Purpose
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.
Design
Retrospective chart review of 812 consecutive 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 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.
Occupational 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 prevented 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 equipment.
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 Massachusetts 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 connection between the intraocular contents and the external environment. The Massachusetts Eye and Ear Infirmary is a specialty eye hospital; the patients in this cohort represent 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. Demographic 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 procedures; 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 injuries at the Massachusetts Eye and Ear Infirmary according to a previously published standardized protocol. 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 population 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 identified 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).
| 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%) |
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 patients (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 intraocular 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%) presented 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 occupational 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 addition to the repair of the ruptured globe, the patients needed many additional surgeries during their ocular rehabilitation ( Table 2 ). Nine patients (6.2%) underwent penetrating keratoplasty, 1 patient (0.7%) underwent glaucoma surgery, 48 patients (32.9%) underwent a vitrectomy, 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 between 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 enucleation, 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 significantly lower than the number of retinal detachments in the control group (8.9% vs 16.4%, P = .02).
