Eye injuries through history
Given how important vision has historically been considered to be, ocular trauma has often provided a dramatic trope in literature or significant historical event
The story of David and Goliath, is thought to be the first description of a trans-orbital injury causing death (4). The thinness of the orbital bones relative to the frontal bones are likely to have allowed the stone to enter through the eye socket and penetrate Goliath’s brain stem, resulting in his death. When developing eye protection, it is important to ensure the eye and surrounding structures are adequately protected to prevent such injuries.
Fig 1: The blinding of Polyphemus
These texts remind us of the importance of vision and underline the universal need for strategies to prevent eye injuries in a range of situations. In this context, it is important to focus especially on high-risk individuals and people participating in hazardous activities. Eye injuries can be classified in a number of ways according to the structures affected or the mechanism and/or setting of the trauma. Eye protection is generally designed and selected based on the setting of the injury as this dictates the likely hazard and, therefore, the mechanisms or cause of trauma.
The evolution of eye protection
Eye protection works in a number of different ways to protect the eye and adnexa. Generally, it provides a barrier to mechanical, actinic, chemical, biological, radioactive or thermal damage, protects the eye from the ingress of airborne or liquid chemicals, and redistributes the force of blunt trauma away from the globe and adnexa. The earliest use of eye protection can be traced back to the deployment of metal helmets and visors to protect the face and eyes of soldiers in armies dating back to antiquity.
Some of the earliest protective lenses known to have been used for mechanical protection were found on a 15th-century helmet with hinged metal-rimmed glass lenses that cover the eyes. Wire gauze and plain glass were some of the first materials used for protective lenses. In his Histoire des lunettes published in 1901, Pierre Pansier described the use of lenses against light and ‘pests’ as far back as 1656. The 19th-century German ophthalmologist Hermann Cohn also had a keen interest in visual hygiene and promoted the use of mica for safety lenses.
Non-mechanical protection mechanisms, whether actinic or photic, historically included the use of whale bones with a small aperture which the Inuit used against sunlight. The development of hardened glass, initially as Columbia Resin #39 (CR39) in the late 1950s, and subsequently polycarbonate in the 1990s, significantly influenced the available materials and designs for eye protection. The characteristics of lens materials used in spectacles and goggles were summarised ahead of a push to introduce mandatory impact resistance for spectacle lenses in the United States(5). Prescription spectacles and sunglasses are known to introduce a secondary hazard if a lens shatters, adding a potentially much more harmful penetrating eye injury to blunt trauma (6). The US Food and Drug Administration established a mandatory impact resistance requirement for all prescription lenses and sunglasses in 1971 (7). Figure 2 provides a summary of key advances in the evolution of eye protection.
Fig 2: Summary of key advances in the evolution of eye protection.
Sports and recreation
Sports and recreational activities involving a bat or other implement, ball and/or the potential for collision are commonly associated with eye injuries. Jousting was a popular sport during the Renaissance and facial injuries were common despite riders wearing heavy armour including a helmet and visor. King Henry II of France suffered an eye injury during a jousting tournament in 1559 (8). He had not fastened his visor properly before a contest and a splinter from his opponent’s lance entered his right orbit. This led to traumatic interhemispheric haematoma, while the splinter, which got stuck in the eye, also caused periorbital cellulitis and left interhemispheric empyema, resulting in the king’s death (8, 9). The death of the king had important ramifications for France, leading to religious wars and internal instability that significantly changed history. Incidentally, Nostradamus was suggested to have predicted it in one of his quatrains (10).
A number of professional athletes have suffered eye injuries that have adversely affected their careers. Ice hockey, for instance, is associated with a high incidence of serious eye injuries in amateur and professional play (11-14). Professional ice hockey players, including Canadian Gerard Desjardins and American Bernie Parent, suffered severe injuries leading to their early retirement from professional sport. The injury to Desjardins in 1977 when a puck penetrated his mask, and Parent’s injury in 1979 when a hockey stick entered his right eye through a hole in his mask, led to many in the sport to stop using fibreglass masks in favour of helmets with cages or face shields. An effective public health campaign by the ophthalmologist Thomas Pashby resulted in changes to the rules and regulations in amateur and professional ice hockey, which reduced eye injuries (15, 16). Despite these changes, eye injuries still occur in ice hockey when adequate eye protection is not worn. In 2000, Bryan Berard suffered a lacerated sclera and retinal tear, which lead to retinal detachment when a stick hit his right eye. In 2013, Marc Staal failed to wear a visor with his helmet and suffered a retinal tear and orbital fracture when he was hit above the eye by the ice-hockey puck, ending his season prematurely.
Baseball players are known to suffer retinal detachments and orbital fractures after being hit by a ball at speed. In 1957, Herb Score, a pitcher for the Cleveland Indians, suffered an eye injury and orbital fractures when the batter struck the ball directly at Score, resulting in his early retirement that season. Major league baseball outfielder and batter for the Boston Red Sox, Tony Conigliaro, suffered a retinal detachment and facial fractures when he was hit in the face by a pitch in 1967. Conigliaro later retired from the game due to permanent damage to his vision.
In the 2009 Hungarian Grand Prix, Philipe Massa suffered an eye injury caused by a loose suspension spring penetrating his helmet during the race. Within a year of the incident, the Fédération internationale de l'automobile (FIA) revised its requirements for helmets, demonstrating the impact a high-profile sports injury could have on safety standards.
While Prime Minister of Australia, Bob Hawke suffered corneal lacerations when his glasses shattered from being hit with a cricket ball during the Prime Minister’s ‘First 11’ cricket match in 1984. This illustrated the fact that appropriate eye protection, rather than regular spectacles, should be worn when undertaking high-risk sports (6).
The use of eye protection in sport is being adopted to varying degrees, with a successful reduction in eye injuries in US field hockey (17), women’s lacrosse (18), and ice hockey (16). Professional players can serve as role models to promote eye protection, as illustrated by basketball player Kareem Abdul-Jabbar (19). Professional sports can influence the development of standards for sports eye protection, with prominent athletes’ injuries resulting in the revision of standards and/or legislation relating to personal protective equipment for sport. It is important that sporting activities can be undertaken without risk of an eye injury, since many sports include hazards such as projectiles and blunt objects like bats and balls which can result in eye injuries. Eye protection has been successfully proven to be an effective method of reducing the impact of these hazards and it is important to continue to promote their use.
A wide range of mechanical, chemical and, more recently, laser-related eye injuries are associated with combat (20). In some mediaeval cultures, the loss of an eye in war was thought to reflect an individual’s valour and stature as a soldier (21). Sertorius, a well- respected general during the civil war in Rome in 82BC, claimed to be proud that he lost an eye in battle, stating that the injury was a trophy greater than any other.
A masterpiece of mediaeval narrative art, the Bayeux Tapestry, depicts the Norman conquest of England in 1066 (22). The narrative concludes in 1066 when Harold, the former Earl of Wessex and King of England, loses his life and crown to William Duke of Normandy. The tapestry shows a person trying to remove an arrow from his eye next to the legend ‘here Harold the King is killed’, which has led to the popular idea that the King was fatally struck in the eye by an arrow. The historical record disputes this story, and the legend may be referring to another figure in the tapestry, but the famous narrative has stuck (23).
Personal protective equipment used by the military often results from novel applications of technologies which are then transferred to products for civilians. In 1910, the French chemist Édouard Bénédictus obtained patents for manufacturing laminated glass that was subsequently used in the lenses of gas masks and the windshields of military vehicles. Military organisations have supported activities investigating the ballistic impact qualities of different materials, leading to the widespread use of polycarbonate for eye protection (24).
The face and eyes represent 9% and 0.1%, respectively, of the body by surface area but these areas are disproportionately injured in battle (25). Between 21 and 39% of combat injuries among US and UK forces are facial (26, 27) and 6% affect the eyes (28). The increased use of improvised explosive devices (IED) has resulted in an increase in injuries associated with small, energised fragments associated with IEDs.(29). The nature and proportion of hospitalisations attributed to combat-related ocular trauma has changed in the last century. An increase in the proportion of hospitalisations due to ocular trauma in combat was 2% in 1914 and 13% during Operation Desert Storm (30).
While helmets protect from brain injury, the need to protect the face and eyes is also being increasingly recognised, as soldiers are substantially incapacitated by an eye injury. The British army introduced mandatory eye protection in 2006 after data showed that personnel who did not wear eye protection were 36 times more likely to sustain an eye injury and that seven deaths could have been prevented by appropriate eye protection (31).
Technological improvements resulted in improved effectiveness of eye protection during the 1980s and ‘90s as focus moved to improved compliance. In the United States, the Authorised Protective Eyewear List was established in 2004 to improve wear compliance, and targeted not only impact performance but also weight, optical properties, style and field of view. The level of compliance increased to 85-95% (32). (See also Figure 3: Oakley eye protection system.) Mandatory eye protection issued to British soldiers in the Afghanistan conflict resulted in a halving of eye injuries. Improved compliance with eye protection during recent combat operations has contributed to a reduction in both the number and severity of eye injuries.
Figure 3: Oakley eye protection system
The role of standardisation in development of eye protection
As new materials and innovations are adopted to improve eye safety, standards play an important role in the application of policies relating to eye protection. In early efforts to reduce the effect of eye injuries and promote the need for eye protection, the Royal Eye Hospital in London displays of safety glass tested with a 14-gram steel ball dropped from a height of 1.83 metres. The impact energy of this test was 0.25 J, which is comparable to current standards for low-impact eye protection (33) and the FDA’s dress optical requirements of 0.87 and 0.21, respectively (7).
National and international standards are in place in many countries for sports, military and occupational eye protection. While they are generally not mandatory, standards provide a basis to ensure that products promoted as eye protection provide an appropriate level of mechanical impact protection. It is also important to ensure that there is no visual impairment caused by optical, transmittance and colouration limitations. Figure 2 summarises some of the key advances in the introduction of policies and products to improve the effectiveness of eye injury prevention strategies.
A wide range of circumstances and mechanisms have been associated with ocular trauma throughout history. Collecting and analysing data has improved our understanding of the hazards and circumstances of eye injuries, informing strategies for their prevention (34). Evidence-based advocacy has been effective in reducing the incidence of ocular trauma through eye protection for those exposed to eye injury hazards. Translating evidence into practice has resulted in key interventions toward eliminating eye injuries over the last century.
The most effective strategy to prevent injuries is to remove hazards. If this isn’t possible, eye protection provides another line of defence. Effective product standards, as well as policies, education and legislation combined with public health campaigns, have been effective strategies in the prevention of ocular trauma in a range of circumstances, including sports, occupations, combat and domestic applications.