Initial Diagnosis
Eye injuries in the workplace are common and can be very serious, although when proper preventive techniques are practiced (such as personal protective equipment in an industrial setting and computer-related ergonomic training in an office environment), most injuries can be avoided. Eye complaints account for approximately 4% of workers' compensation claims.
Common Hazards
- Dust, concrete, and metal particles
- Falling or shifting debris, building materials, glass
- Smoke, noxious/poisonous gases
- Chemicals (acids, bases, fuels, solvents, lime, wet or dry cement powder)
- Welding light and electrical arc
- Thermal hazards and fires
- Bloodborne pathogens (hepatitis or human immunodeficiency virus [HIV]) from blood, body fluids, human remains
Common Injuries
- Corneal abrasions and conjunctivitis (red eyes)
- Concrete or metal particles or slivers embedded in the eye
- Chemical splash or burn
- Welder's flashburn
- Eyeball laceration
- Facial contusion and black eye
- Bloodborne pathogen exposure from blood or other body fluids or human remains
Initial Evaluation
The most common initial complaints are of blurred vision, red eye, or visual fatigue. More serious conditions, such as corneal perforation, chemical splash, or welding burns are usually directly incident-related and require immediate, emergency attention or referral. Examination for red flags (signs or symptoms of a potentially serious condition) is the first step in any initial evaluation. Always check visual acuity, peripheral vision, and extra-ocular movements.
Presumptive Diagnosis and Initial Therapy
The patient may present with complaints of:
Red Eye: Red eye is often a sign of a subconjunctival hemorrhage, which will usually heal on its own. A corneal abrasion, foreign body, allergy, or dry eyes, all of which may also be indicated by an itching or burning of the eye, could also cause red eye.
Ask the patient
- To explain the symptoms and how they are affecting his or her vision
- To explain any past history involving red eye or any other eye related problems, as well as any other medical problems such as diabetes or high blood pressure
- To indicate what triggered the onset of symptoms
- To explain what makes the problem worse or better
The eye should be tested for visual acuity, as well as examined with a penlight or transilluminator for irregularities of the corneal surface. Look for noticeable symptoms such as irregularity of the pupils, including uneven dilation or slow reactivity, and lid malfunction.
The following symptoms present with red eye should be considered red flags for immediate referral: severe pain, photophobia, reduced vision, colored halos around point of light in the patient's vision, ciliary flush, high intraocular pressure, corneal epithelial disruption, corneal opacity, proptosis, a smaller pupil in the problem eye, or shallow anterior chamber depth.
In the absence of red flags, contact lenses should be removed and the irritated eye may be treated with topical non-steroidal anti-inflammatory drugs non-steroidal or non-prescription analgesics to relieve discomfort until symptoms resolve within 48–72 hours.
Blurred Vision: Blurred vision, whether central or peripheral, can last from a few seconds to over 24 hours to a lifetime of gradual loss.
Short term blurred vision that heals itself within a few hours could be the result of a migraine headache, transient ischemic attack (occurs when blood supply to the brain is interrupted), or papilledema (optic disc swelling secondary to high intracranial pressure).
Painless loss lasting over days or weeks could be the result of cataracts, vitreous hemorrhage, or retinal detachment, while painful loss could occur from acute angle-closure glaucoma, optic neuritis (pain with eye movements), uveitis, or corneal hydrops (keratoconus).
Long term, gradual change is most likely nearsightedness or farsightedness.
Unless the blurred vision appears to be a temporary result of too much intense close-up work (see visual fatigue), referral to a specialist is recommended.
Visual Fatigue: Visual fatigue usually occurs because of intensive use of the eyes, and is especially prevalent in visual display terminal workers. Rest breaks for the eye are temporary solutions, but for long-term prevention and treatment, the cases should be managed with good visual ergonomics and proper vision care.
Some Common Work-Related Eye Injuries
Foreign Body in Eye
Symptoms include:
- Sharp pain, burning, irritation, tearing, and redness
- Patient feels something in the eye when moving the eye around while it is closed
- Scratching sensation when blinking
- Blurred vision or vision loss
- Bleeding into the white part of the eye (can be either a conjunctival hemorrhage or a subconjunctival hemorrhage)
- Hyphema - blood layering in front of the iris and behind the cornea (could be a sign of a more serious injury)
Medical Treatment for Foreign Body in Eye
- For corneal abrasions, treat with an antibiotic ointment and/or antibiotic eye drops and pain medicine.
- Subconjunctival hemorrhage usually heals on its own in one to two weeks. Artificial tears may ease the irritation.
- Damage to the iris, the lens, or the retina requires immediate evaluation by an ophthalmologist and may or may not require surgery.
- A ruptured eyeball requires surgery by an ophthalmologist.
- If no other injury is noted, hyphema requires close follow-up care with an ophthalmologist.
- Removal of a metal object may require follow-up treatment of a rust ring.
Chemical Burns
Chemical burns fall into one of three categories: alkali, acid, and neutral irritants.
- Alkali burns are the most dangerous. Alkalis (chemicals that have a high pH) penetrate the surface of the eye and can cause severe injury. Common alkali substances include lye, cement, lime, and ammonia.
- Acid burns result from chemicals with a low pH and tend to be less severe than alkali burns. The exception is a hydrofluoric acid burn, which is as dangerous as an alkali burn. Acids usually damage the very front of the eye. Common acids causing eye burns include sulfuric acid, sulfurous acid (such as acid from an automobile battery), hydrochloric acid, nitric acid, acetic acid, chromic acid, and hydrofluoric acid.
- Neutral irritants tend to cause more discomfort to the eye than actual damage. Many household detergents fall into this category. Pepper spray is also an irritant. It can cause significant pain but usually does not affect vision and rarely causes any damage to the eye.
Medical Treatment for Chemical Burns
Wash the eye with at least 1 liter of fluid and, if necessary, test the pH of your eye and continue washing until the pH returns to normal. Administration of topical anesthetic eye drops to numb the eye and make washing less painful may be helpful. Wipe or irrigate away any solid foreign material in your eye. Your tetanus immunization status may be determined and updated.
- Minor burns - prescribe antibiotic eye drops and oral pain medications. Dilating eye drops may also be administered.
- Significant burns - may require admission to the hospital.
An ophthalmologist should evaluate the affected eye(s) within 24 hours after treatment.
Serious damage still reported at follow-up could require a corneal transplant or surgical reconstruction. Injury increases the risk of glaucoma, a boost in pressure in the eye. Several medications effectively treat this condition.
Medications for Chemical Burns
- Topical antibiotics in the form of eye drops or ointments to reduce risk of infection while healing.
- Topical steroids to reduce inflammation and to facilitate healing early in the recovery period after a chemical injury. These medications should be used judiciously, because they can cause long-term complications, such as infections and glaucoma.
- Other medications used to support corneal repair include topical citrate and ascorbate drops, oral antibiotics (e.g., tetracycline, doxycycline), and oral vitamin C.
- Glaucoma medications may be used temporarily to control the pressure.
- Pain medications and dilating eye drops are often also used to control pain and to aid recovery.
Surgery for Chemical Burns
Surgical measures are usually not undertaken early after chemical injuries.
- When severe, chemical injuries may necessitate surgery to the eyelids and the ocular surface.
- If the cornea becomes opaque (or cloudy) following a chemical injury, a corneal transplant may be required.
- Chemical injuries, especially from alkaline substances, can cause cataracts and glaucoma, which may require later surgical intervention.
Ultraviolet (UV) Burns (Welder's Flashburn)
The most common form of radiation burn is due to unprotected welding. "Arc eye" presents several hours after exposure with painful, weeping eyes. Excessive exposure to sunlight (e.g., snow blindness, tanning booths) is another common cause.
Symptoms include: Pain (mild to very severe), bloodshot eyes, light sensitivity, watery eyes, blurred vision, and the feeling of having something in the eye.
Medical Treatment for UV Burns
Mild flash burns heal in a few days. There usually is no lasting eye damage.
If treatment is required, it may include:
- Atropine drops - to relax the eye muscles and ease pain
- Dressing - cover the eye(s) with a padded dressing
- Antibiotics - drops or ointment prescribed for use at home to stop infection
- Follow-up in 24 to 48 hours to check on healing
Thermal Burns
Thermal injuries most often result from direct contact with a hot object. Although these burns can affect a large ocular surface area, they are usually superficial. Symptoms are similar to a corneal abrasion and may include tearing, photophobia, or a foreign body sensation.
Medical Treatment for Thermal Burns
The treatment of isolated thermal corneal burns is usually similar to the treatment of corneal abrasions.
- Remove the offending agents, which may require lid eversion to remove debris. Irrigation also aids in debris removal as well as to cool the surface.
- Treat intraocular inflammation.
- When the lids are burned, cool saline compresses are needed, and adequate lubrications for the globe are important. The burned eyelashes and eschar may need to be removed.
Facial Contusion and Black Eye
Symptoms: Pain, swelling and discoloration, as well as some blurry vision and difficulty opening the eye.
Initial Treatment for Black Eye
Ice, pain relievers (avoid aspirin because it can predispose to bleeding), rest, and protection of the injured area
Signs of a more serious injury may include:
- Double vision
- Loss of sight
- Loss of consciousness
- Inability to move the eye
- Blood or clear fluid from the nose or the ears
- Blood on the surface of the eye itself
- Persistent headache
Surgery
Surgery is rarely a consideration for work-related eye complaints. In the absence of red flags, occupational physicians or primary care providers can safely treat most eye-related complaints. Most conservative treatment (such as non-steroidal anti-inflammatory ophthalmic drugs or non-prescription analgesics to relieve discomfort) for standard eye complaints including superficial foreign bodies, corneal abrasions, conjunctivitis, and ultraviolet radiation damage, will lead to healing within 48–72 hours. Return to modified work should be encouraged as the condition permits. If there is no sign of improvement after 48–72 hours, referral to a specialist is recommended.
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Official Disability Guidelines (ODG) Return-To-Work Pathways - Open Wound of Eyeball
Modified work: 1 day
Regular work, loss of binocular-visual acuity, based on Department of Transportation (DOT) rules: 14 days
ODG Return-To-Work Pathways - Corneal Abrasion
Medical treatment not required: 0 days
With eye patch, modified work: 0 days
With eye patch, regular work: 1 day
ODG Return-To-Work Pathways - Corneal Ulcer
Medical treatment not required: 0 days
Simple, one eye: 1 day
Simple, two eyes: 6 days
Dendritic: 14 days
ODG Return-To-Work Pathways - Acute Conjunctivitis
Modified work: 0 days
Regular work: 1 to 2 days
ODG Return-To-Work Pathways - Other and Unspecified Conjunctivitis
0 days
Viral, until cleared: 5 days
ODG Return-To-Work Pathways - Superficial Injury of Eye
Medical treatment not required: 0 days
With eye patch: 1 day
ODG Return-To-Work Pathways - Contusion of Eye
Superficial contusions: 0 days
Injury to eyeball without associated intraocular injury: 10 days
ODG Return-To-Work Pathways - Nystagmus and Other Irregular Eye Movements
0 days
ODG Return-To-Work Pathways - Disorders of Vitreous Body
Without surgery: 0 to 1 days
Vitrectomy, clerical/modified work: 21 days
Vitrectomy, manual work: 56 days
ODG Return-To-Work Pathways - Myopia
With glasses or contacts: 0 days
With laser correction: 2 days
With radial keratotomy (RK): 3 days
ODG Return-To-Work Pathways - Astigmatism
0 days
ODG Return-To-Work Pathways - Strabismic Amblyopia/Blurred Vision
0 days
ODG Return-To-Work Pathways - Subjective Visual Disturbances
0 days
ODG Return-To-Work Pathways - Color Vision Deficiencies
0 days except for certain occupations (e.g., pilots, electricians, jewelers, artists)
ODG Return-To-Work Pathways - Foreign Body
Slit lamp removal of ocular foreign body: 0 to 1 days
ODG Return-To-Work Pathways - Dry Eye
0 days
(See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in the Procedure Summary of the original guideline document)
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