Eur J Ophthalmol 2010 ; 20 ( 4 ): 770 - 775

ORIGINAL ARTICLE

Work-related eye injury: the main cause of ocular

trauma in Iran
Mohammad Reza Mansouri1, Mona Hosseini2,3, Masoumeh Mohebi1, Fateme Alipour2,
Ramin Mehrdad4
1
Department of Ophthalmology, Tehran University of Medical Sciences, Tehran
2
Eye Research Center, Tehran University of Medical Sciences, Tehran - Iran
3
Genomic Medicine and Statistics, University of Oxford, Oxford - UK
4
Department of Occupational Medicine, Tehran University of Medical Sciences, Tehran - Iran

Purpose. Occupational eye injuries are among the major causes of ocular trauma and can cause severe
visual impairment, with even minor injuries incurring considerable financial costs due to work absen-
teeism. This study was designed to evaluate the epidemiology of eye trauma and the role of occupa-
tional injuries at Farabi Eye Hospital, which is the largest eye hospital in Iran.
Methods. In this prospective, cross-sectional study, 822 eyes from 768 trauma patients presenting to
Farabi Eye Hospital were enrolled in the study. The Birmingham Eye Trauma Terminology System and
the United States Eye Injury Registry model were adopted as the basis for the study questionnaire.
The questionnaires were completed through in-person interviews and comprehensive ocular exami-
nations.
Results. The mean age of ocular trauma patients was 31.11 years, and 685 (89.2%) patients were
male. Of all eye injuries, 73.7% were work-related. Only 2.2% of the patients were wearing safety
goggles at the time of injury. History of previous eye trauma was positive in 44.3% of cases. An Ocular
Trauma Score 3 or more was present in 4% of patients.
Conclusions. Work-related eye trauma is the major cause of eye injury in Iran and most often occurs
as a result of the lack of proper eye protection. Most work-related eye injury patients are young men.
(Eur J Ophthalmol 2010; 20: 770-5)

Key Words. Eye injury, Eye trauma, Iran, Occupational, Work-related

Accepted: August 13, 2009

INTRODUCTION
Ocular trauma is a common cause of emergency ophthal-
mologic visits. In the United States alone, it is estimated
that more than 2.4 million eye injuries occur annually (3).
The cumulative lifetime prevalence of eye injury in the Uni-
ted States is estimated to be over 1,400 per 100,000 popu-
lation (4). There are considerable discrepancies in inciden-
ce by factors such as gender, age, occupation, and area
of residence (rural versus urban areas; developed versus
developing countries). Ocular trauma is more common in
young people (5), males, workers, and those who do not
use safety goggles at work (6-11).
It has been suggested that about one quarter of all serious
eye injuries are related to activities in the workplace (7).
Each year, more than 65,000 work-related eye injuries and
illnesses, with significant visual consequences, are repor-
ted in the United States (12). However, there is a substan-
tial lack of knowledge about the different aspects of eye in-
juries in developing countries. Additionally, the proportion

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 Mansouri et al

of work-related eye injuries due to different causes varies
between countries (7), and findings from other developing
countries cannot be generalized to Iran.
Systematic collection of standardized data on the occur-
rence of eye injuries can lead to health system action plans
to prevent serious visual impairment. Using the United Sta-
tes Eye Injury Registry (USEIR) as our framework (1, 2), this
study was designed to elucidate information regarding the
causes, settings, possible prognosis, and role of work-re-
lated accidents in ocular trauma epidemiology in Iran. Our
results provide useful information for ophthalmologists as
well as the health system, and could be useful for preven-
ting occupational eye injuries in the workplace.
MATERIALS AND METHODS
In this prospective, cross-sectional study, 822 eyes from
768 ocular trauma patients presenting to the Farabi Eye
Hospital (Tehran, Iran) emergency clinic were enrolled. The
study protocol was approved by the ethics committee of
Tehran University of Medical Sciences. All subjects signed
informed consent forms prior to participating in the study,
and patient care was independent of the patients’ deci-
sions regarding this issue.
One day in each week was randomly selected from Sep-
tember 1, 2005, to February 28, 2006. During the selected
days, all patients with complaints of trauma presenting to
the Emergency Clinic at Farabi Eye Hospital were exami-
ned. The Birmingham Eye Trauma Terminology System (1)
and the USEIR model (2) were adopted as the basis for
the study questionnaire. In each case, the questionnaire
was completed through an in-person interview and a com-
prehensive ocular examination. All interviews and exami-
nations were done by 3 ophthalmologists familiar with the
study questionnaire.
Demographic data and data on the clinical presentation
such as cause and place of injury, use of protective eyewe-
ar, and nature of the injury as accidental or intentional were
collected via standardized questionnaires by the same
physician. The Ocular Trauma Score (OTS) (13) was calcu-
lated for each injured eye.
Data were analyzed by SPSS 16.0. We compared demo-
graphic data, clinical signs, and initial diagnosis between
occupational and nonoccupational subgroups using a t
test for continuous variables and the chi square test for
binary or categorical variables. p Values <0.05 were consi-
dered statistically significant.
RESULTS
A total of 822 eyes from 768 patients were evaluated in this
prospective study. Age, gender, laterality of the injured eye
or eyes, and hospitalization are summarized in Table I.
Approximately 73.7% of eye injuries were work-related.
Industrial environments were the most common site
for ocular trauma to take place (71.5%), with the home
ranking second (13%), and streets or highways third
(11%). The mean and mode time to presentation in the
emergency room were 11 and 8 hours after the trauma,
respectively, but the presenting time varied between im-

TABLE I - DEMOGRAPHIC DATA, LATERALITY, AND HOSPITALIZATION

Total, n=768 Work-related, n=566 Nonoccupational, n=202 p value

Age, y, mean (SD) 31.1 (12.7) 32.7 (11.00) 26.7 (15.8) 0.000*
Gender, n (%)
  Male 685 (89.2) 545 (96.3) 140 (69.3) 0.000*
  Female 83 (10.8) 21 (3.7) 62 (30.7)
Laterality, n (%)
  Right 373 (48.6) 266 (47.0) 108 (53.5)
  Left 336 (43.7) 252 (45.5) 83 (41.1) 0.198
  Bilateral 59 (7.7) 48 (8.5) 11 (5.4) 0.164
Hospitalization, n (%)
  No 730 (98.4) 544 (98.6) 186 (97.9) 0.54
  Yes 12 (1.6) 8 (1.4) 4 (2.1)

*Statistically significant at <0.001.

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 Work-related eye injury in Iran

mediately (less than 1 hour) to 240 hours.
About 92% of eyes had no eye protection at the time of
injury, and only 2.2% were protected by safety goggles.
More than 95% of traumas were unintentional and 3.5%
of injuries were secondary to assault. Self-inflicted ocular
traumas were reported in 0.7% of cases.
The 3 most common sources of trauma both for the group
as a whole and within the occupational group were scatte-
red particles of stone blade, blunt object, and arc welding,
with 40%, 16%, and 9%, respectively. In patients with no-
noccupational eye injuries, the 3 most common sources
were blunt objects (39.8%), sharp objects (14.8%), and
falls (6.5%).
A history of previous eye trauma was positive in 44.3% of
patients. Among those who had a positive history of trau-
ma, 91.8% were work-related and the odds ratio for the
current injury being work-related was 7.72 (95% confiden-
ce interval 4.93–12.09).
At the time of presentation, 3% of eyes had visual acuity
less than 20/200 and 1% of eyes had visual acuity betwe-
en 20/120 and 20/200. Fortunately, 88% had visual acuity
greater than 20/40.
The cornea was the most commonly involved tissue; distri-
bution of involved tissues is shown in Table II. Almost all
patients (97.7%) had more than one tissue involved.
Major diagnoses on presentation were open globe inju-
ry, intraocular foreign body, endophthalmitis, and corneal
burn. Table III shows the frequency and patterns of open
globe injuries.
Endophthalmitis was the initial diagnosis in 4 (0.5%) pa-
tients. All of the endophthalmitis cases had occupational
injuries. Intraocular foreign body (posterior or anterior) was
the initial diagnosis given to 2 (0.2%) patients; 1 had endo-
phthalmitis at the time of initial presentation and both had
occupational injuries.
Corneal burn was observed in 22 (2.7%) patients; 1.6%

TABLE II - COMPARISON OF INVOLVED TISSUES BETWEEN OCCUPATIONAL AND NONOCCUPATIONAL INJURED EYES

Involved tissue Total, Occupational, Nonoccupational, p value OR (95% CI)

n=822, n (%) n=606, n (%) n=216, n (%)

Lids 115 (14) 33 (5.4) 82 (38) 0.000* 0.09 (0.06–0.15)

Conjunctiva 153 (18.6) 80 (13.2) 73 (33.8) 0.000* 0.30 (0.20–0.43)
Lacrimal system 6 (0.7) 3 (0.5) 3 (1.4) 0.189 0.35 (0.07–1.76)
Cornea 648 (78.8) 538 (88.8) 110 (50.9) 0.000* 7.62 (5.28–11.00)
Sclera 9 (1.1) 7 (1.2) 2 (0.9) 1.000 1.25 (0.26–6.06)
Iris 21 (2.6) 14 (2.3) 7 (3.2) 0.457 0.70 (0.28–1.77)
Anterior chamber 46 (5.6) 20 (3.3) 26 (12) 0.000* 0.25 (0.14–0.46)
Lens 6 (0.7) 4 (0.7) 2 (0.9) 0.656 0.71 (0.13–3.90)
Vitreous 2 (0.2) 1 (0.2) 1 (0.5) 0.457 0.36 (0.2–5.70)
Retina 13 (1.6) 8 (1.3) 5 (1.3) 0.343 0.56 (0.18–1.74)
Macula 13 (1.6) 6 (1.0) 7 (3.2) 0.49 0.30 (0.10–0.90)
Choroid 3 (0.4) 3 (0.5) 0 (0.0) 0.571 1.00 (0.99–1.01)
Optic nerve 2 (0.2) 0 (0.0) 2 (0.9) 0.069 0.99 (0.98–1.00)
Extraocular muscles 0 (0.0) 0 (0.0) 0 (0.0) NA NA
Orbit 0 (0.0) 0 (0.0) 0 (0.0) NA NA

*Statistically significant at <0.001.

TABLE III - PATTERNS OF OPEN GLOBE INJURIES

Open globe injury Corneal, n (%) Scleral, n (%) Corneoscleral, n (%)

Full-thickness corneal laceration 13 (1.6) 4 (0.5) 0 (0.0)

Rupture 5 (0.6) 1 (0.1) 1 (0.1)
Penetrating Injury 11 (1.3) 1 (0.1) 2 (0.2)
Perforating Injury 3 (0.4) 0 (0.0) 1 (0.1)

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 Mansouri et al

were chemical with 1.1% acidic and 0.5% alkali burns.
Corneal thermal and electrical burns were observed in
0.9% and 0.2% of corneal burn patients, respectively.
Among corneal burn cases, 59% (13 patients) were occu-
pationally related.
The OTS for injured eyes was calculated in 799 injured
eyes. In 23 patients, most of whom were children under 5
years of age who could not cooperate for visual acuity te-
sting, the OTS could not be calculated. Results are shown
in Table IV.
DISCUSSION
Our study population consisted mainly of patients who
were male (more than 89%), workers (approximately 74%),
and young people (mean age of 31 years). These findings
are compatible with other published reports (6-11, 14, 15),
but the percentage of work-related ocular traumas is higher
in our study compared to rates of up to 25% in the litera-
ture (7, 9). The reported ratio of occupational eye injuries in
developing countries is higher. For example, work-related
eye injuries are reported to be responsible for 20.5% to
56% of ocular traumas in Singapore (16) and 55.9% of eye
injuries in a rural population in southern India (10). These
differences can be attributed to differing study designs and
variable definitions, cultural differences, different locations
(rural versus urban), and different patterns of ocular injuri-
es. Due to these factors, it is a widely held hypothesis that
the incidence of ocular trauma varies by population, giving
rise to the necessity of conducting epidemiologic studies
in each region.
Only 3.6% of workers in our study were using safety gog-
gles at the time of injury. This finding may show the effica-
cy of safety goggles in preventing eye injuries; however,
because of our study design, we cannot know the ratio
of their use in the general working population. More than
44% of cases had a history of previous eye trauma, but
even in those with a positive history, only 1.9% wore safety
glasses at the time of injury. This is the same behavior as
reported in Singapore (16). It clearly shows that awareness
of the possibility of trauma alone is not enough motivation
to use safety goggles.
In one study in India, 97.8% of patients were not wearing
any eye protection at the time of trauma (10). This is similar
to our finding, and much lower than the reported use of
safety goggles by 32% of US adults engaging in activities
that could cause an eye injury (17). It appears that the use
of preventive means is neglected in developing countries,
and more attention should be paid to this issue.
Cornea was the only tissue which reached statistical signi-
ficance for more involvement among occupational injuries,
primarily because of the nature of work-related eye injuri-
es, which usually result from foreign bodies. As the source
of trauma was scattered particles of stone blade in about
40% of occupationally injured patients, most corneal injuri-
es were superficial corneal foreign bodies. Lid, conjunctiva,
and anterior chamber involvement were significantly more
prevalent among nonoccupational injuries. This differen-
ce is explained by blunt objects being the most common
source of injury in this group.
Although most of the injuries were minor and more than
86% of our patients had an OTS of 5, we did encounter 4
cases of endophthalmitis and 2 intraocular foreign bodies.
All of these serious cases were occupationally related.
Also, from a preventive perspective, although most ocular
traumas are minor and do not require hospitalization (18),
each trauma indicates a lack of preventive measures and,

TABLE IV - OCULAR TRAUMA SCORE (OTS) AMONG INJURED, N (%)

OTS Total Occupational Nonoccupational p value

1 2 (0.3) 1 (0.2) 1 (0.5) 0.457*

2 6 (0.8) 2 (0.3) 4 (2.0) 0.044*†
3 23 (2.9) 14 (2.3) 9 (4.4) 0.155
4 77 (9.6) 50 (8.4) 27 (13.3) 0.066
5 691 (86.5) 529 (88.8) 162 (79.8) 0.001‡
Total 799 (100) 596 (100) 216 (100)

*p values by exact test.

†Statistically significant p<0.05.
‡Statistically significant p<0.01.

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 Work-related eye injury in Iran
especially in work-related injuries, can be interpreted as a
shortage of laws, supervision, awareness, and accessibili-
ty to proper safety equipment, leading to catastrophic se-
quela (18). Even minor traumas such as superficial corneal
foreign bodies result in 1 to 2 days absence from work,
and the accumulation of such absences results in signifi-
cant financial costs (7). Considering the workload in emer-
gency ophthalmologic units and the expense of treatment,
the economic consequences of eye injuries become even
higher.
In summary, occupational eye injuries are the most com-
mon cause of ocular trauma among Farabi Eye Hospital
emergency room patients. The high proportion of work-
related eye trauma among our patients may be attributed
to several causes, the most important of which is the pro-
bable low use of safety goggles among Iranian workers.
Work-related ocular injuries have not received enough at-
tention in Iran. Many employers, especially those in small
businesses, do not provide appropriate safety goggles for
their employees, and even when the goggles are provided,
many workers do not use them at all because of inconve-
nience or distortion of vision. Our data suggest that this
needs more attention.
Eye injuries may be reduced substantially by educating
workers about potentially risky behaviors and convincing
them to use safety goggles, instituting laws requiring em-
ployers to provide well-made, appropriate safety goggles
for their employees, and close supervision.
REFERENCES
1. Kuhn F, Morris R, Witherspoon CD. Birmingham Eye
Trauma Terminology (BETT): terminology and classifica-
tion of mechanical eye injuries. Ophthalmol Clin North
Am 2002; 15: 139-43.
2. Kuhn F, Pieramici DJ, eds. Ocular Trauma: Principles and
Practice. Italy: Thieme; 2002.
3. Salvin JH. Systematic approach to pediatric ocular trau-
ma. Curr Opin Ophthalmol 2007; 18: 366-72.
4. Kuhn F, Morris R, Witherspoon CD, Mann L. Epidemio-
logy of blinding trauma in the United States Eye Injury
Registry. Ophthalmic Epidemiol 2006; 13: 209-16.
5. Nzeh DA, Owoeye JF, Ademola-Popoola DS, Uyanne I.
774
EJO_09_84_ALIPOUR.indd 774
Several of this study’s strengths lie in its prospective nature,
a relatively large sample size, and the use of a standardized
questionnaire. Our study population may not be conside-
red to be a representative sample of all eye trauma patients
throughout the country. Because Farabi Eye Hospital is the
largest eye hospital in Iran and additionally because of the
services Farabi Eye Hospital offers, the hospital receives
referrals from all over the country. Further research inve-
stigating the exact incidence of eye injuries throughout the
country of Iran and its sequela are necessary.
ACKNOWLEDGEMENTS
The authors thank Drs. R. Ghafari and M. Malihi for their help in
visiting patients and Dr. Caroline Hedges for editing the manu-
script.
This study was supported by a grant from Tehran University of
Medical Sciences.
The authors report no proprietary interest.
Address for correspondence:
Fateme Alipour, MD
Eye Research Center
Tehran University of Medical Sciences
Tehran
005 63110 Iran
alipour@tums,.ac.ir
Sonographic evaluation of ocular trauma in Ilorin, Nige-
ria. Eur J Ophthalmol 2006; 16: 453-7.
6. Mansouri MR, Mirshahi A, Hosseini M. Domestic ocular
injuries: a case series. Eur J Ophthalmol 2007; 17: 654-
9.
7. Vasu U, Vasnaik A, Battu RR, Kurian M, George S. Occu-
pational open globe injuries. Indian J Ophthalmol 2001;
49: 43-7.
8. Vats S, Murthy GV, Chandra M, Gupta SK, Vashist P, Go-
goi M. Epidemiological study of ocular trauma in an ur-
ban slum population in Delhi, India. Indian J Ophthalmol
2008; 56: 313-6.
9. McCall BP, Horwitz IB. Assessment of occupational
eye injury risk and severity: an analysis of Rhode Island
28-04-2010 17:20:12
 Mansouri et al
workers’ compensation data 1998–2002. Am J Ind Med
2006; 49: 45-53.
10. Krishnaiah S, Nirmalan PK, Shamanna BR, Srinivas M,
Rao GN, Thomas R. Ocular trauma in a rural population
of southern India: the Andhra Pradesh Eye Disease Stu-
dy. Ophthalmology 2006; 113: 1159-64.
11. Cillino S, Casuccio A, Di Pace F, Pillitteri F, Cillino G. A
five-year retrospective study of the epidemiological cha-
racteristics and visual outcomes of patients hospitalized
for ocular trauma in a Mediterranean area. BMC Ophthal-
mol 2008; 8: 6.
12. Peate WF. Work-related eye injuries and illnesses. Am
Fam Physician 2007; 75: 1017-22.
13. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Wither-
spoon CD. The Ocular Trauma Score (OTS). Ophthalmol
EJO_09_84_ALIPOUR.indd 775
Clin North Am 2002; 15: 163-5, vi.
14. Ritenour AE, Baskin TW. Primary blast injury: update on
diagnosis and treatment. Crit Care Med 2008; 36: S311-7.
15. Gyasi M, Amoaku W, Adjuik M. Epidemiology of hospi-
talized ocular injuries in the upper East region of Ghana.
Ghana Med J 2007; 41: 171-5.
16. Ngo C S LSW. Industrial accident-related ocular emer-
gencies in a tertiary hospital in Singapore. Singapore
Med J 2008; 49: 280-5.
17. Forrest KY, Cali JM, Cavill WJ. Use of protective eyewear
in US adults: results from the 2002 national health inter-
view survey. Ophthalmic Epidemiol 2008; 15: 37-41.
18. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan
EK, Katz J. The epidemiology of ocular trauma in rural
Nepal. Br J Ophthalmol 2004; 88: 456-60.
775
28-04-2010 17:20:12