Eye injuries are prevalent in environments with high-velocity particle motion and/or high temperatures, and injuries range from periocular contusions and burns to corneoscleral lacerations and frank globe ruptures . Although they often are available, protective devices may be unused and/or not mandated. Such environments include heavy industrial settings such as metalworking and welding, in which workers are exposed to threats from sometimes red-hot and fast-moving metal shards, although these risks can be reduced with mandatory safety regimens. Many sports, including lacrosse, baseball, squash, and ice hockey – activities that particularly center around relatively small and hard balls and pucks moving at high speeds – also feature high eye injury rates, usually in the absence (baseball, squash) or inefficacy (ice hockey, lacrosse) of safety equipment.

A survey of serious eye injury occurrence in the United States published in 2000 pronounced the home to be the area of greatest danger, with 41% of all injuries occurring in this environment; industrial settings placed second at 14%, and sports and recreation activities third at 13% [22]. This marked a substantial decrease from the 69.9% injury share for workplace-related incidents reported in a comparable British study from 11 years earlier [20]. Unsurprisingly, the vast majority of all ocular injuries in US analysis , 78%, involved individuals wearing no eye protection, compared to 2% wearing actual safety glasses and 3% with use of any eyewear [22]. Industries requiring welding tasks, including the manufacturing and construction sectors, form a representative and instructive case of the circumstances and prevalence of ocular injuries. According to one analysis, 25% of all workers’ compensation claims filed by welders during the year 2000 were related to ocular injuries; by comparison, eye injuries comprised 5% of all injuries to all workers [19]. The most common source of injury was a foreign body such as particulate matter, hot substances or chemicals, which comprised 71.7% of eye injuries. Periocular and corneal burns from either heat and/or UV light were next most frequent at 22.2% [19]. The effect of using protective eyewear could not be determined reliably, as only 14.7–17.6% of claims even mentioned the use (or non-use) of personal protective equipment . Industrial ocular injuries, although frequently minor and not vision threatening, result both in worker anxiety and lost productivity, and the effect of such injuries on worker retention has not been studied. More serious injuries, such as corneal scarring from UV exposure and globe perforation by foreign bodies, also can be prevented but continue to occur nonetheless [27].

If the impact of mandating safety equipment can be so marked – reducing the occurrence of eye injuries by as much as a factor of 14.5 in one study of metalworking facilities [3] – how come such measures have not become universal? Obstacles of cost and cultural resistance form the most significant barriers towards increasing the rate of eye protection adoption.

The cultural roadblock is particularly noticeable in industrial settings, likely due at least in part to both sectors’ historical association with demonstrable masculinity. In tasks commonly associated with ocular injuries  – grinding, welding, drilling, automotive work, and other working-class industries – the index of dissimilarity measuring the gender employment gap has remained between 55 and 60 since 1950 [8]. The gender gap in work-related eye injuries, however, has been reported as even more skewed, at 98.8% for men and just 1.2% for women [20]. Simply put, industrial workers are disproportionately male, and even accounting for this imbalance, men are more likely to sustain ocular injuries in these fields. Victims of industrial eye accidents who were not wearing eye protection – a condition usually admitted by anywhere from 39.6% to 84.6% of the affected [20] – cite beliefs that eye protection is unnecessary, interferes with work performance, or is uncomfortable [3]. Military studies, dealing with a similar culture of masculinity, make a substantially more blunt prognosis, describing the infantryman, comparable to “another industrial worker needing eye protection,” as – “young, emmetropic, unsophisticated, skeptical, denial-practicing, and body-image-conscious” [15] – i.e. sensitive to the age-old stigma that nerds, not real men, wear glasses. Not all of these concerns are unfounded, however, as a study of young, healthy volunteer subjects showed that wear of ANSI Z87.1- compliant eyewear diminished postural stability especially on an uneven standing surface [33]. Ongoing efforts to design more ergonomic and attractive protective equipment continue and are discussed below.

In theory, these stigmas, aversions, and economic obstacles could be addressed at the workplace level through comprehensive provision of protective eyewear, training in its use, and enforcement of its use. Unfortunately, even in the United Kingdom, where national legislation mandates the implementation of all three such stages, a workers’ survey reported just 40% awareness/availability at the provision stage, and 20% conductance at the training stage [30].

In the United States, the Occupational Safety and Health Administration (OSHA) is responsible for enforcing eye protection standards and regulation. Protective eyewear standards first began to be codified in the US in 1922, when the National Bureau of Standards, in consultation with the War and Navy Departments, issued the Z2 standard for head and eye protection, primarily addressing exposure to dust and fumes. Until 1961, the Z2 was revised on average once every decade, incorporating respiratory standards in 1938, and the advent of plastic materials in 1948 [1]. At that time, eye protection was transferred to its own standard, the Z87, which continues to be adjusted to this day, most recently in 2010 and 2015, and covers protective spectacles, goggles, welding helmets, faceshields, and anything else related to eye protection. A significant change in the 2010 edition was the introduction of standards for extent of eye coverage as well as introduction of more widely used test head models [1].

While the 2015 standard is still being adopted in some industries, the 2010 standard is codified in US safety regulations, and as of 2016, OSHA orders that employers provide personal protective eyewear to employees exposed to “flying particles, molten metal, liquid chemicals, acids or caustic liquids, chemical gases or vapors, or potentially injurious radiation.” [32]. In turn, the American National Standards Institute (ANSI) and the International Safety Equipment Association (ISEA) are responsible for developing the exact standards for individual eyewear units, based on the recommendations of a panel of representatives from the optical, industrial, manufacturing, and military fields [1]. To comply with the ANSI/ISEA standards, all protective eyewear must meet standards in optical (addressing requirements such as minimal transmission and maximum astigmatism) and physical (addressing requirements such as coverage area, proper ventilation, and lens thickness) categories [1]. Based on exposed hazards, protective eyewear also must meet requirements in other categories such as radiation protection (including automatic darkening and filtering), or droplet/splash hazards (including occlusion to liquid and fine dust particles) [32].

As part of its pre-European Union move to establish an internal continental market, the European Commission established uniform health and safety requirements for all personal protective equipment , including protective eyewear , in December of 1989, in the form of a directive of ambiguous binding status [7]. The European Commission continues to maintain these standards, attempting to regulate both economic and safety questions. In general, the safety standards outlined are quite similar to the ANSI/ISEA standards, with the addition of manufacturing inspection standards. Under recent European Parliament action, the European Commission directive will be repealed in 2018 and replaced by a new set of regulations, ostensibly designed to increase conformity in manufacturing [26].

The status of standards and enforcement is less clear in the rest of the world. The efficacy such programs is difficult to determine even in India and China, both of which have been at the forefront of the developing world in terms of standard creation and enforcement. India’s standards for industrial eye hazards and eyewear selection appear to have gone unchanged since 1977 although they were reaffirmed in 2002. They cover the same danger categories and the US and EU standards, but with unclear strictness and/or testing procedures [10]. China has conducted its own extensive government research on laser hazards to eye and other organ systems, although implementation seems to have focused on regulating hazard sources rather than human hazard protection [36].

The occupational health and vision screening aspects of industrial ophthalmology are beyond the scope of this chapter, and the reader is directed to an excellent overview of this topic by Blais [5].

To sports fans and the observant public at large, eye injuries in professional sports occupy a category of unacceptability that transcends even unsettling “normal” trauma such as cuts and contusions. While fans consider Derek Jeter bloodying his chin launching himself into the seats at nearly 20 mph to catch a foul ball inspiring, they are appalled and nauseated when Juan Encarnación takes a foul ball to the orbit.

Unfortunately, the viewing public has witnessed many sports-related tragic eye injury incidents over the last several decades. Some of these injuries have ended careers, and others have led to campaigns for additional safety equipment. Some of the most prominent examples, culled from various sports, follow:

August 18, 1967, baseball: Boston Red Sox outfielder Tony Conigliaro was struck in the left periorbital area by a pitch from Jack Hamilton of the California Angels. Wearing an old-style batting helmet lacking an ear flap, Conigliaro had acute vision loss in the left eye and subsequently was diagnosed with traumatic macular hole. This injury resulted in poor depth perception and effectively ended his career. By 1983, Major League Baseball (MLB) mandated the use of a batting helmet with an ear flap facing the pitcher.

December 13, 2002, softball squash: Canada’s Jonathon Power was hit accidentally in the left eye by an errant racquet move from his opponent David Palmer during their semifinal at the world championships [37]. Due to bleeding and periocular edema that did not allow him to open the eye, Power, the second-ranked player in the world, was forced to withdraw. Other players have suffered more serious and vision-threatening consequences such as retinal tear or detachment from such injuries, and Power was fortunate to escape with superficial injury alone [6]. Power was not wearing any eye protection during the match; competitors at the international senior level continue to be permitted to, and favor, wearing no eye protection, although polycarbonate goggles are required at the youth and collegiate levels internationally, and at the senior level in the United States.

March 5, 2013, ice hockey: New York Rangers’ defenseman Marc Staal, wearing a helmet (mandatory since 1979) but not a visor, had a deflected slap shot impact his right orbital area. The resulting orbital fracture and traumatic retinal tear ended his season. Following his injury, Staal actively campaigned for a mandatory visor requirement in the National Hockey League (NHL), which was adopted beginning with the following (2013–2014) season, although players active before that season retain the right to go without a visor if they so choose. Even before the regulation took effect, visor use increased from 32% in the 2002–2003 season to 73% by the 2012–2013 season, and players who do not wear a visor are at over fourfold increased risk of incurring an eye or orbital injury [23]. There is some evidence that more skilled players have a higher rate of visor use [24], and as youth players look to these players as role models, they will hopefully see visor use in a positive light.

The modern military poses a very interesting case study for the timely development, adoption, and future of eye protection devices. The need for credible eye protection in military settings is statistically clear and intuitive – according to an observational study of Israeli Defense Force records, eye injuries account for approximately 8–13% of battle-related injuries, despite the eye’s comprising about 0.1% of body surface area [9]. This rate marks only the latest uptick in a worrisome trend, following such markers as estimated 0.5%, 2.0%, and 9.0% ocular injury shares during the US Civil War, both World Wars, and the Vietnam War respectively [15].

Furthermore, in terms of severity, 62.5% of the eye injuries in the Israeli study involved ballistic fragmentation and globe penetration, and 66% of such injuries (41.25% of all eye injuries) resulted in the victim being declared no longer fit for combat duty [9]. These figures reveal a minimal reduction in ultimate disability over the past 45 years of combat operations around the world, as 50% of American soldiers who suffered a penetrating eye injury in Vietnam ultimately lost the affected eye, even when receiving immediate and quality care [15].