1. mistory mivision • ISSUE 97 • DEC 14
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.
22
writeR Annette Hoskin

2. mivision • ISSUE 97 • DEC 14 23
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
mistory
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
“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”

3. 24 mistory mivision • ISSUE 97 • DEC 14
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
High risk Moderate risk Low risk
Small fast projectiles, e.g. paintball,
Tennis Swimming
air rifle
Baseball Badminton Diving
Basketball Soccer Bicycling
Cricket Volleyball Non-contact martial arts
Lacrosse Waterpolo Wrestling
Field and ice hockey Fishing
Racquet sports eg squash,
Golf
racquetball
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

4. 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”
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.

5. 26 mistory mivision • ISSUE 97 • DEC 14
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
• Limit access to household
chemicals
• Buy age-appropriate toys
• Children under 13 should
travel in a rear seat with
age-appropriate restraints
Eye Protection Advice
• Provide comfortable wrap-around sunglasses and encourage their use
• Be a good role model for eye protection
• Always prescribe polycarbonate or trivex for children
• Wear polycarbonate, polarised wrap-around sunglasses while fishing
• Replace regular dress optical spectacles with eye protection
– for all sports for amblyopic children
– for medium- to high-risk sports for all children
Behavioural Optometrists
Optimising Growth and Learning
Behavioural optometrists
and ACBO Accredited
Vision 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
comfort and efficiency and
to 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

6. 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
Joyce Henderson Bequest Fund
The 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