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OPTOMETRY REVIEW

Spectacle-related eye injuries, spectacle-impact performance and eye protection Clin Exp Optom 2015; 98: 203–209 Annette K Hoskin* BOptom MBA Swetha Philip* MSOphthal Stephen J Dain† PhD FCOptom FAAO David A Mackey* MD FRANZCO * Centre for Ophthalmology and Visual Science, University of Western Australia, Lions Eye Institute, Perth, Western Australia, Australia † School of Optometry and Vision Science, University of New South Wales, Kensington, New South Wales, Australia E-mail: [email protected]

Submitted: 29 April 2014 Revised: 11 December 2014 Accepted for publication 13 December 2014

DOI:10.1111/cxo.12283 The aim was to review the prevalence of spectacle-related ocular trauma and the performance of currently available spectacle materials and to identify the risk factors associated with spectacle-related ocular trauma. A literature review was conducted using Medline, Embase and Google with the keywords ‘eyeglasses’ OR ‘spectacles’ AND ‘ocular injury’ / ‘eye injury’/ ‘eye trauma’ / ‘ocular trauma’. Articles published prior to 1975 were excluded from this review because of advances in spectacle lens technology and Food and Drug Administration legislative changes requiring impact resistance of all prescription spectacle lenses in the United States. Six hundred and ninety-five individual ocular traumas, for which spectacles contributed to or were the main cause of injury, were identified in the literature. Eye injuries occurred when spectacles were worn in sports, in which medium- to high-impact energies were exerted from balls, racquets or bats and/or as a result of a collision with another player. Frame, lens design and product material choice were found to be associated with ocular injury, with polycarbonate lenses cited as the material of choice in the literature. International, regional and national standards for spectacle lenses had a wide range of impact requirements for prescription spectacle lenses, sports eye protection and occupational eye protection. Spectacle-related injury represents a small but preventable cause of ocular injury. With the increasing numbers of spectacle wearers and calls to spend more time outdoors to reduce myopia, spectacle wearers need to be made aware of the potential risks associated with wearing spectacles during medium- to high-risk activities. At particular risk are those prone to falls, the functionally one-eyed, those who have corneal thinning or have had previous eye surgery or injury. With increased understanding of specific risk factors, performance guidelines can be developed for prescription spectacle eye-protection requirements.

Key words: eyeglasses, eye injury prevention, eye protection, eye trauma, spectacle design Worldwide, studies have shown that the proportion of the population with refractive error and therefore, the number of people wearing spectacles, is increasing.1–4 The incidence of spectacle-related ocular trauma has been estimated to be between three and seven per cent of all ocular injuries.5,6 Fractured spectacle lenses have the potential to convert a blunt trauma into a penetrating eye injury.7–10 Spectacle lens fracture associated with blunt trauma may precipitate serious and permanent eye damage when airbags are deployed,11 when participating in sports12–14 and as a result of falls.9 Additional risk factors for spectacle-related eye injury include previous ocular surgery or injury.15 Spectaclerelated eye injuries continue to be a small but mostly preventable problem. It is estimated that eye protection, worn appropriately, will prevent 90 per cent of sports-

and work-related eye injuries.16 The introduction of mandatory eye protection programs in sports has achieved a reduction in eye injuries of between 77 and 84 per cent.17,18 Eye injuries in hurling in Ireland dropped from 43 in the 15 months before eye protection became mandatory to 17 in the following 15 months.17 Ocular injuries in field hockey in the US dropped from 181 in 2009 to 31 in 2010 with the introduction of eye protection.17,18 In the 1970s, studies highlighting ocular injuries resulting from spectacles prompted the US Food and Drug Administration (FDA) to introduce requirements for impact resistance for all prescription spectacle lenses.19 In Australia since 2007, prescription eye protection can be manufactured to the voluntary Australian Standard (AS/NZS 1337.6) with the same impact protection as non-prescription eye protectors (AS/NZS 1337.1).

© 2015 The Authors Clinical and Experimental Optometry © 2015 Optometry Australia

Campaigns to remove or reduce eye hazards and to introduce personal eye protection in industry have resulted in a reduction in occupational eye injuries;20,21 it is now more common for eye injuries to occur outside of work with as many as 76 per cent of ocular injuries occurring at home.22,23 More effort needs to be devoted to developing standards for eye protection for recreational activities and educating people about the ocular hazards that exist in the home. The impact resistance of spectacle lenses is well understood but not widely published in the literature. The introduction of modern plastic spectacle lenses has resulted in improved impact performance but not all plastics offer the same protection.16,24,25 Several authors have advocated the use of stronger spectacle lens materials, such as polycarbonate and improved frame design to ensure Clinical and Experimental Optometry 98.3 May 2015

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Spectacle-related eye injuries and eye protection Hoskin, Philip, Dain and Mackey

better protection and reduce spectacle-related ocular injury.26–28 Further insights into the hazards to spectacle wearers, the performance of newer high-index plastics and polyurethane and improved guidelines are required.24 We undertook this review to understand better the incidence of spectacle-related ocular injuries and the risks associated with spectacle wear. METHOD A search of Medline and Embase using the keywords ‘eyeglasses’ OR ‘spectacles’ AND ‘ocular injury’ / ‘eye injury’ / ‘eye trauma’ / ‘ocular trauma’ revealed 64 articles reporting spectacle-related ocular injuries published since 1975. A review of additional literature, including current legislation and standards relating to the performance of spectacle frames and lenses was also conducted using Google (Figure 1). Articles published prior to 1975 were not included in this review, since there have been significant advances in spectacle lens technology and changes in prescribing patterns since that time. Hard resin and polyurethane plastics have replaced glass as the material of choice for prescription spectacle lenses and polycarbonate is universally used for non-prescription safety spectacles. RESULTS

Spectacle-related ocular trauma Several studies have highlighted the shift in the setting in which ocular injuries occur. They are now two to three times more likely to occur outside work, with recreational and sporting activities contributing to more injuries than occupational.20–23 Safer eyewear design, the promotion of protective eyewear in sports and recreational activities and use of more impact-resistant plastics in everyday spectacles is advocated.5,9,29 Twelve studies were identified in which broken spectacles contributed to 695 spectacle-related ocular traumas: six case reports, three population-based studies and three retrospective hospital-based studies (Table 1). Sporting activities and their equipment were associated with sports-related spectacle ocular injury, including golf (ball or club),30 badminton (shuttlecock)31 and cricket (ball).32 In a retrospective study on paediatric eye injuries from Taiwan, 58 per cent of spectaclerelated injuries resulted from contact with a Clinical and Experimental Optometry 98.3 May 2015

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Figure 1. Summary of results of literature review. Prisma diagram showing the results of the literature review conducted in PubMed using the terms ‘eyeglasses’ or ‘spectacles’ and ‘ocular’ or ‘eye’ and ‘trauma’ or ‘injury’. Sixty-four articles where returned from this search and 36 of these proved to be unrelated. To the remaining 28 articles were added a further 12 articles identified in cross-referencing. In total, 40 articles were reviewed. 12 related to ocular trauma, 12 related to the technical performance of spectacle lenses and 16 related to policies and recommendations for spectacle lenses. ball.6 In one study of 16 spectacle-related ocular trauma cases in Canada, 40 per cent were associated with sport.29 Serious eye injury in badminton has been implicated with the use of glass spectacles.33 In a large population-based study, spectacle-related ocular trauma associated with sports was most common in the 17 years and under-age group, representing 36.6 per cent of these injuries.9 The same study identified 89.5 per cent of spectacle-related injuries in those aged 65 years or older occurring due to falls. It is well reported in the literature that stationery items are involved in penetrating eye trauma.21,22,34 A large retrospective study of hospitalised eye injuries in Taiwan found that spectacles were also significant contributors to penetrating eye injury (12, 7.7 per cent), along with scissors (21, 13.5 per cent), pencils and pens (19, 12.2 per cent) and knives

(10, 6.4 per cent).6 It is worth noting that a high proportion of high school students in Taiwan wear spectacles (80 per cent).35 It has been reported that when an airbag is deployed in motor vehicle accidents, spectacle-related ocular injuries have resulted.36–40 In the three cases presented,11,41,42 it was suggested that wearing spectacles presented an additional risk for ocular injury during airbag inflation. Glass spectacle wearers are at particular risk of severe ocular injury associated with airbag deployment;11 however, one author argued that spectacles may have a protective effect from the chemical burns that sometimes result when airbags are deployed.43 Frame design was identified as a contributing factor to ocular injury in three case reports, in which there was a small vertex distance,15 the frame was rimless44 or metal.45 Frame size and previous surgery were also implicated in a case report of an aphakic patient wearing a spectacle frame smaller than his orbital rim that resulted in ocular injury.15 Where available, visual outcome data were reviewed, with open5 and closed6 globe injuries almost equally represented. Vision was 6/60 or worse in three cases, 6/24 in two patients and 6/12 or better in three patients.11,15,41 One injury resulted in death45 and three in enucleation.30 In the US, the hospital emergency department admission rate for spectacle-related ocular trauma (four per cent)9 was similar to total eye injuries reporting to emergency departments (approximately three per cent).46 Two of the three golf-related ocular traumas, in which spectacles were implicated resulted in enucleation.30 Prior to 1975, when glass spectacle lenses predominated, enucleation rates were at 7.5 per cent for spectacle glass injuries.19

Impact resistance of spectacles Twelve studies were identified in which the impact resistance of spectacle lenses was reviewed. The impact resistance of spectacle lenses is dependent on a number of factors, including the material, centre and edge thicknesses and refractive power.25 Generally, plastics are more impact-resistant than glass, especially with small, fast-moving objects. Polycarbonate is universally reported as the most impact-resistant spectacle lens material.16,24,29 Frame design and frame material choice are also factors in the protection provided to the wearer.24 Materials commonly used in © 2015 The Authors

Clinical and Experimental Optometry © 2015 Optometry Australia


Data years presented (published)

Author

Data source and size

Population

Spectacles worn

Spectacle-related trauma data

Country

1985 to 1991 (1993)

Parver et al.5

National Eye Trauma System 1- to 92-years-old 2.9% of cases nonRegistry used to collect data on safety spectacles 2,939 penetrating eye injuries were worn (45)

16 cases where spectacles were worn, glass or plastic was reported as the cause, suggesting that the shattered lens contributed to the injury.

US

10 years to 1977

Christianson et al.29

Retrospective review of 446 penetrating ocular traumas over a 10-year period

Children and adults

Spectacles worn type not specified

16 penetrating ocular injuries due to spectacles

Canada

May to July 2008

Ong et al.31

Review of 48 ED ocular sports trauma presentations

Children and adults


One patient wearing prescription lenses which shattered when impacted by a shuttlecock resulting in a penetrating injury.

UK

2002 to 2003

Sinclair et al.9

Review of 642 spectaclerelated ocular trauma cases from ED presentations NEISS (National Electronic Injury Surveillance System)

Children and adults


642 spectacle-related traumas presented at ED. Estimated 27, 152 injuries for whole population over the period.

US

1993 to 2000

Weitgasser et al.30

Retrospective review of seven 29- to 63-years-old Sunglasses (2) golfing-related eye traumas Spectacles (1) admitted to hospital

3 spectacle-related traumas wearing sunglasses or spectacles

Austria

2008

Liu et al.6

Retrospective hospital-based review of 156 paediatric ocular traumas in Taiwan

≤15-year-olds

Spectacles

7% (12) spectacle-related ocular traumas resulted from blunt trauma from a ball and one from a broomstick.

Taiwan

1994

Braude41

Single case study

20-year-old man

Glass sunglasses

Passenger side airbag burn from airbag chemicals and corneal laceration from fractured lenses.

US

2001

Clarke et al.15

Single case study

79-year-old aphake

Small-framed spectacles with small vertex distance

Choroidal ischaemic infarction as a result of ocular compression with a small frame

US

2007

Jain et al.32

Single case study

16-year-old boy

Polycarbonate spectacles

Cricket ball impact resulted in frame torsion and blunt trauma from spectacle arm resulting in prolapsed uvea.

India

2000

Newsom et al.44 Single case study

37-year-old

Rimless glass spectacles

Collided with lamppost at approximately 15 mph resulting in ocular compression from frame

UK

2008

Sharpurkar et al.45

Single case study

40-year-old

Metal rim spectacles Fence post and spectacle arm penetrated right orbit

India

1999

Tsuda et al.42

Single case study

38-year-old

Glass spectacles

Japan

Motor vehicle accident - airbag causing lens shatter and corneal lacerations.

ED: emergency department

Table 1. Summary of studies identified with spectacle-related ocular trauma

the manufacture of eye protector frames include polycarbonate and other thermoplastic materials, which may incorporate foam liners to increase comfort and dampen any impact transferred to the orbit. Due to manufacturing variables, prescription, lens treatments such as anti-reflection

coating and abrasion-resistant coatings and variations in thickness, impact performance of spectacle lenses may significantly vary.47,48 In studies by Vinger and colleagues16 on spectacle lens materials, glass allyl resin and highindex hard resin plastic shattered at much lower impact energies than polycarbonate.


Studies on impact energy to shatter lenses are summarised in Tables 2 and 3, highlighting the variability in the result depending on the projectile and test method adopted.16,25,48 The impact energy required to penetrate a polycarbonate lens clearly demonstrates its Clinical and Experimental Optometry 98.3 May 2015

205


Lens type

Velocity of penetrating projectile (m/s)

Mass (gm)

Energy of penetrating projectile (J)*

Glass

84

0.34-0.51

2.425

CR39

97.67

0.34-0.51

3.3725

High index

107.74

0.34-0.51

4.0925

Polycarbonate spectacles

210.07

0.34-0.51

58.7725 25

Polycarbonate goggles

204.00

0.34-0.51

Hoya EYAS. 2.5mm

36.0

0.88

0.6848

Hoya Phoenix. 2.0 mm

49.2

0.88

1.2748

Nikon 1.67. 2.0 mm

39.6

0.88

0.8248

Younger Trilogy with hardcoat. 2.0 mm

55.7

0.88

1.6248

CR39 uncoated

52.5

0.88

1.4448

DISCUSSION

82.19

*Penetration threshold derived from BB and pellet gun impacts

Table 2. Lens-penetration threshold and impact energy for lens materials

Kinetic energy calculation

Speed

Rock (rock velocity 110 km/h meeting vehicle travelling at 110 km/h)

45 m/s

Tossed magazine

13 km/h

Mass (gm) 1.00 336 0.51

Impact energy (J) 1.31 2.3

Air gun pellet

645 km/h

Golf ball

145 km/h

45.8

37.1

Tennis ball

177 km/h

58.9

68.3

Lacrosse ball

113 km/h

150.4

Baseball

152 km/h

142

8.2

69.0 125

Table 3. Impact energy of common hazards16 superior performance;25 however, reduction in centre thickness and the use of coatings, such as anti-reflection coating, have been shown to reduce lens impact resistance.48 In addition to lens choice, frame and fit may reduce the protective effectiveness of a spectacle or increase its propensity to be a secondary hazard.24 In a large audit conducted on work-related ocular injuries, those that occurred despite the use of eye protection were attributed to objects travelling over, under or to the side of the eye protection.49 Smaller frames and frameless spectacles may increase the risk of ocular injury to the wearer.15

Policies and recommendations The introduction of FDA requirements for spectacle lenses in the 1970s represented an important step in reducing spectaclerelated ocular injuries. Across Europe, USA and Australia, there are some differences in the method of testing requirements for Clinical and Experimental Optometry 98.3 May 2015

206

improper or inadequate material selection.10 A liability lawsuit, such as those that have occurred with tonometry52 and dilation53 may set a precedent leading to the more common use of stronger spectacle lens materials.28

spectacles, sunglasses and eye protectors. The requirements and relative impact energy are summarised in Table 4. American standards for spectacle lenses incorporate a low-impact requirement for impact resistance, whereas the Australian Standard incorporates a test of robustness. The Australian Standard’s recommended practices for eye protection recognise the hazard associated with spectacles by incorporating a warning that ‘fractured spectacle lenses represent a significant secondary hazard to the eye’ (Australian New Zealand Standard AS/NZS 1336 Eye and Face Protection-Guidelines50). In the state of New Jersey, legislation was passed in 2004 requiring all children who wear spectacles when participating in medium- to high-risk sports, to have eye protection supplied by the state.51 It has been suggested that a legal liability exists for the prescriber of spectacles for sports participants, if the lens material fails as a result of

Prescription glasses are not an adequate substitute for protective eyewear.54 Ophthalmologists, optometrists and dispensers have a duty of care to ensure that the spectacles they prescribe or supply do not introduce new hazards to their patients. When compared with other spectacle lens materials, it is commonly argued that polycarbonate is more expensive (approximately $100 per pair),55 has a much lower Abbe number (and is therefore less optically clear) and is less scratch-resistant. Polycarbonate is widely recognised as the most impactresistant spectacle lens material available. Once polycarbonate is coated its abrasion resistance is the same as other plastic lens materials.56 Many of the disadvantages of polycarbonate are outweighed by the cost of an eye injury and the long-term consequences of visual loss. The direct cost of hospitalisation for eye injuries from July 2003 to June 2005 in New South Wales alone was estimated at AUD $7,434,186.57 Polyurethane lens manufacturers have claimed impact resistance at up to 60 times greater than glass; however, coated polyurethane lenses fracture when impacted by a 6.0 mm steel ball at between 54 and 83 metres per second, whereas polycarbonate will withstand an impact in excess of 190 metres per second.58 Polyurethane has a more favourable Abbe number and therefore, better optical clarity than polycarbonate, although glass or hard resin plastic is superior to both in this regard. Prescribing patterns have changed significantly, since the 1970s when polyurethane materials were yet to be introduced and glass and hard resin plastic were used in approximately equal proportions.59 Hard resin plastic (including high index) and polyurethane now dominate. Glass is almost never dispensed.60 Additional research needs to be conducted to determine the protective characteristics of new materials and to understand better the resistance of all lens materials to domestic and recreational hazards. An eye protector’s ability to protect the wearer is dependent upon the frame and lens as a complete unit. Use of more flexible frame materials may assist in reducing the © 2015 The Authors

Clinical and Experimental Optometry © 2015 Optometry Australia


Projectile size (mm)

Standard and requirement

Projectile mass (gm)

Drop height (m)

Velocity (m/s)

km/h

Impact energy (J)

1.27

5

18

0.85

43.2

0.08

Occupational eye protection ANSI Z87.1 American National Standard for Occupational and Educational Personal Eye and Face Protection Devices65 (low)

25.4

68

AS/NZS 1337.1 Personal eye protection Part 1: eye and face protectors for occupational applications66 (low)

6.35

1.046

na

12

AS/NZS 1337.1 (med)

6.35

1.046

na

40

144

0.84

AS/NZS 1337.1 (high) (NB High not applicable to spectacles)

6.35

1.046

na

110

396

6.33

EN 166 Personal eye-protection- Specifications67 (low)

6

0.86

na

45

162

0.87

EN 166 (medium)

6

0.86

na

120

432

6.19

Spectacles and sunglasses ISO 21987* Ophthalmic optics- mounted spectacle lenses68

Minimum robustness requirement

ANSI Z80.1 and 80.3 American National Standard for Ophthalmic- Prescription Spectacle Lenses69 and Non-prescription sunglasses and Fashion Eyewear Requirements70

15.9

16

1.27

5

18

0.20

AS/NZS 1067 Sunglasses and fashion spectacles71

16

16

1.3

5.1

18

0.21

EN 1836 Personal eye equipment- Sunglasses and sunglare filters for general use and filters for direct observation of the sun72 (superseded)

16

16

1.3

5.1

18

0.21

ISO 12312-1 Eye and face protection- Sunglasses. Part 1: Sunglasses for general use73†

16

16

1.3

5.1

18

0.21

AS/NZS 4066 Eye protectors for racquet sports71

40

BS 7930-1 Specification for eye protection for racket sports. Part 1: Squash.74

na

ASTM F1776-12 Standard Specification for Eye Protective Devices for Paintball Sports75

na

ASTM F803- 11 Standard Specification for Eye Protectors for Selected Sports76

na

AS/NZS 1609 Eye protectors for motor cyclists and racing car drivers77

6.35

EN 1938 Personal eye protection- Goggles for motorcycle and moped users78

na

23.3

na

40

144

18.64

23.3

na

40

144

18.64

na

122

439

6.40

na

40

144

18.64

1.046

na

50

180

1.31

0.86

na

45

162

0.87

0.86 23.3

*ISO 21987 is adopted identically in Australia as AS NZS ISO 21987 and in Europe as EN ISO 21987 with members of the European Union adopting under their national standard eg Germany, DIN EN ISO 21987 † ISO 12312-1 is adopted identically in Europe as EN ISO 12312-1 with members of the European Union adopting under their national standard, for example, Germany, DIN EN ISO 12312-1

Table 4. Impact requirements and impact energy for eye protection and spectacle lens standards likelihood of frame-related blunt trauma. Innovative designs that incorporate closed-cell foam and rubber components may also be able to assist in improved designs and better fit. Further analysis of the risks associated with sports and recreational activities, collaboration with eyewear designers and refining standards for spectacles will assist in the overall aim of eliminating spectacle-related injuries. Early studies of spectacle lenses showed reduced impact resistance of lenses that were scratched or damaged.61 Modern materials have not been subject to the same tests and further research would help in developing recommendations around the need for regular replacement of spectacles, when there is a risk of ocular injury.

Recreational activities are a source of spectacle-related ocular trauma. Some relevant questioning about activities both at work and at home coupled with advice at the time of prescribing spectacles could reduce ocular injuries incurred during leisure activities. It has been suggested that spectacles have the potential to protect against dust and other hazards;62 in our opinion, this should be the case only when no other hazards are present. When medium- to high-impact hazards are present any protective effect may be negated and there is the potential for ocular injury from the frame or fractured lenses. The perception that spectacles are an adequate substitute for eye protection is flawed.


A full risk analysis of the types of activities commonly undertaken and the capability for everyday spectacles to provide adequate protection would assist in advising patients on the most appropriate frame and lens choice. The Asian ‘myopia epidemic’ has prompted significant research into the relationship between time spent outdoors and myopic progression.63,64 Any recommendation to spend increased time outdoors should be coupled with an understanding of the potential risks associated with these activities and appropriate advice of the required eye protection. Our study is limited by the absence of detailed research in the area of lens performance. An opportunity exists to improve Clinical and Experimental Optometry 98.3 May 2015

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Group A. Individual risk factors a. Monocular b. Previous eye surgery c. Previous eye injury d. Thin corneas, brittle cornea syndrome e. Elderly (those at risk of falls) f. Marfan syndrome (potential for sub-luxation of crystalline lens)

Group B. Spectacles worn when undertaking medium to high risk activities a. Medium to high risk sports involving bat, ball or risk of collision, e.g. basketball, baseball, raquet sports, golf. b. Activities involving lowmass high-speed or high-mass low-speed projectiles, e.g. grinding, use of electrical tools

Recommended eye protection: i. Use impact-resistant lenses that meet AS1337 low impact, e.g. polycarbonate lenses ii. Choose plastic frame iii. Avoid smaller frames and frames with small vertex distance

Figure 2. Risk factors and recommendations for spectacle wearers. Two distinct groups were identified, for whom eye protection is recommended. Group A consists of individuals who have personal risk factors, such as those who are functionally monocular, have had previous eye injury or surgery, have thin corneas or brittle cornea syndrome, are elderly, are at increased risk of falls or have Marfan syndrome. Group B encompasses individuals who undertake activities that put them at increased risk of impact, including those who participate in medium- to high-risk sports and/or activities. reporting on types of spectacle and/or eye protection worn at the time of eye injuries to better delineate specific risks.

Recommendations The incidence of spectacle-related ocular injury is a small but significant sub-group of all eye injuries that could be reduced with the implementation of appropriate policies. The current review suggests additional protection for people with individual risk factors or who participate in medium- to high-risk activities, Group A and B, respectively (Figure 2). Further research is warranted to better understand the hazards associated with recreational activities and the appropriate protection required. CONCLUSION Spectacle-related ocular injury represents a small but preventable cause of ocular injury. With increasing prevalence of spectacle wearing and calls to spend more time outdoors to stem, possibly, the increase in myopia, Clinical and Experimental Optometry 98.3 May 2015

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spectacle wearers need to be made aware of the risks and how best to avoid them. Those at risk of falls, participating in certain sports, functionally monocular, with corneal thinning or previous eye surgery or injury are of particular concern. With increased understanding of specific risk factors, performance guidelines can be developed for eye protection requirements. Key to the implementation of these guidelines will be support of ophthalmologists, optometrists, optical dispensers and orthoptists, as well as health authorities and retailers of prescription spectacles to ensure that patients are made aware of the hazards and their avoidance. ACKNOWLEDGEMENTS

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