
injured at work had endophthalmitis, which can be asso-
ciated with delays in surgical repair. There is a clear set of
policy guidelines governing reporting and evaluation of
however, this study indicates that
there is clear room for improvement in compliance to
these guidelines. One would expect that if these policies
were working properly, work-related injuries should present
for medical evaluation rapidly and sooner than other types
of ocular injuries.
With respect to occupational open globe injuries, the
best treatment is prevention. Many of these injuries could
be prevented with the proper use of safety glasses or other
protective equipment. Numerous studies have clearly dem-
onstrated that the use of safety glasses prevents eye injuries
in the workplace.
In addition, simply having a clear
requirement for employees to use eye protection decreases
the risk of eye injury.
Another factor previously impli-
cated in occupational eye injuries is worker fatigue. A
previous study has shown a double peak in the time of
injury during the work day, with most injuries occurring
either before lunch or near the end of the day.
found the same double peak in the time of occupational
open globe injury. Workers could beneﬁt from better
training on recognizing fatigue and strategies to prevent it
from impacting their work, especially while completing
hazardous tasks. Another explanation for this double peak
could be the workﬂow at job sites; more hazardous work
may be undertaken at these times. More research is needed
to better understand the signiﬁcance of these time-related
peaks in injuries. Industry-wide or regionally based eye
safety campaigns are another method of encouraging the
use of protective equipment and preventing occupational
Occupational open globe injuries are a type of on-the-
job injury that can be largely prevented with proper
education and use of safety equipment. This study provides
important epidemiologic and outcome data about these
vision-threatening injuries. Employers should use this in-
formation to strengthen and reﬁne their policies on the use
of eye protection in the workplace. Opportunities for
further research include better understanding the difﬁcul-
ties with compliance with protective eyewear regulations
and barriers to obtaining timely medical attention for
THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. INVOLVED IN DESIGN AND
conduct of study (J.M.K., C.M.A., M.T.A., A.V.T.); collection (C.M.A., M.T.A.); management (C.M.A., M.T.A.); analysis (J.M.K., C.M.A., M.T.A.,
A.V.T.); interpretation of data (J.M.K., C.M.A., M.T.A., A.V.T.); and preparation, review, or approval of manuscript (J.M.K., C.M.A., M.T.A.,
A.V.T.). The Massachusetts Eye and Ear Inﬁrmary institutional review board approved this study (IRB approval #05-06-037X).
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WORK-RELATED OPEN GLOBE INJURIESVOL. 150,NO. 2 269
Christopher M. Andreoli, MD, is a vitreo-retinal surgeon in practice at Harvard Vanguard Medical Associates in Boston,
Massachusetts. He is a Clinical Instructor of Ophthalmology at Harvard Medical School and an Assistant in
Ophthalmology, active staff at the Massachusetts Eye and Ear Inﬁrmary, Boston, Massachusetts. Dr Andreoli received his
medical degree from Boston University School of Medicine and completed his residency, chief residency, and
vitreo-retinal fellowship at the Massachusetts Eye and Ear Inﬁrmary. His clinical interests include diseases of the retina
and vitreous and ocular trauma.
MERICAN JOURNAL OF OPHTHALMOLOGY269.e1 AUGUST 2010
Justin M. Kanoff, MD, is a second-year resident in the Department of Ophthalmology at Harvard Medical School in
Boston, Massachusetts. Dr. Kanoff received his Bachelor of Arts degree from the University of Pennsylvania summa cum
laude and his Doctorate of Medicine from the University of Texas Southwestern Medical School where he was elected
to the Alpha Omega Alpha medical honor society.
ORK-RELATED OPEN GLOBE INJURIESVOL. 150,NO. 2 269.e2