Characteristics and Outcomes of Work-Related Open Globe Injuries

Article (PDF Available)inAmerican Journal of Ophthalmology 150(2):265-269.e2 · August 2010with67 Reads
DOI: 10.1016/j.ajo.2010.02.015 · Source: PubMed
Abstract
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.

Figures

Characteristics and Outcomes of Work-Related Open
Globe Injuries
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
2008.
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 .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).
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
reserved.)
O
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.
1
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.
2
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.
3
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.
4
In India, a
developing nation, 33% of open globe injuries presenting
to a major medical center were occupational-related trauma.
5
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
4
and in another
only 25% of workers were using proper protective equip-
ment.
6
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.
METHODS
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.),
Boston, Massachusetts.
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
doi:10.1016/j.ajo.2010.02.015
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.
7
Upon
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.
RESULTS
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
8
(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
group.
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)
Demographics
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).
DISCUSSION
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
Lensectomy 57
Vitrectomy 48
Scleral buckle 11
Penetrating keratoplasty 9
Anterior chamber washout 9
Enucleation 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.
9
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
ruptured globes.
10–12
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
workplace injuries;
13
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.
14,15
In addition, simply having a clear
requirement for employees to use eye protection decreases
the risk of eye injury.
14
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.
15
Our study
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
eye injuries.
16
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
injuries.
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
Biosketch
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.
A
MERICAN JOURNAL OF OPHTHALMOLOGY269.e1 AUGUST 2010
Biosketch
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.
W
ORK-RELATED OPEN GLOBE INJURIESVOL. 150,NO. 2 269.e2
    • "To predict the vision outcome in ocular trauma patients, there has been numerous literatures till date. 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18 Several studies have suggested that the factors that significantly predict visual outcome after open globe injuries are initial visual acuity 5,6, presence of RAPD, 7,8 mechanism of injury, 7,9,10 wound location, 7,11,12 lens damage, 7,12 hyphaema, 14 vitreous haemorrhage, 11,15 and retinal detachment. 11,16 time lag between injury and surgery. "
    [Show abstract] [Hide abstract] ABSTRACT: AIM : To evaluate the prognostic value of OTS in open globe injuries. MATERIAL METHOD : Retrospective analysis of 77 eyes with open globe injuries was done from 01/07/2013 to 31/12/2014. Patients were assigned raw score sum based on initial V/A, and ocular findings then classified into 5 categories for predicting final visual outcome based on ocular Trauma score (OTS). RESULT : We estimated final V/A in 77 cases of open globe injuries (64.93%) had raw sc ore between 65.91 (category 3, 4) Six months after the injury, 42.85% patients of categories 1 (raw score 0 - 44) achieved V/A of PL/HM as compared to 17% in OTS study. 16 patients with raw compared to OTS study. We reported comparable visual outcome with OT S study except in category 1 & 2. CONCLUSION: OTS score is valuable in triage, patient counseling and decision making for the management of ocular trauma. We recommend that OTS should be used routinely for open globe injuries as it is a simple guide
    Article · Oct 2015
    • "The experience of elder workers did not help reduce their exposure to accidents. Consistent with previous clinical studies [18][19][20], our data revealed that eye injuries were far more common in males (occupational 92.1% and non-occupational 71.6%). Unlike other regions such as Hong Kong [5], our study showed that most injured workers were in manufacturing (60.7%), followed by construction (19.6%), agriculture (8.2%), and services (4.0%). "
    [Show abstract] [Hide abstract] ABSTRACT: Purpose: To determine the epidemiological characteristics of work-related eye injury in representative southwest region of China. Methods: Patients with eye injuries treated at the Ninth People's Hospital of Chongqing from 1 January 2014 to 31 December 2014 were included in the current study. All patients completed a comprehensive examination and interview. Demographic characteristics and injury details were recorded. The International Classification of Diseases (ICD-10) and Birmingham Eye Trauma Terminology (BETT) were used. Results: The average age of eye injury patients was 37.52 years and the majority were male. Among the 1055 total patients, approximately 42.9% of the injuries were work-related. The highest proportion of occupational eye trauma was observed in the group between 36 and 45 years of age. Occupational ocular trauma occurred more frequently in summer, with most from 16:00 to 18:00. Metal was the most common injury cause. Foreign body on external eye was the most common diagnosis. Workers in the manufacturing industry without pre-work safety training or eye protection were far more likely to suffer from occupational ocular trauma than those with training and protection. Conclusions: This study provides insight into the epidemiological characteristics of occupational ocular trauma in southwest region of China. The current findings might be considered as a baseline for future research on regional work-related eye injuries. Our findings will provide valuable information for further development of preventive strategies.
    Full-text · Article · Aug 2015
    • "Most studies have shown no significant difference in final visual outcome for repairing emergently versus postponing for a reasonable amount of time so that appropriate operating room personel or medical clearence can be obtained. Barr showed that a delay in repair of up to 36 hours does not impact postoperative visual acuity [6] contrary to Cruvinal-Isaac et al. who proposed that a delay in surgical repair may be associated with the reduced vision [5]. It is important to discuss the relative risks so that informed decisions can be made regarding the best timing for surgery. "
    Article · Jan 2014
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