The eye has innate defense mechanisms, primarily the eyelids, eyelashes, blink reflex, pupillary constriction, and bony orbit. However, when external forces, chemicals, or radiation exceed these mechanisms, eye injury occurs.
Approximately 55 million eye injuries occur worldwide each year. According to estimates by the World Health Organization (WHO, 1998), about 19 million people worldwide have monocular blindness or low vision due to trauma. The incidence of eye injuries requiring hospitalization is reported to be 13 per 100,000 population, and in Australia, it is reported to be 11.9–25.5 per 100,000.
In the United States, an estimated 24 million people have a history of eye injury, of whom 1.5 million have visual impairment, 1.7 million have partial blindness, and 147,000 have complete blindness. Up to 40% of individuals cannot return to their previous jobs after severe vision loss, resulting in enormous social and economic losses. The direct medical costs associated with hospitalization for eye injuries in Australia are estimated at 23.57 billion dollars annually.
On the other hand, the incidence of eye injuries (at the hospitalization level) is reported to be 3.5–4.5 per 100,000 population worldwide1), and the dissemination of appropriate preventive measures is urgent.
90% of eye injuries are preventable. Measures at the individual, workplace, and administrative levels are the most important approach to protecting vision.
QIs it true that 90% of eye injuries are preventable?
A
Yes. Most eye injuries can be prevented by wearing protective eyewear, improving hazardous work processes, using sports protective equipment, and managing chemicals and sharp objects at home. However, this does not mean that injuries heal naturally after they occur; rather, it means that preventive measures to reduce the occurrence itself are important. Especially in occupational, sports, and pediatric domestic accidents, preemptive measures considering hazardous situations greatly influence visual prognosis.
2. Classification and Severity Assessment of Ocular Trauma
The standard classification for ocular trauma is the Birmingham Eye Trauma Terminology (BETT). It systematically categorizes injuries by site, mechanism, and depth of damage, enabling international data comparison.
There is also a broad classification into mechanical and non-mechanical trauma (chemical burns, thermal burns, photic injury, radiation, barotrauma, vibration).
Open Globe Injury (OGI)
Definition: A full-thickness wound of the eyewall (cornea or sclera).
Rupture: Caused by blunt force.
Penetrating injury: A single full-thickness wound caused by sharp force.
Perforating injury: Has both an entrance and an exit wound.
Zone classification (I–III): I = cornea and corneoscleral limbus, II = sclera within 5 mm of the limbus, III = posterior sclera more than 5 mm from the limbus.
Closed Globe Injury (CGI)
Definition: An injury that does not cause a full-thickness wound of the eyewall.
Contusion: Closed injury caused by blunt force.
Lamellar scleral laceration: A partial-thickness wound caused by sharp force.
Zone classification (I–III): I = external surface (conjunctiva, sclera, corneal epithelium), II = anterior segment (anterior chamber, iris, lens), III = posterior segment (vitreous, retina, choroid, optic nerve).
The Ocular Trauma Score is a scoring system that predicts prognosis based on six parameters: initial visual acuity, globe rupture, endophthalmitis, penetrating injury, retinal detachment, and relative afferent pupillary defect.
Score 0–44: 74% chance of no light perception (NLP) outcome
Score 92–100: 94% chance of visual acuity 20/40 or better
Limitations of the Ocular Trauma Score include handling of zone II/III boundaries, exclusion of adnexal injuries, and non-mechanical trauma. Further subdivision of zone III (anterior/posterior) has been proposed, with posterior zone III associated with worse visual outcomes, higher rates of retinal detachment, and proliferative vitreoretinopathy (PVR).
The occurrence of ocular trauma varies by age, sex, setting, and country. Age shows a bimodal peak, with higher incidence in younger and older populations. Males have higher rates of ocular trauma than females, except in pre-ambulatory infants and adults over 75 years, where rates are similar or reversed.
The table below shows the main settings and causes.
Setting
Main Causes
Occupational
Hammering, grinding, cutting (metalwork), welding, chemical exposure
Common in heavy industries such as forestry, fishing, agriculture, construction, and mining. Hammering, grinding, and cutting (metalwork) are the leading causes of occupational open-globe injuries. Welding and artificial radiation sources can also cause injuries. Metal grinder (sander) cutting and welding often cause corneal foreign bodies, while hammering can lead to foreign bodies in the anterior chamber or intraocular foreign bodies.
Chemical eye injuries are often due to alkali exposure in the workplace, most common in men, and bilateral in 12.3% of cases. Alkali saponifies lipids in tissues, causing liquefactive necrosis, and penetrates deeper than acids (ammonia penetrates the cornea instantly, NaOH reaches the anterior chamber within minutes). In developed countries, occupational eye injuries are decreasing due to improved occupational safety and health regulations.
70-80% of sports-related eye injuries are caused by balls. Common in soccer, baseball, tennis, and softball. Softballs and soccer balls can deform upon hitting the orbital wall, transmitting significant force to the eye, leading to severe cases. Golf balls are small and can become lodged in the orbit, potentially causing globe rupture. In combat sports (rugby, boxing), traumatic retinal detachment due to ora serrata tears and giant tears is a concern. The anterior segment is affected in 72% of cases, and the posterior segment in 59%.
In infants (0-4 years), cleaning detergents are the most common cause. In school-age children (5-9 years), pens, pencils, knives, forks, and toys are common, and intraorbital foreign bodies from chopsticks and pencils are relatively frequent. Airsoft guns, yo-yos, and elastic straps are also causes. Stationery items (scissors, pens, pencils) have been reported as causes of penetrating eye injuries in children in Taiwan and Australia.
In Japan, mandatory seatbelt use in 1985 and mandatory high-performance laminated glass in 1987 reduced windshield-related eye injuries. Airbags inflate in 0.03 seconds and deflate in 0.07 seconds, making them impossible to avoid by blinking, and can cause corneal abrasions, burns, and alkali injuries. Patients after refractive surgery (RK, LASIK) are at risk of corneal rupture or flap displacement.
Fireworks-related eye injuries occur frequently in India, the United States, Colombia, and other countries. They are concentrated on New Year’s Eve, Diwali, Lunar New Year, and Independence Day.
With the increased use of IEDs, the profile of combat-related eye injuries has changed. In the 1990s, 13% of hospitalized casualties had eye injuries (a significant increase from 2% in World War I). In the 2020 Beirut port explosion, 39 patients and 48 eyes were injured, with 54.2% superficial injuries, 41.6% eyelid lacerations, 29.2% orbital fractures, 20.8% open globe injuries, and 53.8% required surgical intervention 2).
QWhat is the most common cause of eye injuries in children?
A
It varies by age. In children aged 0–4, household chemicals such as cleaning detergents are common; in ages 5–9, stationery and toys such as pens, pencils, knives, and forks are the main causes. Intraorbital foreign bodies from chopsticks and pencils are also relatively common in children.
QHow can I protect my eyes during sports?
A
The American Academy of Ophthalmology (AAO) recommends wearing polycarbonate sports protective eyewear for all sports. Although plastic lenses are common in everyday glasses, they can still cause penetrating eye injuries, so switching to sports-specific protective eyewear is effective.
Examination of eye injuries proceeds systematically in the order: appearance → simple visual function tests → ocular morphology tests → detailed visual function tests.
Head and facial injury assessment: Check the location and depth of lacerations, contusions, and perforations.
Slit-lamp microscopy: Evaluate the extent of anterior segment injury. Perform Seidel test to confirm aqueous humor leakage (evidence of full-thickness wound of the eye wall).
Bacterial culture: In open globe injuries, the incidence of endophthalmitis is 2–7%; be alert for virulent organisms such as Bacillus species.
A comparison of major imaging methods is shown below.
Contraindicated if metallic foreign body is suspected
If there is a history of trauma, even if the anterior segment appears normal, CT imaging can help prevent overlooking a ruptured globe or intraocular foreign body.
Prevention of ocular trauma is systematically organized based on the Hierarchy of Controls (HOC). Higher-level measures are more effective and fundamental.
① Elimination
Eliminate the hazard itself: Remove dangerous work processes or products. This is the most effective preventive measure.
② Substitution
Replace with a safer method: Substitute hazardous chemicals with less toxic ones. Ensure safety at the product design stage.
③ Engineering Controls
Establish physical barriers: Install machine guards, protective screens, and safety containers. Place a physical separation between the hazard and people.
④ Administrative Controls & ⑤ PPE
Improve work procedures: Provide safety education, labeling, and work manuals.
Personal Protective Equipment (PPE): Safety glasses, face shields, etc. Considered as the last line of defense.
Sports: The American Academy of Ophthalmology (AAO) recommends the use of polycarbonate sports protective eyewear. Daily eyeglass lenses (plastic) cannot prevent penetrating eye injuries during sports, so switching to dedicated protective eyewear is necessary.
Workplace: Due to design advances and regulatory improvements, occupational eye injuries are declining in developed countries. Employers should integrate vision correction into safety glasses and ensure their consistent use.
Legislative measures such as banning product sales, setting minimum safety standards, and mandating labeling and usage instructions are also effective in reducing the hazard of eye injuries.
Performing primary repair of open globe injuries within 24 hours of injury reduces the risk of endophthalmitis (odds ratio 0.30, 15 studies, 8,497 eyes)1). No significant difference in visual prognosis is observed between repair within 24 hours and beyond1).
QWhat should you do first if chemicals enter the eye?
A
Immediately irrigate the eye continuously with at least 500 mL of running water before seeing a doctor. Alkalis penetrate deeper than acids, so rapid irrigation directly affects prognosis. After irrigation, promptly visit an ophthalmologist and provide information on the type, amount, and time of injury.
Acids: Denature and coagulate tissue proteins. The coagulated necrotic tissue acts as a barrier, limiting deeper penetration to some extent.
Alkalis: Saponify lipids, causing liquefactive necrosis. They penetrate deep into tissues, and some (e.g., ammonia penetrates the cornea instantly, NaOH reaches the anterior chamber within minutes) can reach the anterior chamber in a few minutes.
The severity of chemical burns is assessed using the Roper-Hall classification or the Kinoshita classification.
The time until removal of an intraocular foreign body greatly affects visual prognosis, so it should be removed as soon as possible. If an iron foreign body remains, iron ions deposit in ocular tissues, causing siderosis bulbi (cataract, retinal degeneration, glaucoma, phthisis bulbi).
Wound cleaning: Clean with saline and achieve hemostasis using bipolar coagulation.
Chemical burns: Continuous irrigation with copious running water or saline. Perform immediately at the scene before visiting a doctor.
Eyelid laceration: Suture end-to-end with 6-0 nylon. If a lacrimal canalicular laceration is suspected, do not suture the wound; promptly refer to a specialist for surgery.
Globe laceration: Watertight closure. Use 9-0 nylon for the limbus, 10-0 nylon for corneal wounds, and 9-0 nylon for scleral wounds.
In epidemiological research on ocular trauma, inconsistencies in terminology and lack of measurement systems pose barriers to systematic data collection. IGATES (International Globe and Adnexal Trauma Epidemiology Study) is an initiative to collect data online from multiple countries as part of APOTS, aiming for global epidemiological understanding.
Mackin et al. (2025) reported a systematic review and meta-analysis of 15 studies involving 8,497 eyes examining the timing of primary repair for open globe injuries 1). Primary repair within 24 hours of injury reduced the odds of endophthalmitis to 0.30 compared to repair after 24 hours. However, no significant difference in visual prognosis was observed. Evidence also showed that delay beyond 24 hours increased the risk of endophthalmitis in penetrating injuries (including intraocular foreign bodies). All studies were retrospective and non-randomized, with low certainty of evidence, and future randomized controlled trials are awaited 1).
Regarding ocular trauma scores, limitations in pediatric application have been noted, and alternative scoring systems specific to children have been proposed but not sufficiently validated. Subdivision of zone III (anterior/posterior) has shown poor prognosis in posterior zone III, and research is ongoing for more precise prognostic prediction.
Mackin D, Boorman L, et al. Early versus Delayed Timing of Primary Repair after Open-Globe Injury: A Systematic Review and Meta-Analysis. Ophthalmology. 2025;132:431-441.
Kheir WJ, Torbey JG, et al. Ophthalmic Injuries After the Port of Beirut Nonnuclear Explosion. JAMA Ophthalmology. 2021;139(9):937-942.
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