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## Complete Summary

#### GUIDELINE TITLE

Eye.

#### BIBLIOGRAPHIC SOURCE(S)

Eye. Elk Grove Village: American College of Occupational and
Environmental Medicine (ACOEM); 2004. 77 p. \[149 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Harris, J, ed. Occupational
Medicine Practice Guidelines: American College of Occupational and
Environmental Medicine. Beverly Farms, MA: OEM Press; 1997.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [June 15, 2005, Non-Steroidal Anti-Inflammatory Drugs
    (NSAIDs)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID):
    U.S. Food and Drug Administration (FDA) recommended proposed
    labeling for both the prescription and over the counter (OTC) NSAIDs
    and a medication guide for the entire class of prescription
    products.

-   [April 7, 2005, Non-steroidal anti-inflammatory drugs (NSAIDS)
    (prescription and OTC, including ibuprofen and
    naproxen)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#Bextra):
    FDA asked manufacturers of prescription and non-prescription (OTC)
    non-steroidal anti-inflammatory drugs (NSAIDs) to revise their
    labeling to include more specific information about potential
    gastrointestinal (GI) and cardiovascular (CV) risks.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Occupational eye injuries and complaints

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Ophthalmology\
Optometry\
Physical Medicine and Rehabilitation\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Physician Assistants\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

-   To provide information and guidance on generally accepted elements
    of quality care in occupational and environmental medicine

-   To improve the efficiency with which the diagnostic process is
    conducted, the specificity of each diagnostic test performed, and
    the effectiveness of each treatment in relieving symptoms and
    achieving cure

-   To provide comprehensive guidelines and practical recommendations
    for treating the three major eye complaints seen most frequently in
    workers: red eye, blurred vision, and visual fatigue

#### TARGET POPULATION

Adults with potentially work-related acute eye complaints seen in
primary care settings

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  History

2.  Observation of the patient

3.  Examination

    -   Visual acuity chart

    -   Penlight (slit lamp preferred)

    -   Tonometer

    -   Sterile fluorescein dye strip

    -   Topical anesthetic drops

    -   Ophthalmoscope

4.  Diagnosis via signs and symptoms and special testing, if necessary

5.  Prevention and control of occupational eye infections

6.  Classification with the Birmingham Eye Trauma Terminology (BETT)

7.  Referral to ophthalmologist or optometrist, as appropriate

8.  Initiate an eye and face safety program

9.  Red eye differential diagnosis

10. Specific treatment for red flag conditions

11. Specific treatment for non-red flag conditions

12. Patient comfort including anesthetic agents, analgesics, pressure
    patching, mydriatics and cycloplegics, antimicrobials, and
    anti-inflammatory agents (steroidal and nonsteroidal)

13. Management of blurred vision and visual fatigue

#### MAJOR OUTCOMES CONSIDERED

Missed work days

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

*Note from the National Guideline Clearinghouse (NGC)*: The American
College of Occupational and Environmental Medicine contracted the Work
Loss Data Institute to provide medical library research services.

**Disability-Duration Data**

This edition includes disability-duration data that have been extracted
from National Health Interview Survey data. Only data from interviews
with individuals without workers\' compensation claims has been
included.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Contributors reviewed at least one chapter each and reviewed the
relevant medical literature that had been published since the creation
of the original Guidelines in 1997.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Following the chapter and literature review, participants provided
written or verbal comments to the American College of Occupational and
Environmental Medicine\'s Practice Guidelines Committee.

Verbal comments were in the form of participation in multi-specialty
conference calls, during which the issues raised in each chapter were
extensively discussed. Draft chapters were prepared and distributed by
the American College of Occupational and Environmental Medicine to all
chapter reviewers. Follow-up multi-specialty teleconferences were then
held as appropriate, during which time the draft was again reviewed.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**General Approach and Basic Principles**

The principal recommendations for assessing and treating patients with
eye complaints are as follows:

-   Initial assessment should focus on detecting indications of
    potentially serious ocular pathology, termed red flags, and
    determining an accurate diagnosis. For these purposes, red flags are
    defined as a sign or symptom of a potentially serious condition
    indicating that further consultation, support, or specialized
    treatment may be necessary.

-   In the absence of red flags, occupational or primary care providers
    can safely and effectively handle work-related eye complaints.
    Conservative treatment can proceed for 48 to 72 hours for
    superficial foreign bodies, corneal abrasions, conjunctivitis, and
    ultraviolet radiation damage. Normally, tissues of the eye heal
    rapidly. If eye damage is not well on the way to resolution within
    48 to 72 hours, referral to a specialist is indicated. Nonspecific
    eye complaints may be monitored for a longer period of time while
    ergonomic and other adjustments are made. The focus is on monitoring
    for complications, facilitating the healing process, and determining
    fitness for return to work in a modified- or full-duty capacity.

-   Corneal discomfort can be relieved safely with a topically applied
    ophthalmic nonsteroidal anti-inflammatory drug (NSAID), a systemic
    nonprescription analgesic, or an intramuscular or intravenous
    narcotic in severe ocular/face injuries when symptoms or physical
    findings mandate. Patients requiring narcotic analgesics generally
    should be referred for ophthalmologic care. Avoid using topical
    anesthetics for purposes other than diagnosis or treatment because
    they may obscure worsening pathology and thus inadvertently cause
    further injury.

-   Visual acuity should be assessed and documented carefully at each
    examination prior to other examinations or treatment, except for
    cases of chemical burns.

-   Patients recovering from acute eye injury or infection should be
    encouraged to return to modified work as their condition permits.

-   Nonphysical factors, such as psychosocial, workplace, or
    socioeconomic problems, should be addressed in an effort to resolve
    delayed recovery.

**Management of Red Eye**

Primary care physicians commonly see patients who complain of a red eye.
This condition may result from a simple disorder such as a
subconjunctival hemorrhage that will resolve spontaneously. The general
physician may treat numerous other causes. Vision threatening disorders
that cause a red eye require early recognition and prompt referral to an
ophthalmologist for optimal management based on the results of the
initial examination.

**History**

Information obtained from a careful history and examination directs the
approach to management. The onset of a red eye, duration of the redness,
and clinical course should be noted to help to distinguish the causative
agents (see Table 16-1, Master Algorithm, and Algorithms 16-1, 16-2, and
16-3 in the original guideline document.)

Asking the patient open-ended questions such as those listed in the
original guideline document allows the clinician to judge the need for
further discussion or specific inquiries to obtain more detailed
information.

**Observation of the Patient**

When the patient enters the examination area, the physician can observe
his or her ability to see the way in and to gauge depth. Photophobia or
pain can be inferred if the affected eye is held shut. Tearing or
discharge can be observed as well. A history of chemical splash is an
emergency, and examination may be delayed until after the eye is flushed
to dilute the chemical.

**Examination**

The primary care physician should evaluate the red eye with a visual
acuity chart, a penlight (slit lamp preferred), a tonometer, a sterile
fluorescein dye strip, topical anesthetic drops, and an ophthalmoscope.
Most clinics today have a Titmus or Stereo Optical visual screener or an
Armed Forces Tester, a noncontact \"puff\" tonometer (Reichert Optical
Company), and a slit lamp. A systematic approach to the examination
should then be conducted, beginning by examining the face, orbital area,
and lids and ending with a close view of the eyeball. The preferred
method for examining the eyeball includes using the slit-lamp
biomicroscope and the ophthalmoscope.

The American Academy of Ophthalmology specifies nine diagnostic steps to
use when evaluating a patient with a red eye (Bradford):

1.  Determine whether the visual acuity is normal or decreased using a
    Snellen chart or (preferred) Early Treatment Diabetic Retinopathy
    Study (ETDRS) chart at 20 feet or six meters, or the 1 meter ETDRS
    chart if required.

2.  Decide by inspection what pattern of redness is present and whether
    it is due to subconjunctival hemorrhage, conjunctival hyperemia,
    ciliary flush, or a combination of these.

3.  Detect the presence of conjunctival discharge and categorize it as
    to amount---profuse or scant---and character---purulent,
    mucopurulent, serous, or hemorrhagic.

4.  Detect opacities of the cornea, including large keratic
    precipitates, or irregularities of the corneal surface, such as
    corneal edema, corneal leukoma (a white opacity caused by scar
    tissue), and irregular corneal reflection. Conduct the examination
    using a biomicroscope, or penlight and transilluminator, at least.
    Biomicroscopy is the practice standard.

5.  Search for disruption of the full thickness of the corneal
    epithelium by staining the cornea with fluorescein and lack of
    corneal epithelium vitality by staining with rose bengal.

6.  Use of a slit lamp (biomicroscope) allows one to estimate the depth
    of the anterior chamber as normal or shallow and to detect any
    microscopic blood or white blood cells, which would indicate either
    hyphema or hypopyon, respectively. (A hypopyon is indicated by the
    presence of protein and white blood cells in the anterior chamber,
    e.g., when a corneal ulcer is present, and a hyphema is indicated by
    protein and red blood cells in the anterior chamber.)

7.  Detect irregularity of the pupils and determine whether one pupil is
    larger than the other. Observe the reactivity of the pupils to light
    to determine whether one pupil is more sluggish than the other or is
    nonreactive.

8.  Determine whether the intraocular pressure is high, normal, or low
    by performing tonometry if indicated clinically (e.g., if acute
    angleclosure glaucoma is suspected). (Tonometry is contraindicated
    when external infection or lack of globe integrity is obvious.)

9.  Detect the presence of proptosis, lid malfunction, or any
    limitations of eye movement.

**Signs of Red Eye**

  --------------------------------------------------------------------------------------------------------------------------------------
  **Symptom**     **Referral   **Acute        **Acute           **Keratitis**   **Bacterial        **Viral            **Allergic
                  Advisable if Glaucoma**     Iridocyclitis**                   Conjunctivitis**   Conjunctivitis**   Conjunctivitis**
                  present**                                                                                           
  --------------- ------------ -------------- ----------------- --------------- ------------------ ------------------ ------------------
  Ciliary flush   Yes          1              2                 3               0                  0                  0

  Conjunctival    No           2              2                 2               3                  2                  1
  hyperemia                                                                                                           

  Corneal         Yes          3              0                 1-3             0                  0-1                0
  opacification                                                                                                       

  Corneal         Yes          0              0                 1-3             0                  0-1                0
  epithelial                                                                                                          
  disruption                                                                                                          

  Pupillary       Yes          Mid-dilated,   Small; may be     Normal or small 0                  0                  0
  abnormalities                nonreactive    irregular                                                               

  Shallow         Yes          3              0                 0               0                  0                  0
  anterior                                                                                                            
  chamber depth                                                                                                       

  Elevated        Yes          3              -2 to +1          0               0                  0                  0
  intraocular                                                                                                         
  pressure                                                                                                            

  Proptosis       Yes          0              0                 0               0                  0                  0

  Discharge       No           0              0                 Sometimes       2-3                2                  1

  Preauricular    No           0              0                 0               0                  1                  0
  lymph-node                                                                                                          
  enlargement                                                                                                         
  --------------------------------------------------------------------------------------------------------------------------------------

Note: The range of severity of the symptoms is indicated by 0 (absent)
to 3 (severe).

*Source*: Table modified from Bradford CA, ed. *Basic Ophthalmology*.
7th ed. San Francisco, Calif: American Academy of Ophthalmology; 1999.

Refer to the original guideline for information on methods of testing,
how to interpret findings of red eye, diagnostic criteria, special
studies and diagnostic treatment considerations, type of red eye, and
prevention and control of occupational eye infections.

**Ocular Trauma**

*Elements of the History of Ocular Injury*

While a detailed, accurate history is essential in all injuries, it is
especially important to obtain a detailed history of an ocular injury
because incorrect or misleading information may lead to blindness. Such
information may be obtained from a variety of sources, including the
patient, the first responder(s), and others involved in or associated
with the accident (see Master Algorithm and Algorithms 16-1, 16-2, and
16-3 in the original guideline document).

Information for acute trauma should include the four *W*s:

-   *Where*: Location of the accident

-   *When*: Time and date

-   *Who*: Other individuals involved

-   *What*: A detailed description of the accident circumstances,
    including force and load

If chemical exposure was involved, seek available Material Safety Data
Sheets (MSDSs) information.

*Ocular Examination for Eye Injury*

The examination of the injured eye should include:

-   Visual acuity (each eye separately) with best correction or pinhole

-   Inspection of the ocular structure. (If an open globe is suspected,
    no pressure should be exerted on the globe.)

-   Position of the eyes and eye movements (six cardinal positions) if
    globe is intact

-   Examination of the pupils for size and reaction to light

-   Gross visual fields by confrontation

-   Ophthalmoscopy

-   Intraocular pressure (IOP) determination if acute glaucoma is
    suspected and the globe is intact

It is important for primary care physicians to make immediate referrals
to the closest ophthalmologist or eye institute when eye injuries exceed
their capability. Make the patient comfortable (with intravenous
analgesics, if necessary), and protect the injured eye from further
injury by applying a rigid Fox shield or equivalent. Depending on the
type of injury, transport the patient on a stretcher.

Yardsticks that can be used to evaluate standard emergency care include:

1.  The detail and accuracy of the history obtained at the time of or
    after admission

2.  The thoroughness of the admission examination

3.  The correlation of critical results with medication and/or other
    treatment provided to the patient

Refer to the original guideline document for information on initializing
an eye and face safety program and personal protective equipment.

**Assessing Red Flags and Indications for Immediate Referral**

Physical examination evidence of severe ocular compromise that
correlates with the medical history and test results may indicate a need
for immediate consultation. The examination may further reinforce or
reduce suspicions of infection or major trauma (e.g., open globe,
chemical exposure, or radiation damage). A medical history suggestive of
pathology in an area other than the eye may warrant examination of the
head, neck, or other areas.

Refer to the original guideline for information on timing of referrals
or special studies and red eye differential diagnosis.

**Red Flags for Potentially Serious Eye Conditions Requiring Immediate
Ophthalmologic Examination**

  ------------------------------------------------------------------------
  **Disorder**     **Medical History**        **Physical Examination**
  ---------------- -------------------------- ----------------------------
  Ocular injury;   Trauma due to high         Visible foreign body in
  open globe       velocity foreign-body      globe; deformity of the
                   injury\                    globe\
                   \                          \
                   Visual loss\               Loss of globe pressure\
                   \                          \
                   Bleeding\                  Distorted pupil and/or iris\
                   \                          \
                   Local pain                 Subconjunctival hemorrhage

  Ocular injury,   Direct blow\               Eyelid ecchymosis\
  closed globe     \                          \
                   Visual loss\               Subconjunctival hemorrhage\
                   \                          \
                   Diplopia                   Vitreous hemorrhage\
                                              \
                                              Lens dislocation\
                                              \
                                              Retinal edema and/or tear\
                                              \
                                              Decreased visual acuity\
                                              \
                                              Hyphema\
                                              \
                                              Retrobulbar hemorrhage\
                                              \
                                              Extraocular motion deviation

  Thermal burns    Exposure of eye to hot     Burns of lids and/or
                   material/extreme heat\     surrounding structures\
                   \                          \
                   Superficial eye pain\      Damage to cornea,
                   \                          conjunctiva, and/or sclera\
                   Photophobia                \
                                              Decreased visual acuity

  Radiation injury Exposure of eyes to        Blepharospasm\
                   ultraviolet, laser, or     \
                   bright light\              Tearing\
                   \                          \
                   Delayed severe superficial Corneal punctate staining
                   eye pain (4-6 hours)\      and/or sloughing of
                   \                          epithelium\
                   Tearing\                   \
                   \                          Retinal damage
                   Photophobia                

  Chemical burns   Alkali, acid, solvent      Corneal erosion\
                   splash\                    \
                   \                          Conjunctival chemosis\
                   Painless visual loss       \
                                              Necrosis of anterior segment
                                              of tissues and vessels\
                                              \
                                              Decreased visual acuity\
                                              \
                                              Circumcorneal vascular
                                              ischemia\
                                              \
                                              Necrosis of cornea and/or
                                              conjunctiva\
                                              \
                                              Glaucoma

  Hydrofluoric     HF acid splash\            Necrosis of cornea and/or
  (HF) acid burns  \                          conjunctiva\
                   Delayed damage             \
                                              Decreased visual acuity

  Corneal ulcer    Abrasion or infection\     Corneal infiltrates and
                   \                          ulcers\
                   Superficial pain\          \
                   \                          Decreased visual acuity\
                   Foreign-body sensation\    \
                   \                          Ulceration on slit-lamp exam
                   Photophobia\               and fluorescein staining
                   \                          
                   Visual loss                
  ------------------------------------------------------------------------

**Diagnostic Criteria for Non-Red Flag Eye Conditions That Can Be
Managed by Primary Care Physicians**

  ---------------------------------------------------------------------------------
  **Probable       **Mechanism**      **Unique       **Unique Signs** **Tests and
  Diagnosis or                        Symptoms**                      Results**
  Injury**                                                            
  ---------------- ------------------ -------------- ---------------- -------------
  Corneal          Direct contact\    Superficial    Possibly visible Fluorescein
  abrasion,        \                  pain\          abrasion on      staining
  conjunctival     Contact lens\      \              magnification    reveals
  abrasion         \                  Foreign-body                    abrasion with
                   Aerosol chemicals  sensation                       use of cobalt
                                                                      blue light\
                                                                      \
                                                                      Visual acuity
                                                                      test results
                                                                      abnormal

  Nonionizing      Ultraviolet        Severe         Injection\       Fluorescein
  radiation        (welding) light\   photophobia\   \                staining
  exposure         \                  \              Blepharospasm\   reveals
                   Bright light       Tearing\       \                punctate
                   (sun)\             \              Corneal erosion  lesions under
                   \                  Sandy          or sloughing\    cobalt blue
                   Laser              sensation\     \                light\
                                      \              Decreased visual \
                                      Possibly       acuity\          Amsler grid
                                      reduced visual \                abnormality
                                      acuity         Central scotoma  

  Chemical splash  Chemical splash    Chemical       Corneal erosion\ Fluorescein
                   (nonacid,          exposure\      \                staining
                   nonalkali; acid;   \              Possibly diffuse reveals
                   alkali)            Painful\       inflammation of  punctate
                                      \              periorbita, lids lesions or
                                      Visual loss    and anterior     abrasion
                                                     segment\         under cobalt
                                                     \                blue light
                                                     Eye burn         

  Foreign body     Projectile         Foreign-body   Visible foreign  Fluorescein
                   material           sensation      body\            staining may
                                                     \                reveal
                                                     Possible corneal abrasion
                                                     abrasion\        under cobalt
                                                     \                blue light
                                                     Possible rust    
                                                     ring             

  Blepharitis      Infectious or      Burning,       Dry or greasy    None
                   eyelid gland       itching of     scales of lid\   
                   dysfunction        lids\          \                
                                      \              Loss of          
                                      Wake up with   eyelashes in     
                                      eyelids stuck  chronic state    
                                      together                        

  Stye             Acute              Acute          Localized acute  None
                   *Staphylococcus*   localized      infection or     
                   infection of       infection of   abscess          
                   glands of Moll,    eyelid in area                  
                   Zeis, and          of cilia or                     
                   Meibomian          meiboman                        
                                      glands                          

  Chalazion        Chronic            Generally      Palpable nodule  None
                   granulomatous      painless lid   associated with  
                   inflammation of    thickening,    cilia of eyelid  
                   either of the      frequently     or meibomian     
                   gland Zeis, Moll,  following      glands           
                   or Meibomian       hordeolum                       

  Conjunctivitis   Microbial          Blurred vision Purulent, watery Culture
                   infection\         or eye stuck   mucous discharge positive for
                   \                  shut\                           bacteria
                   Viral infection\   \                               
                   \                  Discharge                       
                   Parasitic                                          
                   infection                                          

  Visual fatigue   Ergonomic factor\  Headache\      Possibly         Evaluate
                   \                  \              refractive error worksite for
                   Refractive error\  Colored        for working      the visual
                   \                  afterimages\   distance         ergonomic
                   Work habits\       \                               status
                   \                  Eye fatigue\                    
                   Workplace          \                               
                   illumination       Diplopia\                       
                                      \                               
                                      Blurred                         
                                      vision,                         
                                      especially                      
                                      near vision                     

  Subjunctival     May develop from   Asymptomatic   Generally a      None\
  hemorrhage       rubbing the eyes,                 light amount of  \
                   sneezing,                         subjunctiva      Rule out
                   Valsalva\                         blood            foreign body
                   \                                                  
                   May be associated                                  
                   with bleeding                                      
                   disorders and                                      
                   hypertension                                       
  ---------------------------------------------------------------------------------

**Management or Referral**

The conditions that a primary care physician may appropriately treat
include blepharitis, stye and chalazion, and conjunctivitis. Patients
requiring prolonged treatment or those in whom the expected response to
treatment does not occur promptly may be referred to an ophthalmologist.

**Red-Flag Conditions and Preferred Specific Treatment**

*Blunt Trauma*

Ocular contusions are caused by blunt trauma to the eye or periorbital
structures that may cause contusion of the globe and/or periorbita.
There may be no symptoms; however, some patients complain of local pain,
visual loss, diplopia, or a red eye. The clinician may observe any of
the following---ecchymosis of the eyelid; corneal edema; subconjunctival
hemorrhage; microscopic or gross hyphema; reduced visual acuity or
abnormal visual fields; dislocation or subluxation of the lens; retinal
tears, edema, or detachment; or restriction of ocular motion if
extraocular muscles are trapped in a blowout fracture.

*Retrobulbar Hemorrhage*

A relaxing incision at the lateral canthus must be completed within 10
minutes of the rise in IOP or the eye may be irreversibly damaged
secondary to the high IOP.

*Orbital Floor Fractures*

Treatment indications for orbital floor fractures are evolving.
Nonresolving oculocardiac reflex, the \"white-eyed\" blowout fracture,
and early enophthalmos or hypoglobus are indications for immediate
surgical repair. Surgery within 2 weeks is recommended in cases of
symptomatic diplopia with positive forced ductions and evidence of
orbital soft tissue entrapment on computed tomographic (CT) scan or
large orbital floor fractures that may cause latent enophthalmos or
hypo-ophthalmos.

*Hyphema*

It is important to identify and treat ocular injuries that often
accompany traumatic hyphema. Consider each of these management issues
and refer to the pertinent literature in formulating the following
recommendations:

-   Advise routine use of topical cycloplegics and corticosteroids,
    consider systemic antifibrinolytic agents or corticosteroids, and
    always use a rigid shield.

-   Recommend activity restriction (quiet ambulation). If compliance
    (with medication use or activity restrictions), follow-up, or
    increased risk for complications (e.g., history of sickle cell
    disease or hemophilia) is a concern, inpatient management can be
    offered.

-   Indications for surgical intervention include the presence of
    corneal blood staining or dangerously increased IOP despite maximum
    tolerated medical therapy, among others.

*Burns*

Thermal Burns of the Eye

If damage exceeds superficial burns of the lids and surrounding
structures, prompt intervention by a specialist is imperative.

Electromagnetic Radiation Injury to the Eye

Patients with electromagnetic radiation injury to the eye may have no
initial symptoms. Severe cases may show a marked decrease in central
visual acuity, but there may be severe delayed consequences. Depending
on the exact electromagnetic spectrum, the symptoms or signs may be
localized to the external segment, lens, retina, and choroid. This type
of injury can cause scarring of the cornea or retina or cataracts.
Visual field disorders also may result from damage to the retina or
choroid. Burns from the blue end of the visible spectrum and ultraviolet
A are discussed under nonionizing radiation exposure.

Chemical Burns

When they make contact with ultrasensitive eye tissues, toxic substances
immediately begin to cause damage. Studies show that after the first 10
seconds of chemical contact, chances of full recovery become fleeting.
Aside from general tissue damage, acids and alkalis can change the pH in
the eye itself. From this detrimental change, severe eye damage,
including blindness, may result. A history of chemical exposure is an
emergency, and examination should be delayed until after the eye is
flushed to dilute the chemical. It is imperative that emergency flushing
begin immediately. To ensure the best chances for a minimal amount of
eye damage, correct emergency equipment, proper placement, and knowledge
of its use are necessary in the workplace. The requirements governing
medical services and first aid is covered in OSHA 1910.151(a)(b),
whereas ANSI Z-358.1, Emergency Eyewash and Shower Equipment, provides
guidance. At the site, water is the initial dilution agent to flush the
eye or body. Subsequently, an isotonic saline or balanced Ringer\'s
solution is preferred and should be used, if available (otherwise, use
sterile intravenous fluids), until a tear pH of about 7 is obtained
after ceasing irrigation for 10 minutes. Proper flushing usually takes
at least 15 minutes, but can take as long as 24 hours.

Refer to the original guideline document for information on irrigation
technique, alkali burns, acid burns, and hydrofluoric acid burns.

*Corneal Ulceration*

Corneal ulcers, which can permanently damage vision, are an
ophthalmologic emergency. They may be bacterial, viral, fungal, or
parasitic in origin and may occur following corneal lacerations,
abrasions, and intrusion of foreign bodies. Patients with corneal ulcers
present with complaints of changes in visual acuity, photophobia and/or
eye pain, tearing, and a sensation that a foreign body is in the eye.
The presence of corneal ulcers can be determined by direct
visualization, but magnified viewing with fluorescein staining is needed
to completely rule out their presence.

*Open Globe Eye Injury*

Direct trauma to the eye from high-velocity objects can cause laceration
or perforation of the globe. The trauma can be perforating or
penetrating. Patients with damage to the integrity of the globe can
present with decreased visual acuity, local pain, and bleeding. The
cardinal sign is distortion of the globe with loss of tension or IOP;
the pupil is not round, but rather is distorted and/or nonreactive. In
addition, ecchymosis or other signs of damage to periorbital structures
are evident. The clinician may observe subconjunctival hemorrhage,
distortion of the iris or pupil, or herniation of the iris through the
cornea. There also may be retinal damage. The injured eye should be
protected with a metallic or plastic shield. Transfer by stretcher is
recommended.

**Non-red-flag Conditions**

Occupational health or other primary care physicians could treat the
conditions listed above in the table entitled \"Diagnostic Criteria for
Non-Red Flag Eye Conditions That Can Be Managed by Primary Care
Physicians\" after thorough evaluation and be within their scope of
practice.

*Abrasion of the Cornea or Conjunctiva*

A corneal abrasion involves denuding of the five layers of corneal
epithelium. Corneal abrasions may be divided into three classes based on
healing time, degree of iridocyclitis, and potential infection
complications. The three types are as follows:

-   *Simple*. Generally less than 3 mm in greatest diameter. Usually
    heals in 24 hours without treatment.

-   *Complex*. Secondary to fingernails, thorns, tree branches, or
    oyster shells. These have a delayed and variable healing time,
    ocular pain and ciliary spasm, and a high rate of recurrent erosion.
    Use nonsteroidal anti-inflammatory drugs (NSAIDs) with ophthalmic
    antibiotics and, frequently, cycloplegics.

-   *Potentially contaminated with bacteria*. Secondary to contact
    lenses, dirt, barnyard, or other traumatic materials. These have a
    higher potential rate of corneal infection or corneal ulcers from
    *Pseudomonas aeruginosa*. No patching is the rule because it
    encourages bacterial growth. Applying cycloplegics and ophthalmic
    antibiotics topically is indicated.

*Recurrent Corneal Erosion*

The diagnosis is confirmed by a history of recent trauma, previous
corneal abrasions, ocular surgery, family history (corneal dystrophy),
and slit-lamp examination with fluorescein staining.

Treatment for an acute episode may be performed by a primary care
physician, but subsequent episodes that do not resolve in 36 to 48 hours
should be referred to an ophthalmologist. Apply a cycloplegic drop
(e.g., cyclopentolate or homatropine) and use antibiotic ointment. If
the defect is large, a pressure patch may be applied. After epithelial
healing is complete, apply artificial tears (e.g., Refresh Plus,
TheraTears, or Celluvisc) and artificial tear ointment (e.g., Refresh
P.M.) or 5% sodium chloride drops four to eight times per day and 5%
sodium chloride ointment at bedtime for at least 3 months.

If the corneal epithelium is loose and heaped and not healing, the
ophthalmologist will consider debridement of the abnormal epithelium.
The following treatments may be considered for erosions that are not
responsive to the preceding treatment:

-   An extended-wear bandage soft contact lens for several months

-   Anterior stromal puncture (generally used in extremely symptomatic,
    refractory cases with erosions outside the visual axis)

-   Epithelial debridement with diamond burr polishing of Bowman\'s
    membrane (effective for large areas of epithelial irregularity and
    lesions in the visual axis)

-   Phototherapeutic keratectomy (PTK). Excimer laser ablation of the
    superficial stroma is successful in up to 90% of patients with
    recurrent erosions from corneal dystrophies. Follow-up may be
    required every 1 to 2 days until the epithelium has healed and then
    every 1 to 6 months depending on the severity and frequency of the
    episodes.

*Nonionizing Radiation Exposure from Ultraviolet and Bright Visible
Spectrum*

This energy may arise from welders\' torches, mercury vapor lamps, and
the sun. The onset of symptoms, including photophobia, corneal pain,
lacrimation, and blepharospasm, usually occurs 5 to 12 hours after
exposure; healing usually occurs within 24 hours (see Tables 16-9 and
16-10 in the original guideline document).

*Foreign Bodies of the Cornea or Conjunctiva*

These may be superficial and may be removed less than 6 hours after the
injury. Superficial foreign bodies generally may be removed with a moist
swab soon after injury and should be handled like a simple abrasion (see
Table 16-8 in the original guideline document). Foreign bodies can be
divided into two types (Table 16-10 in the original guideline document
presents details for treating various types of foreign bodies):

-   *Simple*. A superficial foreign body removed within hours generally
    will heal within 24 hours and have a low rate of inflammation of the
    cornea or conjunctiva and no iritis.

-   *Complex*. A foreign body of the cornea and conjunctiva in which the
    trauma has taken place generally will heal in 24 to 48 hours. A
    metallic foreign body may be surrounded by swollen necrotic tissue
    and metallic pigmentation.

*Chemical Splashes*

Chemical splashes from a solvent, acid, or alkali agent generally are
red flag conditions, but preliminary treatment by a primary care
physician can be provided before referring the patient to an
ophthalmologist. Primary treatment is irrigation of the eye with water
and/or isotonic saline until the pH returns to approximately 7, measured
by pH paper, 10 minutes after stopping irrigation.

*Subconjunctival Hemorrhage*

In the absence of blunt trauma, hemorrhage beneath the subconjunctiva
(the potential space between the conjunctiva and the sclera) requires no
treatment and, unless recurrent, no evaluation. Causes may include a
sudden increase in ocular venous pressure, such as occurs with coughing,
sneezing, vomiting, or vigorous rubbing of the eye. Many subconjunctival
hemorrhages occur during sleep when no prodomal conditions exist. If
recurrent, an underlying bleeding disorder should be ruled out.

*Blepharitis*

Response to the treatment of blepharitis, or inflammation of the eyelid,
is often frustratingly slow, and relapses are common. The mainstays of
treatment are as follows:

-   Apply a warm compress over the closed eyelids for 10 to 15 minutes
    with the cloth rewarmed (by running through hot water) as it cools.
    The compress helps to increase the fluidity of the meibomian glands
    and loosen the debris from the bases of the lashes.

-   To remove the secretions, follow compresses with lid scrubs, such as
    baby shampoo diluted with water (one drop of shampoo in cup of
    water) on a cotton ball or clean cloth, which is preferable to a
    cotton-tipped applicator. These measures may be performed two to
    four times daily.

-   Apply a topical antibiotic (erythromycin or bacitracin) following
    lid scrubs twice daily. Tetracycline (orally, daily) or doxycycline
    (orally, daily) is added for patients with rosacea or chronic
    blepharitis who are not responding to conservative measures. For
    pregnant or breastfeeding women and children younger than 12 years
    of age, substitute erythromycin.

-   Give patients with punctate epithelial keratitis (PEK) artificial
    tears five to six times daily.

*Chalazion*

Chalazion is a chronic granulomatous inflammation of a meibomian gland
that may develop spontaneously or may follow a hordeolum, acute
meibomitis, or stye. Chalazia are chronic granulomata of fat bodies and
they may require excision. Because most chalazia are sterile, antibiotic
therapy is of no value, but hot compresses may be useful for early
lesions. Incision with curettage is indicated when lesions do not
resolve spontaneously or with other medical therapy. A persistent or
recurring lid mass should undergo biopsy because it may be a rare
meibomian gland carcinoma or a squamous cell carcinoma of the
conjunctiva rather than a benign chalazion.

*Bacterial Conjunctivitis*

Bacterial conjunctivitis is treated with frequent antibiotic eye drops
as well as antibiotic ointment applied at bedtime. Cool compresses may
give some relief. There is no specific medical treatment for viral
conjunctivitis, but patients should be instructed in proper precautions
to prevent contagion. Corticosteroids have no place in treating
infectious conjunctivitis. Eye drops containing a combination of
antibiotics and corticosteroids are not indicated for the treatment of
ocular inflammation by the primary care or occupational medicine
physician.

*Stye or Hordeolum*

A stye or hordeolum is an acute inflammation of the eyelid that may be
characterized as an external swelling (involving the hair follicle or
associated glands of Zeis or Moll) or an internal swelling (involving
the meibomian glands). An external hordeolum occurs on the surface of
the skin at the edge of the lid. An internal hordeolum presents on the
conjunctival surface of the lid. Styes, generally localized abscess, are
treated initially with hot compresses and topical antibiotics. An
internal or external hordeolum (stye) may be a sequela of acute
blepharitis (meibomitis) and require incision and drainage of the
abscess. Incision with curettage is indicated when lesions do not
resolve spontaneously or with medical therapy.

**Initial and Definitive Care of Red Flag and Non-red-flag Conditions**

*Patient Comfort*

Comfort is often a patient\'s first concern. Nonprescription analgesics
provide sufficient pain relief for most patients with acute eye
symptoms. Persistence of eye pain is a red flag. If treatment response
is inadequate (i.e., symptoms and limitations continue), prescription
pharmaceuticals can be tried, but only briefly, before referring the
patient to an ophthalmologist. Comorbid conditions, side effects, cost,
and provider and patient preferences guide the clinician\'s choice of
recommended agents. Table 16-11 in the original guideline document
summarizes comfort options.

Generally, three sources of pain are secondary to a red eye:

-   Periorbital pain

-   Cornea, conjunctival, or eyelid pain

-   Ciliary and iris spasm

Conditions that require referral must be diagnosed and treated
initially, and the patient must be stabilized while making preparations
for transfer. A series of general and diagnostic treatment modalities
for red flag and non-red flag conditions are provided.

*Anesthetic Agents*

Topical anesthetics of short onset and duration with a low potential for
causing hypersensitivity (e.g., proparacaine hydrochloride 0.5%) are
used commonly during the eye examination and treatment only to
facilitate removal of superficial foreign bodies or rust rings or to
facilitate the examination when blepharospasm or severe local pain
prevents adequate visualization of the eye (e.g., in patients with flash
burns or severe corneal abrasions). The agents listed below (see also
Table 16-11 of the original guideline document) allow the clinician to
perform ocular procedures such as tonometry, removing foreign bodies
from the surface of the eye, and lacrimal canalicular manipulation and
irrigation. Refer to the original guideline document for further
details.

-   Cocaine hydrochloride

-   Proparacaine hydrochloride

-   Tetracaine hydrochloride

*Analgesics*

Systemic

The safest and most effective analgesic medication for acute eye
problems appears to be acetaminophen. Opioids may be no more effective
than acetaminophen but should be avoided if possible or used only until
an emergent referral to an ophthalmologist is made. Details regarding
major orbital or periorbital trauma appear in Chapter 3 of the original
guideline document.

Ophthalmic Topical

Four topical nonsteroidal anti-inflammatory drugs (NSAIDs) are available
for ophthalmic application that function as local anesthetics and
analgesics. They are diclofenac, flurbiprofen, ketorolac, and suprofen
(see Table 16-14 in the original guideline document).

*Pressure Patching*

Antibiotic ointment, with or without a topical mydriatic and a pressure
patch, has been the traditional treatment of traumatic, non-contact
lens-related corneal abrasions. Unfortunately, using a pressure patch is
not a benign treatment because it removes binocular vision, can be
uncomfortable for the patient, and may retard healing.

Potential disadvantages of patching can be noted. Pseudomonas ulcers
have been documented after eye patching of corneal abrasions cased by
contact lenses. Also, patching has been noted to decrease the natural
irrigation effect of tears and to decrease corneal oxygen tension while
increasing corneal temperature. Adverse effects on depth perception and
visual fields are well known.

In cases of open globe and/or major injury to the orbit, the injured eye
should be covered with a metallic or plastic shield for protection.

*Mydriatics and Cycloplegics* (see Table 16-12 in the original guideline
document for full listing)

The autonomic drugs that produce mydriasis (pupillary dilatation) and
cycloplegia (paralysis of accommodation and iris constriction muscles)
are among the most frequently used topical medications in ophthalmic
practice. The most commonly used mydriatic is the direct-acting
adrenergic agent phenylephrine hydrochloride, usually in a 2.5%
concentration.

Phenylephrine is used alone or, more commonly, in combination with a
cycloplegic agent for refraction or for pupillary dilatation.

*Antimicrobial Therapy* (see Table 16-13 in the original guideline
document for full listing)

Antibiotics are used routinely in ophthalmology for both treatment and
prophylaxis. They are used prophylactically to manage foreign bodies and
corneal abrasions and in pre- and postoperative care, where they are
administered as an ophthalmic solution or ointment. Because these
antibiotics are prescription drugs, no known over-the-counter
antibiotics are available to be used.

Corneal abrasions associated with contact lens wear are commonly
evaluated and treated in acute care clinics and emergency departments by
nonophthalmologists. The risk of progression to suppurative keratitis in
this setting requires management distinct from that of other mechanical
(e.g., fingernail scratch) corneal abrasions. The antibiotic chosen
should reflect the need for prophylaxis against Pseudomonas. Conditions
favoring bacterial growth, specifically occlusive patching and/or use of
steroid-containing compounds, must be avoided, and a 24-hour follow-up
examination is recommended.

Again, ensure that the patient is not allergic to the proposed
antibiotic prior to its use. Patients with more serious conditions, such
as bacterial corneal ulcers (red flag), or those whose foreign-body
abrasion is not healed in 24 hours or is showing no evidence of healing
should be referred to an ophthalmologist for further treatment. Patients
with potentially contaminated corneal abrasions or foreign bodies may
have their tetanus immunization evaluated and may be treated in
accordance with the tetanus immunization protocol.

*Ocular Anti-inflammatory Agents (Steroids)*

The wide variety of medications available to treat ocular inflammation
are listed in Table 16-14 of the original guideline document.
Corticosteroids (steroids) are used most commonly, and many are
available in combination with antibiotics and/or other medications.
Ocular anti-inflammatory drugs (steroids) should not be initiated by the
primary care physician but may be followed after initiation by an
ophthalmologist. Herpes simplex keratitis may be difficult to diagnose
by a nonophthalmologist and can be extremely progressive when steroids
are used without the presence of an appropriate antiviral agent.

Corticosteroids once were thought to be contraindicated in infectious
disease states. However, it is now appreciated that steroids, when used
in conjunction with appropriate antimicrobial, antifungal, or antiviral
agents, may help to prevent more serious ocular damage. The correct
diagnosis and appropriate agent are critical. Steroids may be
administered by four different routes when treating ocular inflammation.
Table 16-15 in the original guideline document lists the preferred route
for various conditions.

Topical corticosteroids can elevate IOP and, in susceptible individuals,
can induce glaucoma. Some corticosteroids, such as fluorometholone
acetate, medrysone, and loteprednol, cause less elevation of IOP than
others. Corticosteroids also may cause cataract formation, a
complication more likely with high systemic use.

**Management of Blurred Vision**

Blurred vision is a symptom of a decrease in visual acuity that may be
central or peripheral. The patient presenting with symptoms or signs of
blurred vision may be referred to an ophthalmologist or, based on
results of visual (ocular) screening, an optometrist (see Algorithm 16-8
in the original guideline document). Refer to the original guideline
document for definitions of central and peripheral visual acuity loss.

**Management of Visual Fatigue**

*Visual fatigue* is a term used to describe phenomena related to
intensive use of the eyes. It can include complaints of eye or
periocular pain, itching or burning, tearing, oculomotor changes, focal
problems, performance degradation, after-colors, and other phenomena.
Patients presenting with signs or symptoms of visual fatigue may be
referred to an ophthalmologist or optometrist (see Algorithm 16-9 in the
original guideline document).

Refer to the original guideline for additional information on factors
influencing the visibility of tasks and ergonomic findings regarding
video display terminals.

**Vision Screening for the Worker**

In order to determine the exact loss of function in patients with
blurred vision and visual fatigue, a visual (ocular) function screening
should be completed (see Algorithms 16-7, 16-8, and 16-9 in the original
guideline document).

**Work-Relatedness**

A thorough work history is crucial to establishing work-relatedness.
Determining whether an eye complaint is related to work requires careful
analysis and weighing of all associated or apparently causal factors
operative at the time. In most traumatic eye complaints, the etiology is
relatively clear. However, identifying the source of cataracts, for
example, may be more difficult. In cases of nonspecific eye complaints,
such as \"eye strain\" or headache, a predominance of work factors
suggests that worksite intervention to prevent recurrences and hasten
recovery is appropriate. A cluster of cases in a work group suggests a
greater probability of associated work-design or management factors.

Refer to the original guideline for additional discussion of work
activities, preventive medicine guidelines, and American with
Disabilities Act (ADA) issues.

#### CLINICAL ALGORITHM(S)

The following clinical algorithms are provided in the original guideline
document:

-   American College of Occupational and Environmental Medicine
    Guidelines for care of eye complaints

-   Care of red eye complaints

-   Initial evaluation of occupational red eye complaints

-   Initial and follow-up management of non-red flag occupational eye
    complaints

-   Evaluation of slow-to-recover patients with occupational eye
    complaints (symptoms \>7 days)

-   Surgical considerations for patients with persistent visual symptoms

-   Further management of occupational eye complaints

-   Visual screening (fitness-for-duty evaluation)

-   Care of eye complaints -- blurred vision

-   Care of eye complaints -- visual fatigue

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Improved efficiency of the diagnostic process

-   Effective treatment resulting in symptom alleviation and cure

#### POTENTIAL HARMS

-   Avoid using topical anesthetics for purposes other than diagnosis or
    treatment because they may obscure worsening pathology and thus
    inadvertently cause further injury.

-   Allergic reactions to topical and systemic medications

-   Side effects of topical and systemic medications

-   Topical corticosteroids can elevate intraocular pressure (IOP) and,
    in susceptible individuals, can induce glaucoma. Some
    corticosteroids, such as fluorometholone acetate, medrysone, and
    loteprednol, cause less elevation of IOP than others.
    Corticosteroids also may cause cataract formation, a complication
    more likely with high systemic use.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Tonometry is contraindicated when external infection or lack of globe
integrity is obvious.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The American College of Occupational and Environmental Medicine
    (ACOEM) provides this segment of guidelines for practitioners and
    notes that decisions to adopt particular courses of actions must be
    made by trained practitioners on the basis of the available
    resources and the particular circumstances presented by the
    individual patient. Accordingly, the ACOEM disclaims responsibility
    for any injury or damage resulting from actions taken by
    practitioners after considering these guidelines.

-   The guidelines for modification of work activities and disability
    duration (see original guideline document) are general guidelines
    based on consensus or population sources and are never meant to be
    applied to an individual case without consideration of workplace
    factors, concurrent disease, and other social or medical factors
    that can affect recovery.

-   The parameters for disability duration are \"consensus optimal\"
    targets as determined by a panel of ACOEM members in 1996 and
    reaffirmed by a panel of ACOEM members in 2002. In most cases,
    persons with one nonsevere injury can return to modified duty
    immediately.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Eye. Elk Grove Village: American College of Occupational and
Environmental Medicine (ACOEM); 2004. 77 p. \[149 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004

#### GUIDELINE DEVELOPER(S)

American College of Occupational and Environmental Medicine - Medical
Specialty Society

#### SOURCE(S) OF FUNDING

American College of Occupational and Environmental Medicine

#### GUIDELINE COMMITTEE

American College of Occupational and Environmental Medicine Practice
Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Chapter Lead*: Bernard R. Blais, MD, FACOEM, FAAO, FACS

*Committee Members*: Jennifer H. Christian, MD, MPH, FACPM; Philip I.
Harber, MD, MPH, FACOEM, FCCP; John P. Holland, MD, MPH, FACOEM; Kathryn
L. Mueller, MD, MPH, FACEP, FACOEM; Douglas J. Patron, MD, MSPH; Bernyce
M. Peplowski, DO, MS; and Jack Richman, MD, CCFP, DOHS, FACOEM

Timothy J. Key, MD, MPH, FACOEM, as Responsible Officer and ACOEM
President Elect, and Edward A. Emmett, MD, MS, FACOEM, Chair of the
ACOEM Council on Occupational and Environmental Medical Practice,
contributed to the development of the guidelines as well.

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Harris, J, ed. Occupational
Medicine Practice Guidelines: American College of Occupational and
Environmental Medicine. Beverly Farms, MA: OEM Press; 1997.

#### GUIDELINE AVAILABILITY

Print copies are available from ACOEM, 25 Northwest Point Boulevard,
Suite 700, Elk Grove Village, IL 60007; Phone: 847-818-1800 x399. To
order a subscription to the online version, call 800-441-9674 or visit
<http://www.acoempracguides.org/>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following implementation tool is available in the original guideline
document:

-   Visual history questionnaire. Table 16-16

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on May 31, 2006. The information
was verified by the guideline developer on November 3, 2006.

#### COPYRIGHT STATEMENT

The American College of Occupational and Environmental Medicine, the
signator of this license, represent and warrant that they are the
publisher of the guidelines and/or possess all rights necessary to grant
the license rights to AHRQ and its agents.

### DISCLAIMER

#### NGC DISCLAIMER

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