Each year it is estimated that up to 5.7 million children worldwide suffer an eye injury.1 While many of these injuries are minor and the child makes a full

recovery, vision loss or blindness occurs in 12–14 per cent of cases.2,3

With 90 per cent of eye injuries being preventable,3 it is important for all health care providers to be aware of and support the strategies available to reduce the incidence of eye injuries. For those children who do suffer an eye

injury, as well as children who live with an eye condition or develop a complex eye disease, eye health professionals are vital. Working closely with both the

child and family, they aim to achieve the very best possible outcomes in eye health, as well as education and social development.

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writer Annette Hoskin

mivision • ISSUE 97 • DEC 14mistory

The impact of eye injuries is significantly worse for a child than an adult because of their visual system’s immaturity and the potential to develop amblyopia.

Minor eye injuries, including corneal and lid lacerations or bruises, do not usually cause permanent damage to vision. However open-globe injuries, including penetrating eye injuries, inter-ocular foreign bodies and globe ruptures, involve full thickness disruption of the eye wall are more likely to result in significant vision loss. A recent study of children’s eye injuries resulting in hospitalisation at Westmead Children’s Hospital in Sydney reported an enucleation rate of 10 per cent. The same study found approximately 30 per cent of open-globe injuries resulted in vision of less than 6/60 and a further 14 per cent with vision 6/15 to 6/60 in the affected eye.4

DomesTic eye injuries The cause and type of children’s eye injuries is extremely diverse although there are patterns depending on the child’s age, where they live (urban or rural; developed or developing nation) and the season. Up to three quarters of eye injuries in children occur at home, with everyday household objects often the cause. Commonly available consumer products including elastic luggage straps (commonly known as ocky straps), kitchen utensils, toys, stationery items and furniture have been associated with devastating eye injuries. Boys are overrepresented in the statistics, being up to three times more likely than girls to experience an eye injury.4

Chemical eye injuries are not uncommon in children 0–5 years,5 and are frequently caused

by household cleaning agents and glues or adhesives. Should a child be exposed to a harmful chemical, immediate and copious irrigation of the eye is known to improve the outcome. Alkalis are capable of causing major damage because of their potential to penetrate the cornea long after the initial exposure. Parents and caregivers should be reminded to be vigilant with children to ensure they can’t access hazardous chemicals and to be aware of appropriate first-aid measures should exposure occur. Consumer and government bodies also need to continue to reinforce the need for child-resistant packaging and warnings for these common household items.

Games anD Toys Games and toys are also a frequent cause of children’s eye injuries. In Australia, the sale of toys capable of launching projectiles, e.g. toy guns, bows and arrow, are regulated through Australian Consumer Law to prevent or reduce the risk of eye injury. Parents and caregivers should be encouraged to purchase toys appropriate to a child’s age and ensure that children are adequately supervised at play.

Products commonly associated with eye injuries, such as ‘air soft’ guns, are considered firearms and are not able to be sold in Australia. Yet paintballing, which is an increasingly popular recreational activity in Australia, presents a similar eye injury hazard to these guns. While eye protection is generally provided for those participating, eye injuries still occur including when players are ‘off field’ adjusting their goggles. This highlights the importance of education for these types of activities as well as the need to ensure that eye protection is comfortable, fits well and doesn’t fog.

moTor Vehicle acciDenTs Changes in design rules and legislation relating to motor vehicles, including laminated windscreens, seatbelts and airbags, have helped reduce eye injuries associated with motor vehicle crashes. However, because of the explosive nature of airbags, in the event of a crash a child travelling in the front seat of a car is more likely to suffer an eye injury than those travelling in a rear seat. Indeed, recent reports have shown that a child travelling in the rear seat of a vehicle is 40 per cent less likely to suffer an injury. For this reason, parents should be encouraged to have their children (<13 years old) travel in the rear seat with an age-appropriate safety seat or restraint.6

Fireworks injuries Fireworks are often associated with catastrophic injuries including burns, abrasions, hyphaema and globe ruptures. Fortunately, the introduction of fireworks

legislation in Australia has significantly contributed to a reduction in eye injuries from these products. Countries with little or no regulation, e.g. India, have a much higher incidence of these injuries, with males around 15 years of age at highest risk. Limited supplies of fireworks still remain in some states in Australia and we must continue to ensure that children’s access to these is restricted.

sporTs eye injuries Sports-related eye injuries – including orbital fractures, lacerations, hypheama, retinal detachment, corneal abrasion and commotion retinae – are most common for 10 to 19-year-olds with children participating in sports that involve a bat or a ball, or a risk of collision, at the greatest risk of eye injury. Participation in competitive sports is known to increase the risk of eye injury even further.

Sports such as ice hockey in Canada and field hockey in the Unites States have successfully reduced eye injuries by introducing mandatory eye protection. In Australia currently there are standards for squash7 and cricket8 eye protection, though eye protection in these sports is not consistently applied. For those playing cricket, a polycarbonate frame and lens provides sufficient ultraviolet (UV) light and impact protection for those fielding, while those in batsman or wicketkeeper positions need better protection in the form of a faceshield that complies with the standard.8

The eyes anD FishinG Fishing is a sport with some of the highest participation rates internationally. The use of a hook, line and often a sinker has been

mistory

“eye care professionals

should ensure that a

range of options that

provide a comfortable

and secure fit and

appropriate coverage

for children’s faces is

available”

“Amblyopic children

are known to be at

increased risk of injury

to their good eye9 and

because of this, should

wear eye protection for

all sports where there is

a risk of eye injury”

mivision • ISSUE 97 • DEC 14 23

used for fishing since prehistoric times. There’s no doubt that a sharp hook and the potential for it to be released at high speed on a weighted fishing line poses a danger to eyes. The size and weight of a sinker, which easily fits into the orbit, is of particular concern with several cases reported of intracranial penetration of hooks and or sinkers via the orbit with devastating effect. Children and bystanders are at particular risk of fishing-related

eye injuries and should be encouraged to wear polarised polycarbonate wrap-around sunglasses to adequately protect them from UV, glare and the potential for blunt or penetrating eye injuries.

Other medium-to high-risk sports are identified in the table below. Parents, sporting clubs and sporting organisations should be encouraged to consider eye protection for sports that have an inherent moderate to high risk of eye injury.

eDucaTinG chilDren As eye health professionals it is important that we continue to work with sporting groups and policy makers to encourage children to wear eye protection in sports that have a high risk of eye injury. We also need to work directly with the parents and children who come into the practice.

Prominent sports people can serve as great role models to use when speaking to children about eye safety. Several professional basketball players in the

United States wear eye protection while playing, including the now retired Kareem Abdul-Jabbar (pictured right) and test match cricket players are often seen wearing the latest sports fashion sunglasses.

The case for eye protection in cricket was highlighted in 2012 when the South African wicketkeeper, Mark Boucher, was forced to retire from professional cricket as a result of a scleral laceration from a ricocheting ball. This injury would more than likely have been avoided if he had been wearing appropriate eye protection. Many adults would remember the former Australian Prime Minister, Bob Hawke, smashing his glass spectacles when playing in the Parliamentarians’ vs. the Media match in 1984. Most spectacle lenses are more impact resistant these days but even so, these cases highlight the need to replace regular spectacles with eye protection in sports where there is potential for medium- to high-impact, and to avoid the use of glass, particularly for children.

aDDeD impacT oF eye Disease Recently the media reported on a basketball professional in the United States, Isaiah Austin (pictured right), who forfeited his career as a professional basketball player when he was diagnosed with Marfan’s syndrome. Austin’s case highlights the added risk that certain eye diseases and previous ocular trauma or operations can have on the likelihood of eye injuries.

The consequences of further vision loss to an amblyopic child, for example, are devastating. Amblyopic children are known to be at increased risk of injury to their good eye9 and because of this, should wear eye protection for all sports where there is a risk of eye injury. These children should also be advised to avoid participating in sports for which adequate eye protection is not available, e.g. mixed martial arts and boxing. As highlighted in the cases above, children with diseases that place them at higher risk should they experience an eye injury, e.g. high myopes, Marfan’s or those who have had a previous injuries or operation, should be counselled about which sports are more likely to result in eye injury and vision loss and appropriate preventive measures.

are Dress-opTical specTacles aDequaTe? Polycarbonate is almost universally reported as the material of choice for eye protection. Regular dress optical spectacles, can pose an additional danger to a wearer who is subjected to blunt or penetrating trauma. Following detailed reports on glass spectacle-related eye injuries in the 1970s in the United States, minimum impact requirements for spectacle lenses and sunglasses were

mivision • ISSUE 97 • DEC 14mistory24

HigH risk Moderate risk Low risk

Small fast projectiles, e.g. paintball, air rifle

Tennis Swimming

Baseball Badminton Diving

Basketball Soccer Bicycling

Cricket Volleyball Non-contact martial arts

Lacrosse Waterpolo Wrestling

Field and ice hockey Fishing

Racquet sports eg squash, racquetball

Golf

Skiing+

Full contact sports eg boxing and mixed martial arts *

(Reference: Protective Eyewear for Young Athletes, The American Academy of Pediatrics and American Academy of Ophthalmology, Pediatrics. 2004) +High risk of UV damage *No adequate eye protection available for these sports

“Prominent sports

people can serve as

great role models to

use when speaking

to children about

eye safety”

sports eye-injury risk

mivision • ISSUE 96 • DEC 14 mistory 25

introduced. Depending on the individual’s risk profile, as discussed above, if he or she is participating in sports with a medium to high risk of impact, regular spectacles should be replaced with eye protection manufactured specifically so that the frame and lens withstand increased impact.

uV proTecTion For chilDren In light of current concerns about growing rates of myopia, children are increasingly being encouraged to spend more time

outside away from their ‘small screens’. However as eye health professionals and parents, it is vital that we ensure a balance is achieved and children are not exposed to additional hazards by being outside.

The long and short-term effects of UV light on our eyes is well known. In Australia we are particularly vulnerable, with high UV levels resulting in significantly higher rates of pterygium. This was evidenced by a recent study of

Western Australians which found pterygia in 1.2 per cent of 20-year-olds.10

The nature of UV light and its interaction with our eyes is complex. Contrary to skin exposure, peak ocular exposure times to UV light are early and late in the day, when the sun is low. Exposure in the middle of the day, when the sun is overhead, is limited by the shape of our face with our brows providing some natural protection. However, in environments with highly reflective surfaces, e.g. on the water, snow and roads, UV light is reflected at a broad range of angles. Sunglasses with good lateral coverage are particularly important for these environments, both for comfort and protection.

Australia is the only country internationally with mandatory legislation that requires sunglasses to offer minimum levels of UV protection.11 The World Health Organisation recommends wrap-around sunglasses and a broad-brimmed hat for children to reduce the effects of UV exposure. Education campaigns such as the ‘slip, slop, slap’ and more recently the addition of ‘seek and slide’ have successfully contributed to sunsmart behaviours that have slowed the rate of skin cancer in Australia. Unfortunately the uptake of children wearing sunglasses remains low, with one study reporting only 18.9 per cent of 14 to 20-year-olds wearing sunglasses.12

While it remains a challenge to encourage children to wear sunglasses, we must continue to reinforce the message that sunglasses are important from a young age. Eye care professionals should ensure that a range of options that provide a comfortable and secure fit and good coverage appropriate for a child is available.

“Australia is the only

country internationally

with mandatory

legislation that requires

sunglasses to offer

minimum levels of

UV protection”

mivision • ISSUE 97 • DEC 14mistory26

The role oF opTomeTry anD ophThalmoloGy Eye health professionals play an important role in educating children and their caregivers about common eye hazards and how to avoid them. We should continue to monitor and review eye injuries and act quickly on any trends. Through community interactions,

optometrists and ophthalmologists have a unique opportunity to be influential and ensure that eye protection and eye injury prevention strategies receive greater attention.

Annette Hoskin is an optometrist with extensive experience in the field of eye protection, eye injury prevention, product development, compliance

and quality control. Her time is spent between roles at the Lions Eye Institute Centre for Ophthalmology and Visual Science at The University of Western Australia as a Research Fellow and consulting to Eyres Optics, a WA based manufacturer of eye protection. She is a committee member for Australian Standards Committees for Eye Protection (SF006), Sunglasses (CS053) and Spectacles frames and lenses(MS024).

Eye Injury Prevention• Limitaccesstohousehold

chemicals

• Buyage-appropriatetoys

• Childrenunder13shouldtravel in a rear seat with age-appropriaterestraints

Eye Protection Advice• Providecomfortablewrap-aroundsunglassesandencouragetheiruse• Beagoodrolemodelforeyeprotection• Alwaysprescribepolycarbonateortrivexforchildren• Wearpolycarbonate,polarisedwrap-aroundsunglasseswhilefishing• Replaceregulardressopticalspectacleswitheyeprotection – for all sports for amblyopic children –formedium-tohigh-risksportsforallchildren

BehaviouralOptometrists OptimisingGrowthandLearningBehaviouraloptometristsandACBOAccreditedVision Therapists take a holistic approach to treating a diverse range of children’s vision problems that may be due to developmental delay or a result of injury or disease. Using individualised vision therapy programs they work to improve visual comfortandefficiencyandto create automaticity of developmentally delayed visual skills.

writer Melanie Kell

areas that can be targeted for improvements within a vision therapy program include amblyopia, strabismus, convergence insufficiency and eye movement control. Therapy can also improve vision processing skills such as visual spatial abilities, visual discrimination and visual memory.

According to Bernie Eastwood, Vice President of the Australasian College of

Behavioural Optometrists, vision therapy programs are optimised when there are regular in-office visits with a therapist who works with a child and their family to guide, challenge, motivate and support the practice of vision activities at home. “Home practice is a vital component in successful outcomes from a vision therapy program. As Malcolm Gladwell states in his book Outliers, ‘Practice isn’t the thing

mivision • ISSUE 97 • DEC 14 mistory 27

References:

1. Abbott J, Shah P: The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol 58:476-485, 2013

2. Armstrong GW, Kim JG, Linakis JG, et al.: Pediatric eye injuries presenting to United States emergency departments: 2001-2007. Graefes Arch Clin Exp Ophthalmol 251:629-636, 2013

3. MacEwen CJ, Baines PS, Desai P: Eye injuries in children: the current picture. Br J Ophthalmol 83:933-936, 1999

4. Kadappu.S., Silveira.S., Martin.F.: Aetiology and outcome of open and closed globe eye injuries in children. Clin Experiment Ophthalmol 41:427-434, 2013

5. Blackburn J, Levitan EB, MacLennan PA, et al.: The epidemiology of chemical eye injuries. Curr Eye Res 37:787-793, 2012

6. Durbin DR, Chen I, Smith R, et al.: Effects of seating position and appropriate restraint use on the risk of injury to children in motor vehicle crashes. Pediatrics 115:e305-309, 2005

7. AS/NZS 4066 Eye protectors for racquet sports. Sydney: Standards Australia/ NewZealand, 1992

8. AS/ NZS 4499.3 Protective headgear for cricket Part 3: Faceguards. Standards Australia/ New Zealand. 1997

9. Tommila V, Tarkkanen A: Incidence of loss of vision in

the healthy eye in amblyopia. Br J Ophthalmol 65:575-

577, 1981

10. McKnight CM, Sherwin JC, Yazar S, et al.: Pterygium

and conjunctival ultraviolet autofluorescence in young

Australian adults: the Raine Study. Clin Experiment

Ophthalmol, 2014

11. AS/ NZS 1067:2003 Sunglasses and

fashion spectacles. Sydney: Standards Australia/

NewZealand

12. Lagerlund M, Dixon H, Simpson J, et al.:

Observed use of glasses in public outdoor settings

around Melbourne, Australia:1993 to 2002. Prev Med

42:291-296, 2006

JoyceHendersonBequestFundThe Joyce Henderson Bequest Fund generously finances the prestigious Joyce Henderson Paediatric Ophthalmology Fellowship. The annual fellowship enables an ophthalmogist to conduct research in this important area. Each year the ophthalmology fellow spends their time jointly between the Lion’s Eye Institute and the Princess Margaret Hospital for Children, in Perth Western Australia. For more information about the fellowship and its valuable work, please refer to the LEI website https://www.lei.org.au/research/genetics-and-epidemiology/joyce-henderson-fellowship/

you do once you’re good. It’s the thing you do that makes you good’.”

a co-orDinaTeD approach Ms. Eastwood said children with dyslexia, learning difficulties, autism spectrum disorder or ADD, may have vision related learning difficulties which could benefit from a vision therapy program. “It is extremely important to reduce the impact that poor visual skills or vision processing skills may be having on these diagnosed conditions,” she said, adding “co-management with other professionals such as occupational therapists or speech pathologists can be of great benefit to the child and family. Communication and shared understanding of all of the child’s needs improves the delivery and outcomes of all therapies that a child may require to reach their potential.”

eDucaTion anD aDVice Education and advice to help children and their families optimise their environment is also a significant role of the behavioural optometrist. “Vision therapy will obviously not change an underlying syndrome or disease and so we can help parents and teachers understand the impact that a child’s visual abilities have on daily life,” said Ms. Eastwood.

“Practical advice such as optimising a child’s vision through their position in the classroom can have great impact. Seating a child with nystagmus so that their eyes are positioned in the null point can optimise vision stability and acuity for that child which in turn optimises their learning in a classroom. Educating parents and teachers as to why a child with diplopia on up gaze should not be

seated on the floor to look up at a board and why they might get frustrated playing volleyball but not soccer can be extremely enlightening for them.”

Programing vision therapy and working with a child and their family to achieve their goals and improve their quality of life is a challenging but ultimately rewarding role within optometry. The Australasian College of Behavioural Optometrists (ACBO), founded in 1987, provides Australian, New Zealand and Asian optometrists with the opportunity for education and training in the field of neurodevelopmental optometry and its application in areas such as learning difficulties, traumatic brain injury, sports vision and binocular vision dysfunction. Visit acbo.org.au