EyeNet Magazine



   
 
Clinical Update: Trauma
Managing Agricultural and Industrial Eye Injuries
By Annie Stuart, Contributing Writer
 
 

For the many Americans who work in business or service sectors of the economy, the prospect of sustaining a serious eye injury on the job may seem remote. But that prospect is very real for millions of workers in agricultural and industrial jobs.

The results of such trauma are not inconsequential: beyond the individual tragedies, 800,000 eye injuries each year in the United States cost more than $300 million in lost production time, medical expenses and workers’ compensation.1

Why eyes get injured. Although manufacturing generates the greatest number of eye injuries, the highest rate of injury occurs in agriculture.2 That rate is largely due to a lack of oversight, said John M. Williams Sr., MD, MPH, a Wisconsin ophthalmologist in private practice who is also board certified in occupational medicine. For instance, he said, “Farmworkers may cut corners because no one is looking over their shoulders, telling them to wear safety glasses.”

Compounding the problems of lax enforcement—and sometimes language barriers with migrant farmworkers—are the moments when job safety requirements and the worker’s economic need are at cross purposes, said Linda S. Forst, MD, MPH, associate professor of environmental and occupational health sciences at the University of Illinois in Chicago.

In citrus groves, for example, farmworkers are paid by the piece, she said. “They want to work as fast as they can, but safety glasses can fog up, slide off and cause vision difficulties, which leads to inefficiency and exposure to other hazards. So it is a complicated problem,” she said.

Paramedic Rod Brouhard added that one of the biggest problems in rural communities is a lack of formal safety training. Although farmers and farmworkers may have a working knowledge of the materials they use, such as chemicals, they often don’t know how to use them safely. “And they don’t know what to do if there is an accident,” said Mr. Brouhard, who has worked as a paramedic for 20 years in the agricultural community of Modesto, Calif.

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Typical Injuries

Hazards in the industrial or agricultural setting can range from dirt or metal particles to corrosive chemicals, welding light and falling or exploding debris. Following are some situations for which treatment is most urgent.

Chemical burns. The pervasive use of pesticides and herbicides in farming can expose workers’ eyes through nebulization in the air or rubbing with contaminated fingers, said Mr. Brouhard. Some of the worst injuries are chemical burns from alkalis, which are heavily used in fertilizers, in cleaning agents and in adjusting pH in canning operations, he said. With their high pH, alkalis can burn through the surface of the cornea.

First response to alkali injury includes flushing the eye with at least one liter of fluid, testing the pH of the eye and continuing flushing until pH returns to normal. Topical anesthetic can ease pain. For minor burns, antibiotic eyedrops and oral pain medications may be all that’s needed initially. Other medications may include topical steroids, glaucoma medications and medications to support corneal repair. More serious chemical burns may require frequent outpatient visits or even hospital admission.

Chemical injury requires urgent evaluation by an ophthalmologist to assess the initial degree of conjunctival and corneal damage. If damage is severe, a corneal transplant or surgical reconstruction may later be required. G. Philip Matthews, MD, PhD, said that progress with chemical burns has come mainly in the area of better triaging to neutralize the burns, such as with an isotonic saline or balanced Ringer’s solution, with the help of a Morgan lens. “Unfortunately, we haven’t made a big jump in progress with later treatment,” said Dr. Matthews, whose Dallas and Ft. Worth ophthalmology practice includes a focus on ocular trauma. “Here’s why: When you have a severe chemical injury, you not only damage the cornea, but you usually damage the surrounding conjunctiva, which is so vital to the health of the cornea,” he said. “When you get corneal scarring, pannus formation and damage to both conjunctiva and cornea, it’s hard to heal without severe visual loss. The pannus ingrowth and conjunctival symblepharon formation are often permanent and remain even after conjunctival or corneal transplants.”

Flash burns. Also known as ultraviolet keratitis, flash burns are most often caused by staring at a welding arc without a properly tinted protective lens. The ultraviolet rays lead to a radiation burn on the surface of the cornea, which causes cells to slough off, leaving bare nerve endings that are tremendously sensitive.

Mr. Brouhard, who grew up on a farm, said that he has often seen these injuries in children who have come up behind a parent using a welder’s arc. “Ten seconds of intently watching the arc can lead to several hours of extreme pain,” he said. Other symptoms may include light sensitivity, blurred vision, watery or bloodshot eyes and a sensation of sand in the eye. If needed, cycloplegic drops can relax eye muscles and ease pain. These injuries usually heal within 24 to 48 hours, he added.

Penetrating trauma. Pounding metal on metal is the most common scenario leading to this type of work-related injury. A piece of fractured metal can fly at high velocity, sometimes penetrating the eye without significant physical findings. “If the worker wearing safety glasses is grinding metal and a metal flake is blown into the eye, then irrigation with water may be all that’s necessary to rinse it out,” said Dr. Williams. If there is evidence that the globe has been penetrated, he said, it is critical to prevent pressure on the eye through use of a Fox shield or, if necessary, through makeshift means, such as a Dixie-cup patch.

Dr. Matthews noted that progress has been made in treating penetrating trauma or ruptured globes. “In the past, we put the globe back together and didn’t worry about vision because it was a foregone conclusion the patient would be lucky just to have an eye,” he said. “Today, the thinking is not only can you save the eye in many cases, but you can restore function as well,” he said. “If you do a full-thickness apposition of the corneal wound, you get back the majority of corneal strength and function because you have full-thickness healing.”

Dr. Matthews added that diagnostic tools such as corneal topography have aided in later surgical rehabilitation of many of these types of injuries.

Corneal abrasions. Corneal abrasions in the work setting are often caused by rubbing an eye that has dust or dirt in it, said Mr. Brouhard. “If workers knew they could rinse the particulates out,” he said, “these wouldn’t pose a big problem. Sometimes people do damage where it didn’t need to be done.”

Dr. Williams recounted a case in which a corneal abrasion was compounded by a bacterial infection. A farmworker had been swatted in the eye by a cow’s tail, which dragged feces across the cornea, he said. “This led to a serious corneal ulcer, which we treated with antibiotics. Although the patient almost lost the eye, treatment was successful.”

Instead of pressure patching, the primary method for treating corneal abrasions today is with a bandage contact lens, said Dr. Matthews. “It’s more comfortable for the patient who can also still see out of the eye.” Since the wound heals just as well as with pressure patching, this is a big advance for a problem ophthalmologists commonly see, he said.

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Everyone Can Learn a Lesson

A thorough history and subsequent physical exam can make the difference in saving an eye, said Dr. Williams. “If a person says, ‘Doc, I was hammering metal on metal,’ that should set off an alarm in your brain.” The diagnostic steps after that would involve a funduscopic exam and imaging studies, possibly an x-ray or CT scan, he said.

The ophthalmologist should also establish communication with the patient’s employer and primary care provider, said Dr. Matthews. “I sometimes hear the complaint that primary care providers refer patients to a specialist and never hear back, and then the primary care physicians don’t learn anything.”

Promoting prevention. An accident is an opportune time for secondary prevention messages, said Dr. Forst. With proper eye and face protection, most of these injuries could be prevented. “When a person gets injured in a workplace, this is a sentinel event, indicative of a failure of protection in that system,” she said, emphasizing that the ophthalmologist needs to capitalize on this opportunity to educate both the employee and employer about prevention. This is the time to reinforce the options for protective eyewear, she said. And in cases of severe injury, where coworkers may be at risk for the same event, the local office of the Occupational Safety and Health Administration should be called.

Building a culture of safety should be a part of every patient visit, said Dr. Williams. “If we were talking about an infectious disease that was that preventable, we’d jump all over it,” he said. “We’re not doing as much as we should to prevent eye injuries.”

“Ophthalmologists have a huge role in dramatizing the problem,” added Dr. Forst. “They see the drama of the failure. You can look at statistics or rates in graphs and charts, but one photo or description of the devastation of an eye injury to get people to ponder blindness is very powerful. The horror of the medical outcome speaks very loudly.”
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1 Vision Council of America. www.checkyearly.com/news/images/Vision%20in%20Business%20Report%20FINAL.pdf.
2 Lacey, S.E. et al. J Agric Saf Health 2007;13(3):259–274.

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