Eye injuries are not new. Throughout the ages men, women, and children have lost their vision and even lost their eyes while going about their day to day activities at home, at work, in competition and at war. Remarkably some of those injuries have changed the course of global history! This article documents some of the more notable incidents that have helped to shape the safety eyewear category today. From unwieldy heavy armour, wire mesh and gauze, to sleek, contemporary impact resistant wrap around frames – technology has come a long way. Yet the public still needs to be convinced of why and when they should protect themselves and their vision.
Our eyes are able to naturally defend themselves against a broad range of hazards: eyelids, eyelashes and the blink reflex all provide a mechanical barrier, and the iris contracts automatically in response to bright visible light. The protruding bony cavity containing the eyeball, the brow and forehead, provide further protection, particularly in children. A combination of lipids and oils in the tears, as well as the conjunctiva, provide a further barrier to injury. Yet natural mechanisms alone are not sufficient to prevent all eye injuries.
The king had not fastened his visor upon returning to the arena and a splinter from his opponent’s lance entered his right orbit
SPORTS AND RECREATION
Sports and recreational activities contribute to our emotional and physical well-being. However, sometimes things go awry. Jousting, for example, was a popular sport for royalty during the Renaissance and although riders wore heavy armour incorporating a helmet and visor, facial injuries were common. King Henry II of France suffered an eye injury during a jousting tournament in 1559.1 The king had not fastened his visor upon returning to the arena and a splinter from his opponent’s lance entered his right orbit (Figure 1). Periorbital cellulitis from the retained wooden orbital foreign body, complicated by left interhemispheric empyema and traumatic interhemispheric haematoma, resulted in the death of ‘the young lion’ from his eye injury.1 Interestingly, Nostradamus had prophesised the tournament would result in Henry II’s death, which it did.2 His death had important ramifications for France, as it led to religious wars and internal instability, significantly changing the respective roles of France and England and the course of Western civilisation and history.
In more recent times, serious eye injuries have occurred in a wide range of amateur and professional sports, that include ice and field hockey, baseball, La Crosse, Grand Prix racing and cricket.
Baseball players commonly suffer retinal detachments and orbital fractures after being hit by the ball at speed. Pitchers and batters suffering retinal detachment and facial fractures when hit in the face have retired from the game due to permanent damage to their vision.
A much publicised case of a cricketing eye injury was that of the late, former Australian Prime Minister, Bob Hawke, who suffered corneal lacerations when his glass spectacles were shattered by a cricket ball during the Prime Minister’s ‘First 11’ cricket match in 1984.
In the 2009 Hungarian Grand Prix, Philipe Massa suffered an eye injury because a loose suspension spring penetrated his helmet during the race. Within a year of the incident, the requirements for Federation Internationale de l’Automobile (FIA) helmets were revised.
In Australia, eye protection was introduced and promoted for junior grades playing squash thanks to campaigning by the Perthbased ophthalmologist Mary Bremner.3
Indeed, many amateur and professional sports have introduced eye and face protection as a result of injuries sustained, however they are only enforced in some cases. Factors that influence the success or failure to introduce eye protection include compliance and cost. Professional athletes can serve as role models to promote eye protection and improve compliance, particularly among school-aged children.4
COMBAT-RELATED EYE INJURIES
The Bible contains some of the earliest references to the protection of the eyes and face during combat. The Maccabees used armour during battle while their adversaries were thrown into confusion as they were ‘blinded by arrows’ (2nd Maccabees 10:30). This highlights the value of appropriate eye protection to preserve sight during battle.
The story of David and Goliath, in which Goliath is killed by David’s slingshot, may be the first description of a trans-orbital injury causing death (Samuel 17:49). One theory is that the thinness of the orbital bones relative to the frontal bones may have allowed the stone to enter through the eye socket and penetrate Goliath’s brain stem, resulting in his death.5
In Medieval times, the loss of an eye in war was thought to enhance an individual’s valour and appearance as a soldier.6 Sertorius, a well-known and respected general during the civil war in Rome in 82 BCE, claimed to be proud that he lost an eye in battle, stating that the injury was a trophy greater than any other. The Sertorian war, waged from 80 to 72 BCE, was noted for the use of chemical weapons, with alkaline dust being used by Sertorius against the enemy.
A masterpiece of Medieval narrative art, the Bayeux Tapestry depicts the Norman conquest of England.7 The narrative concluded in 1066 when Harold, the former Earl of Wessex and King of England, lost his life and crown to the Duke of Normandy. Though debated in the literature, the fatal strike in the eye from an enemy’s arrow is evident from the depiction of the King trying to remove the arrow from his eye.8
Personal protective equipment used by the military has often been the result of the novel application of technologies, transferred to products for civilians. Wire gauze and plain glass were some of the first materials used for protective lenses. A 15th century CE helmet features metal-rimmed glass lenses that were hinged to cover the eyes. In 1910, a French chemist, Edouard Benedictus, obtained patents for manufacturing laminated glass which was used in the lenses of gas masks as well as the windshields of military vehicles. Military organisations have supported activities investigating the ballistic impact qualities of different materials, which have in turn, led to the widespread use of polycarbonate for eye protection.9
World War I
World War I (WWI) was marked by the increased use of chemical agents, particularly mustard gas, which was widely employed to disable and kill soldiers. The first reported use of mustard gas was in July 1917, just before the third battle of Ypres commenced. Soldiers exposed to mustard gas suffered photophobia, tearing and kerato-conjunctivitis with temporary visual incapacity.
The first major use of chlorine gas was at the Second Battle of Ypres in 1915. Other chemical agents used in combat include tear gas, lewisite, phosgene and nerve gas, with a range of both ocular and systematic temporary and permanent consequences.10 During WWI, more than 1,200,000 soldiers were exposed to mustard gas, and more than 400,000 British soldiers required prolonged medical treatment as a result.11 A large number of individuals who were exposed experienced keratitis from the chemical by-products that rapidly penetrated the cornea.
Gas masks were developed to protect the eyes and prevent inhalation of the gas. Early attempts included full-face hoods with a small window for the eyes (Figure 2), however the fact that the early protective devices hampered movement and vision, caused some soldiers to remove their protective masks during attacks.12 As the war progressed, masks with improved field of view and comfort were developed, including the M2 and Tampon T mask (Figure 3,4,5). This led later, to the adoption of goggles for employees in manufacturing environments.
In 1917, following assessment of 320 soldiers’ eye injuries during WWI, the British ophthalmologist, Sir Richard Cruise, introduced the concept of a visor composed of steel mesh rings intended to be attached to the soldier’s helmet.13 The visor was subsequently developed and deployed (Figure 6).
The face and eyes represent 9% and 0.1%, respectively, of the body by surface area, but these areas are disproportionately injured in battle.14 Between 21% and 39% of injuries for the United States and United Kingdom forces are facial15 and 6% affect the eyes.16
The nature and proportion of hospitalised casualties attributed to combat-related ocular trauma has changed over the last century. In more recent hostilities, expanded use of improvised explosive devices (IEDs), which project small, energised fragments at a range of angles, has increased eye injuries.17 The percentage of combat casualties hospitalised due to ocular trauma increased from 2% in 1914 to 13% in the 1990s Desert Storm conflict.18
While helmets protect from brain injury, the need to protect the face and eyes is being increasingly recognised. The British and American armies have introduced mandatory eye protection, resulting in a reduction in both the incidence and severity of eye injuries.19,20
With improved effectiveness of eye protection during the 1980s and 90s, the focus moved to compliance. In the United States in 2004, the Authorized Protective Eyewear List was established, targeting not only impact performance but also weight, optical properties, style and field of view to improve wearer compliance. The level of compliance rose between 85 and 95%.21
EYE INJURIES IN THE WORKPLACE
Awareness of the mechanisms of eye injuries and education about appropriate interventions has helped contribute significantly to preventing work-related eye injuries. Heat cataracts, caused by exposure to infra-red radiation, were a common cause of blindness in glass blowers and foundry workers. Knowledge of the hazard was evident as early as the 15th century, with illustrations showing foundry workers wearing a turban-like head wrap, perhaps intended to shield the eyes.22
The first and second Industrial Revolutions increased demand for energy and materials, which resulted in the employment of large numbers of people in mining in the period immediately preceding WW1. At that time, more than 70% of eye injuries were occupational. Coal miners and those working with metal represented 73% of occupational injuries,23 with a high incidence of heat cataracts in foundry workers and glassworkers and arc eye reported.22
At that time, there was no impact-resistant clear material available for eye protection, and instead wire mesh or gauze was used. Wetting-down procedures on worksites, and individuals’ use of eye protection with a partial seal to prevent the ingress of dust, has greatly reduced corneal abrasions and subsequent infection from dust exposure, particularly in mining.
During the period 1920 to 1930, almost 11,000 workers were compensated under the Workmen’s Compensation Act of 1907.24 Following introduction of work health and safety standards in developed countries, occupational-related injuries have decreased. Improved understanding of materials and their impact-resistance properties as well as the nature of hazards has resulted in the development of standards and products to ensure adequate protection.25 Identifying hazards, their impact energy and resulting eye and face injuries has helped to define when full-face protection, i.e. a face-shield, is required vs targeted eye protection, i.e. spectacle-type eye protectors.26,27
Agriculture, mining, manufacturing and fishing continue to present hazards to workers and a high proportion of eye injuries occur in these fields. Mandatory occupational health and safety requirements, and the successful deployment of eye-injury prevention strategies, has reduced the number of occupational injuries. Compliance, however, continues to be an issue, with patients with eye injuries usually reporting not wearing eye protection due to problems with comfort or fogging of the eye protection as a result of poor fit.28
It has been estimated that ocular hazards sustained during work-related activities and ‘do-it-yourself ’ home projects in Australia cost AU$59 million in the period November 1989 to April 1991.28
Improvements in technology and the design of safety eyewear (Figure 8) as well as legislation and public advocacy programs have improved compliance, facilitating a reduction in occupational eye injuries. While factors such as task and occupation28 and previous ocular trauma29 have been found to be associated with correct use of eye protection, rates of wear remain low, indicating a need for better education and health promotion strategies.
PREVENTION OF OCULAR TRAUMA
In the hierarchy of risk controls, hazard minimisation, in the form of elimination or substitution to avoid exposure to a hazard entirely, is the most effective means of injury prevention. Eye protection is generally designed and selected based on the setting of the activity as this dictates the likely hazard, and therefore the mechanisms/cause of trauma.
National and international standards are now in place in many countries for sports, military and occupational eye protection. While they are generally not mandatory, they do provide a basis to ensure products promoted as eye protection provide an appropriate level of mechanical impact protection. It is also important to ensure there is no visual impairment introduced through optical, transmittance and colouration limitations.
Initial eye protection standards focused on lens performance and were materialspecific. As knowledge of the nature of eye injuries and frame and lens technology has evolved, standards have incorporated impact performance and coverage requirements for the complete product, rather than being material- or design-specific. With the long-term effects of environmental ultraviolet (UV) radiation apparent, UV requirements are also incorporated in eye-protection standards. Another requirement in current eye protection standards is ensuring no secondary hazards are introduced by the inappropriate use of frame or lens materials that are harmful to the wearer.30
In Australia, the first prescription eye protection standard (AS1337.6) included requirements for the complete spectacletype eye protector, tested with a range of prescription powers to ensure compliance across a specified power range.
Legislation and policies in occupational environments across the last century have successfully reduced eye injuries in developed countries such as the United States, United Kingdom and Australia.
Eye protection programs and evidencebased advocacy have been effective in reducing ocular trauma, with prominent ophthalmologists and health-care providers playing an important role.
However it is up to us, as eye care professionals, to continue to advance compliance with ongoing patient education and advocacy for improved eye injury prevention programs.
Annette Hoskin is a research fellow focusing on eye injuries and their prevention. She holds positions at the Save Sight Institute, University of Sydney and Lions Eye Institute, University of Western Australia. She is a committee member for Standards Australia and International Organization for Standardization committees for eye protection, sunglasses, spectacle lenses and frames and Global Standardization Manager for Essilor International.
Annette Hoskin is supported by an NHMRC Dora Lush PhD scholarship.
Professor David A Mackey is an ophthalmologist and researcher with Lions Eye Institute, Western Australia.
Professor Lisa Keay, is Head of the School of Optometry and Vision Science, University of New South Wales.
Dr Rupesh Agrawal, is a clinician scientist at Tan Tock Seng Hospital, Singapore, Singapore
Professor Stephanie Watson is an ophthalmic surgeon and researcher with Save Sight Institute, The University of Sydney
This article has been adapted from one published in Acta Ophthalmologica, Mar 2019, “Eye injuries across history and the development of eye protection.”
References available online at mivision.com.au