Ocular injuries are common in childhood, and their etiology and epidemiology are well documented.1 Internationally, 20% to 59% of all ocular traumas occur in children,2,3 a higher rate than that in adults because of their developing physical coordination, limited ability to detect risks inherent in the environment, and more vulnerable facial morphology.2,3 Children’s visual outcomes after trauma are worse than those of adults because of their visual immaturity, increased years of visual compromise, and the potential for amblyopia, resulting in an increased impact on their personal, social, and economic outcomes.4–7 Severe visual impairment or blindness occurs in 12% to 14% of these children, impacting their subsequent careers and social opportunities.3,8–10
Children are exposed to a range of ocular hazards at home, school, work, or during leisure activities. Significant research has been undertaken on the etiology and management of eye injuries in children.1,11–14 Challenges associated with reducing children’s eye injuries include a lack of standardized data collection systems and insufficient funding for prevention research.15 In developing countries, treatment of ocular trauma is often inadequate or delayed, and thus outcomes are significantly worse than those in developed nations.16 Public policy should be aimed at promoting eye protection and behaviors to reduce the incidence of eye trauma.17 We anticipate that our review of existing eye protection strategies, highlighting successful interventions and policies in pediatric eye injury prevention, will be useful for policy makers and manufacturers of eye protection along with physicians, optometrists, and other health care providers who treat children.
MATERIALS AND METHODS
A literature search was conducted in the MEDLINE, EMBASE, AUSTHealth, and Cochrane databases using the terms “pediatric,” “children,” or “adolescent” and “ocular” or “eye” and “protection” or “injury prevention.” References from relevant articles, governmental and health collative reports, and reports in the public domain, including newspapers and health magazines, were hand searched using Google and Google Scholar. Articles were retrieved based on titles and abstracts. The retrieved articles and public domain information were then assessed in the context of our research question. If the article was deemed suitable or possibly suitable, the full text was retrieved and independently assessed by 2 authors (S.S.P. and A.K.H.). The reference list from each article was used to identify other useful publications. Articles published more than 50 years ago were incorporated only when they remained relevant. A search of the literature in the public domain also provided information regarding worldwide policies, standards, and legislation.
Articles were categorized based on whether they related to 1 of 3 broad injury-prevention categories: legislation and policies, education, or personal eye protection. We defined as “successful” any strategy that provided a measurable improvement in outcome, either a change in behavior or a reduction in eye injuries, as a result of the injury-prevention strategy.
RESULTS
It has been reported that 90% of ocular trauma is preventable.18,19 The incidence of pediatric eye injuries varies with age,1 sex,11,20 socioeconomic status,8–10 season,11 and geography.12 Between 44% and 76% of pediatric ocular injuries occur at home.13,14,16,17
A total of 86 articles were identified as relevant to the research question. These included 6 prospective and retrospective interventional studies (Table 1), 9 observational studies relating to attitudes and use of eye protection (Table 2), and 35 prospective and retrospective hospital- and population-based reviews of eye injuries (Table 3). Five review articles examining pediatric eye injuries1,20,55–57 and 1 Cochrane review12 that examined educational interventions for the prevention of eye injuries were identified. The remaining studies provided information relating to eye protection policies and programs (17 in total, see Legislation and Policies to Minimize and Eliminate Ocular Hazards) and the performance of eye protection (13 in total, see Results section).
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TABLE 1: Prospective and Retrospective Interventional Studies of Children’s Eye Injuries
TABLE 2: Nonrandomized Surveys of Attitudes, Awareness, and Utilization of Eye Protection
TABLE 3: Retrospective and Prospective Hospital- and Population-Based Reviews of Children’s Eye Injuries
Legislation and Policies to Minimize and Eliminate Ocular Hazards
A number of laws and policies with the specific aim of eliminating children’s eye injuries were identified. Legislation and policies that have successfully reduced ocular trauma by eliminating or controlling hazardous substances or activities are detailed as follows.
Consumer/Domestic Related
Consumer products and common household objects that are accessible to children, such as toys, items of stationery, cleaning goods, and poisons, can cause vision-threatening ocular injuries.55 Adult supervision of children reduces the risk of injury, and as a result, many products carry warnings for use only under adult supervision (or words to that effect).40 In many developed countries, medications and household cleaning products or poisons are required to have warning labels or “child-resistant” packaging to reduce potential exposure to children.18
Games and toys that incorporate high-speed projectiles are known to result in serious eye injuries.1,11 Legislation governing the sale and supply of toys varies internationally; for example, bows and arrows are sold with warnings regarding supervision and age appropriateness in Australia.58 In Europe, the standard EN71-1 Safety of Toys regulates the sale of any toy with a kinetic energy greater than 0.08 J, with warnings relating to age appropriateness and recommendations for supervision required to accompany specified toys, for example, slings and catapults.37
Paintball and airsoft guns can cause severe ocular injuries because of the force generated and the small size of the projectiles.49,50 Rules regarding the sale and use of these items vary considerably, with almost 30 states in the United States having regulations, ordinances, and laws pertaining to nonpowder guns. New York City and New York State prohibit air rifles and BB guns. In Florida, it is a second-degree misdemeanor for a minor younger than age 16 to use a BB gun, air gun, or gas-operated gun without adult supervision and permission.19
Safety concerns raised about elastic luggage straps25 encouraged the introduction of modified designs and mandatory warning labels for these straps sold in Australia.56 Consumer products are reviewed for ocular hazards in many developed countries, with recalls and product modifications resulting from these reviews when hazards or noncompliance is identified.
Despite the high risk of eye injury, many countries continue to have no or only some restrictions on the sale of fireworks.20 Common fireworks-related ocular injuries include burns, abrasions, hyphema, and globe rupture, with the average age for injury of this type reported to be 15 years old.46 One in 6 fireworks-related ocular traumas results in severe vision loss, with males (77%) and bystanders (47%) at increased risk.46 Countries with restrictive fireworks legislation have successfully reduced the incidence of fireworks-related ocular trauma (0.35 per 100,000) compared with countries without restrictions (2.70 per 100,000).46 An increase in trauma was associated with relaxation of the class of fireworks available for sale in Norway and the United States.36,59
Sports Related
Changes to sporting equipment or rules, for example, the use of thumbless gloves in boxing, have been introduced with the aim of reducing eye injuries (such as corneal abrasion).26,40,60 Injury in boxing remains contentious, and organizations including the American Medical Association continue to call for bans on the sport.38 Studies have shown that in field hockey, sticks and balls contribute to head and ocular injuries. Rules aimed at preventing dangerous play including preventing hockey sticks or balls being played above shoulder level have been introduced in Australia.61
Motor Vehicle Related
In countries that mandate seatbelt use and laminated windscreens in vehicles, road traffic–related ocular injury has decreased53 overall, and the incidence of open-globe injuries has gone from 17.7 to 9.6 per 100,000.39 An open-globe injury involves a full-thickness disruption of the eye wall.62 Airbags are known to reduce motor vehicle accident fatalities,48 and they have been shown to reduce the risk of motor vehicle accident–related ocular injury by an estimated 2.5 times.55 However, airbag inflation is associated with an increased incidence of ocular injury and mortality for children traveling in the front seat.40,48,63 Children are 40% less likely to suffer an ocular injury if traveling in the rear seat of the car, and many countries have implemented legislation requiring children to travel in the rear seat of a vehicle.58
Education to Prevent Pediatric Ocular Trauma
Children are less able to detect and avoid risks associated with ocular hazards.12 Therefore, educational interventions that bring about behavioral change are an effective approach to eye injury prevention in the pediatric age group. Educational interventions range from 1-on-1 counseling to population-wide mass marketing campaigns. Target groups may be based on geography, school group or age, and recreational activity.
Consumer/Domestic Related
Many readily accessible household and domestic chemicals are hazardous to the eye. Children aged 0 to 5 years are overrepresented in chemical eye injury statistics.37 Chemicals commonly associated with eye injuries include household cleaning agents (48%) and glues/adhesives (17.2%).37,50 In the United States, chemicals are responsible for 17% of pediatric eye injuries, second only to sports- and recreation-related injuries (24%).49 Safety caps and warnings have been successfully used to reduce the incidence of eye injuries, but these are not guaranteed to eliminate the hazard. When combined with appropriate parent education about hazards, a reduction in eye injury incidence has been shown.12 The media have been used successfully to highlight ocular hazards, with news articles on the ocular injuries from contact with artificial snow during Israel’s independence day celebrations leading to a reduction in eye injuries from 85 in 2007 (117 eyes) to 11 (18 eyes) in 2008.25
A significant peak in ocular trauma occurs in children aged 5 to 8 years.46,56 Web-based education has been proven to be an effective tool for teaching safety behaviors.64 “EyePlaySafe” is an example of Web-based education designed to teach young children about common eye hazards around the home.65 Injury-prevention organizations such as the Child Accident Prevention Authority (United Kingdom) and the Children’s Health and Safety Association (Canada) have played a role in educating parents about common ocular hazards, for example, with leaflets aimed at highlighting the dangers associated with liquitab detergent dispensers and recommendations for the safe use of fireworks.
Adler-Grinberg et al26 reviewed the effectiveness of short films, songs, posters, and stickers to educate primary school children in the United States about the principles of eye health and safety. Although effective tools for education, it was recommended that these programs be supported by others targeting parents and caregivers.
Sports Related
Kidsafe (Australia) has worked closely with Princess Margaret Hospital for Children, Western Australia (WA), in promoting eye injury prevention and has released a number of programs in schools aimed at educating primary school children about common causes of eye injury and avoidance strategies.60 Campaigns about safe play implemented in the WA primary school curriculum, combined with board games, color-in booklets, and TV advertisements aired in the school holidays, were associated with a drop in severe eye injuries from 120 in 1983 to 72 in 1986.38 The same program also made contact with administrators of all squash courts to ensure all those younger than age 18 were wearing approved eye protection, and instructions about eye protection in cricket were given at all indoor cricket outlets in WA.
Eye Protection
When elimination of ocular hazards is not possible, personal eye protection becomes the last line of defense. Eye protection has been used successfully in a number of environments to reduce eye injuries. Eye protection programs can be difficult to implement. Children often face significant peer pressure to resist wearing eye protection, and eye protection is costly. With these limitations in mind, some have suggested eye protection only for boys because of their increased risk of ocular trauma.61
Product standards form an important foundation on which to base policies, legislation, and recommendations. Currently, there is no uniform international standard for children’s eye protection. Standards for children’s sports, occupational, and UV eye protection eyewear were identified from US, Australian, Canadian, British, and European standards organizations (Table 4). Specific requirements for pediatric eye protection identified in these standards included smaller frame and lens size and reduced impact resistance.
TABLE 4: Eye Protection Standards Incorporating Children’s Requirements
Sports Related
Sports-related eye injuries are more common in 10- to 19-year-olds.53 Consistent with other ocular trauma, boys are at increased risk compared with girls (1.27 vs 0.75 per 100,000).42 Increased participation in competitive sports is associated with higher incidence of ocular injury, with more ocular injuries associated with competition than during practice in high school–aged children (2.06 vs 0.70 per 100,000, respectively).42
Research into eye injuries and the promotion of eye protection for ice hockey was first discussed in 1958 by the Canadian ophthalmologist Thomas Pashby. The widespread introduction of eye protection in this sport did not occur until 1978, which is indicative of the long lead times associated with the translation of research into injury-prevention strategies. The adoption of eye protection for ice hockey in Canada effectively reduced eye injuries from 30% of all eye injuries in 1974–1975 to 7% in 1978–1979.23,66 Mandatory eye protection complying with ASTM F2713 for high school field hockey players and women’s high school lacrosse in the United States and face shields for all hurling players younger than age 18 in Ireland resulted in a 60.4% to 80% reduction in eye injuries21,22,24 (Table 1).
The United States has the most comprehensive range of sports eye protection standards incorporating the requirements of children and young adults, with 8 standards relating to eye protection, whereas the United Kingdom, Australia, and Canada each have 2 relevant sports eye protection standards.
Many of the eye protection policies identified focus on sports (Table 5) and include the introduction of mandatory eye protection for sports with a high incidence of ocular trauma. A number of other policies support the use of eye protection in medium- to high-risk sports such as rugby union, rugby league, darts, soccer, badminton, baseball, volleyball, water polo, tennis, basketball, Australian rules football, American football, snow skiing, fishing, cricket, golf, and lacrosse.67 Eye protection policies for junior squash leagues in Australia, the United States, and the United Kingdom are enforced for competitive matches with good compliance achieved in Australia.68,69 Typical children’s sports eye protection is shown in Figure 1.
TABLE 5: Organizations Supporting Eye Injury Prevention
FIGURE 1: Example of eye protection available for children.
Occupational
Young workers remain at higher risk of injury because of their reduced knowledge and experience in an occupational environment, with ocular injuries occurring at a higher rate than in older workers.33,45,70 Teenage workers are targeted in the US state of Maryland with the promotion of safe work practices, including the use of safety eyewear. In 2012, the Australian standard for occupational eye protection (AS NZS1337.1) incorporated the dimensions of an average 12-year-old, allowing for better fit and coverage for young adults and children.
Functionally 1-Eyed Children
A child is considered 1-eyed when the best-corrected visual acuity in the weaker eye is less than 20/40. A person with this vision would not be able to hold a commercial driver’s license in many jurisdictions but would satisfy the criteria for most other functions. The consequences of an eye injury are more devastating for monocular children. Because they are more likely to suffer trauma to their good eye,54 we should ensure that these children wear eye protection in any situation in which there is a risk of eye injury. Many policies incorporate recommendations for functionally 1-eyed children to wear eye protection for all sports and to avoid high-risk sports such as mixed martial arts for which adequate eye protection is not available.71–75 Monocular children represent a unique opportunity, as they are more likely to be under the care of an ophthalmologist or optometrist and are more likely to be aware of the impact of vision loss.
UV Eye Protection
The long-term effects of UV exposure on the eye are well known,76 and many countries and organizations have developed policies that encourage children to wear wraparound sunglasses with UV protection and a broad-brim hat to reduce the effects of UV exposure. The World Health Organization promotes the use of sunglasses for school children. In Australia, children are encouraged to follow sun-safe behaviors such as wearing sunglasses and a hat for outdoor activities. Internationally, the Australian government is the only country that has enacted legislation for the supply of sunglasses, ensuring all sunglasses meet minimum UV requirements. Despite moderate levels of knowledge with respect to UV light and eyes,27 sunglasses utilization remains low, with only 18.9% of 14- to 20-year-olds wearing sunglasses.28,29 In 2 separate studies, sunglasses usage was observed to be only 6% in Japanese adolescents and 12% in Hawaiian children.31,35
Eye Protector Material and Design
A number of studies discussing the materials, design, and performance of eye protectors were identified.77–80 Polycarbonate was identified almost universally as the material of choice for eye protection.57 Standards for eye protectors (AS 1337.1, AS 1067, AS 1337.6, ANSI Z87.1, ASTM F803-11, and ASTM 659-10) are now performance based, with a range of impact resistance tests to ensure compliance to the standard, rather than specifying a center thickness.
In 1976, the United States legislated a minimum impact protection requirement for spectacle lenses and sunglasses. Recently, the sharp rise in myopia81 has been associated with a high rate of pediatric spectacle-related ocular trauma while participating in sports.44 Dress optical spectacles (regular spectacles) can pose an inherent danger due to the nature of the lens materials and the frame design,41,47,52 and many sources recommend replacing spectacles with prescription eye protection while participating in sports.82,83 The state of New Jersey has legislated that all children requiring an ophthalmic correction and participating in organized sports in which there is a risk of ocular injury wear protective eyewear in place of their regular dress optical spectacles.
Although polycarbonate prescription spectacle lenses are the material of choice based on impact resistance,77–80 they are not always dispensed or worn, with compliance rates as low as 31.6%.83
Barriers to Eye Protection Utilization
Athletes are reluctant to wear eye protection because of concerns relating to style, reduced peripheral vision, fogging, comfort, and visual acuity.84 Barriers to eye protection use in an occupational setting have been similarly described and include concerns about visibility, cleanliness, and comfort.85
Nine studies were identified that surveyed the public, including children, parents, and caregivers, on their attitudes and awareness of the use of eye protectors with utilization rates relatively low, ranging from 12% to 18.9%.29,31,32,35 Discomfort and poor visibility were often reported as the reason for not wearing eye protection.33 Awareness of issues relating to the need for eye protection was reported as lacking in some studies,34 with the major influencers on attitudes to eye protection being parents and peers, with opposing results on the impact of the media on attitudes.27,28 Contributing to this lack of awareness, high-risk activities are rarely depicted as contributing to eye injuries in children’s television programs, and protective eyewear is rarely featured.30
Developing Countries
The profile of ocular trauma in developing countries is dramatically different to that of first-world countries. In countries such as India and Nepal, pediatric ocular trauma commonly occurs in agricultural and work environments.15,43 The need for eye protection in these countries and the capacity to provide it are limited by factors including lack of financial resources, education, and policies and the ability to effectively implement them. In developing countries where more children are engaged in hazardous occupations, there are no known or published eye protection standards.51 In addition, no other evidence was found that demonstrated strategies or interventions for eye injury prevention in sporting or domestic environments in developing countries.
Global Networks and Cooperation to Minimize Morbidity of Pediatric Ocular Injury
A number of groups were identified with policies or strategies aimed at reducing children’s ocular trauma (Table 5). National and state organizations internationally have played a role in lobbying government and educating the public about common ocular injuries affecting children and their prevention. Garnering the support of these agencies to develop a stronger voice through better understanding of trends in pediatric ocular injury and prevention strategies is integral to the success of eye injury prevention strategies.
Monitoring Eye Injury Statistics
Improved availability of eye injury data is necessary to monitor trends and readily identify the effectiveness or otherwise of any eye injury prevention strategies. Eye injury registers, such as the US Eye Injury Register (http://www.useironline.org/), available internationally would help to ensure more effective monitoring of changes in eye injuries and associated protection practices. Standardization of data reporting systems—ensuring they incorporate information about the nature of the injury, the presence or absence of eye protection, demographic data, and final visual outcome from the injury—would highlight areas to focus on. Risk profiles for individual activities should also be encouraged, with better access to the number of children exposed to a hazard, for example, the number of participants per sport. International collaboration to improve monitoring and distribution of eye injury data should be further encouraged.
DISCUSSION
It is widely quoted that up to 90% of pediatric ocular trauma is preventable.86 Recent population-based reviews of eye injuries have all demonstrated a shift in the setting of eye injuries to the home,1,14 highlighting the need for improved eye injury prevention strategies in this area.
This review identified the paucity of research and information in this area. Lack of available scientific literature regarding the use and impact of eye protection in children limits this analysis further. A major review of educational strategies conducted by Shah et al12 found no reliable evidence of the effectiveness of these strategies. However, this does not mean that these strategies are ineffective but that proving their efficacy is very challenging. Future research is needed to understand the causes and societal practices with regard to ocular injuries and the gaps in existing policies/legislation, education programs, and products available to the public.
Based on our review of successful interventions in the area of pediatric eye injury prevention, we recommend introducing strategies in the 3 key areas of policies and legislation, education, and personal eye protection. Specifically, strategies should include different elements as follows.
Legislation, Standards, Policies
- Legislation and policies aimed at eliminating or isolating hazards can be an effective first step in reducing eye injuries. Education targeting children, who lack the ability to detect and avoid ocular hazards, is integral to eye injury prevention strategies. Although government agencies play a role in monitoring consumer products such as toys, health care providers should be encouraged to identify hazards through trends in ocular trauma and approach government agencies to encourage product modification or recall.
- Children who are at higher risk of eye injury, including those with previous ocular surgery/trauma or disease and functionally 1-eyed individuals for whom the impact of an injury is more devastating, should be encouraged to wear eye protection for all medium- to high-risk activities. In addition, this cohort should avoid sports or activities for which no adequate eye protection is available, such as mixed martial arts and boxing. It is imperative that policies reinforce the needs of this group to ensure their vision is protected appropriately.
- Dress optical spectacles can pose an inherent danger due to the nature of the lens materials and the frame design. Polycarbonate or Trivex lenses should be recommended for all children participating in low- to medium-impact sports.
Education
- Increase awareness of eye injuries and utilization of protective eyewear in activities at home along with sports, recreation, and outdoor activities:
- ○ Adequate supervision is important, particularly when using potentially hazardous items found at home (eg, scissors and knives). Hazardous chemicals such as dishwashing soap, toilet cleaners, paint, superglue, and sprays should be kept out of young children’s reach. Purchasing toys that are age appropriate and do not have sharp or projecting edges can help avoid children’s eye injuries.
- ○ It is important that children, parents/caregivers, teachers/coaches, and sports venue operators be made aware of the risks involved in particular sporting activities and the eye protection that is available. Health campaigns on eye protection, using mass media and targeted education campaigns, should highlight the long-term impact of vision loss, garnering support from professional organizations.
- Provide positive role models for appropriate use of eye protection: Parents/caregivers, teachers, coaches, and celebrities can all be role models for children when undertaking activities involving a high risk of eye injury or for individuals for whom the consequences of eye injury are greater, for example, amblyopic children. Professional basketball players, such as Kareem Abdul-Jabbar (Fig. 2), have helped promote the role of eye protection in basketball.
- Garner the support of children’s groups and health alliances: Many countries have developed policies that encourage children to wear wraparound sunglasses with UV protection and a broad-brim hat to reduce the effect of long-term UV exposure. Programs such as Sun Smart and slogans such as “no hat, no play” have been effective in preventing skin cancer, yet the message for eye protection while out in the sun still needs to reach the masses. It is important that the medical community keep themselves well informed about eye injuries and preventive measures, as the public and policy makers look upon them as advisors. Groups such as Kidsafe are integral to the role of promoting messages of safe behaviors.
FIGURE 2: Photo of Kareem Abdul-Jabbar wearing eye protection.
Personal Eye Protection
Eye protection forms the last line of defense from eye injury. It is therefore vital to ensure adequate fit and comfort to achieve adequate protection and compliance. Manufacturers should be encouraged to develop models that fit the facial morphology of children closely to ensure a secure and comfortable fit.
Advances in the development of comfortable and effective eye protection in the industrial context for adults have resulted in more comfortable and flexible solutions. Children’s eye protection is yet to benefit from many of these advances. Designers need to develop eye protection solutions for children that meet standard requirements and address aesthetic and comfort issues to maximize compliance and utilization.
CONCLUSIONS
As health care providers, our role should include a focus on the protection of vision and the promotion of eye safety. Education programs, legislation, policies, standards, and eye protection specifically designed for children need to be developed further to reduce the estimated quarter of a million children’s eye injuries occurring annually worldwide.
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When watching after yourself, you watch after others. When watching after others, you watch after yourself.
— Guatama Buddha
