HEAD AND NEUROLOGICAL CONDITIONS

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Ocular Injuries in Sports

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Shane P. Cass, DO

physical examination, these injuries

Abstract
can be managed on the field, in the
Eye injuries are common in sports. Team physicians need to be able to
office, and in the training room. This
recognize and treat common injuries and know when to refer other prob-
article will review some of the new
lems. This article highlights the current treatment of common sports-
literature in the area of sports-related
related eye injuries and reviews some of the new literature. Nearly 90% of
ophthalmology.
all sports-related eye injuries can be prevented with adequate eye pro-
tection and will be discussed in some detail in the article.
‘‘Eye Tray’’
Many eye injuries can initially be
Introduction diagnosed and managed with a minimum of equipment and
Although less common than musculoskeletal injuries, should be considered an essential component of any game
sports-related eye injuries have the potential for major bag or training room. A slit lamp examination may occa-
morbidity and loss of function. Sports are responsible for a sionally be necessary for diagnosis but is often unavailable.
third of eye injuries in the United States that lead to blind- Most eye carts should contain the following: ophthalmo-
ness (29). An estimated 100,000 physician visits per year scope, a penlight and a light source with a blue filter or cobalt
from sports are reported to cost greater than $175 million blue, fluorescein dye, cotton-tipped swabs, a vision chart, eye
(22). Reviewing data from the National Electronic Injury shields, loupes or magnifying glass, 18-gauge needles, sterile
Surveillance System, recent studies show 208,517 cases of saline, and a contact lens remover. Medications include top-
sports-related eye injuries were treated in U.S. emergency ical anesthetic drops, mydriatic drops, and antibiotic oint-
departments between 2001 and 2009. Per-risk classification ment. A tonopen for measuring intraocular pressures may be
by the American Academies of Ophthalmology and Pedi- considered if funding is available (30).
atrics (Table 1), high-risk activities contributed 55% of
eye injuries, moderate-risk activities contributed 27%, low- History
risk activities contributed 16%, and eye-safe activities con- The physician should try and deduce the force and
tributed 3%. Although eye injury trends declined from 2001 direction of impact. If the physician is not present at the
to 2005, they showed increasing injury rates from 2007 to time of injury then a thorough explanation of mechanism of
2009 (17). injury is necessary. High-velocity injuries or those dealing
Data from The National Eye Trauma System found that with glass should raise the question of a penetrating eye
sports account for 13% of all penetrating ocular injuries. The injury. Blunt, forceful injuries may direct one to look for
most common sports relating to eye injury in the United signs of orbital blow out fractures. Symptoms such as for-
States are as follows in descending order: baseball and soft- eign body sensation, perception of decreased visual acuity,
ball, basketball, racquetball, football, and soccer. Among and diplopia are helpful to direct evaluation.
these injuries, 82% wore no form of eye protection (12).
With injury trends on the rise and the potential for serious Physical Examination
functional loss with these injuries, it is important for the A good examination can diagnose many eye injuries but
sports medicine professional to accurately diagnose, treat, should be systematic to avoid missing specific signs. An
and know when to refer common ocular injuries. With a assessment of visual acuity should be done first. This can
minimal amount of equipment and a good history and give a baseline for further follow-ups and give clues to more
serious problems. This can be obtained with a portable
Primary Care Sports Medicine Fellowship, University of New Mexico,
snellen chart. For those with smart phones, many free apps
Albuquerque, NM
are available. Confrontational visual fields should be checked
Address for correspondence: Shane P. Cass, DO, Primary Care Sports to evaluate for retinal, optic nerve, or central nervous system
Medicine Fellowship, MSC09 5040, 1 University of New Mexico, injury.
Albuquerque, NM 87131-0001 (E-mail: shanepcass@gmail.com). Pupils should be examined with a penlight or other bright
1537-890X/1101/11Y15
source of light. The physician should look for pupil size,
Current Sports Medicine Reports reactivity, shape, and extraocular muscles. At this time, one
Copyright * 2012 by the American College of Sports Medicine should check for a relative afferent pupillary defect. This

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Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 Table 1. vision (28). It should be noted that this is mainly regarding
Selected sports by risk category. simple corneal abrasions and that further research is needed
Risk Sport on lesions greater that 10 mm. The systematic review by
Fraser (16) did demonstrate two studies that gave some
High BB and paintball evidence that topical diclofenac can be useful for pain alle-
viation. It may be prudent to refer contact lens wearers to an
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Basketball
ophthalmologist for frequent slit lamp examination because
Baseball this population is more likely to develop secondary infec-
Softball tion. Contact lens use should be discontinued until healing
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Ice hockey
and drops are stopped. In addition to the review, Fraser
gives referral guidelines. These include a history of signif-
Moderate Tennis icant trauma, worsening symptoms despite treatment, in-
Soccer filtrates around the edge of abrasion that may suggest
secondary infection, and recurrent erosion syndrome.
Volleyball
Football Corneal Foreign Body
Fishing Symptoms of a retained corneal foreign body are similar
to symptoms of abrasions. Diagnosis of corneal foreign
Golf body requires a high index of suspicion to rule out. Com-
Low Swimming monly missed foreign bodies are under the upper lid in the
Snow skiing tarsal plate. A full evaluation to rule out foreign bodies
should include inversion of the upper and lower lid. Foreign
Water skiing bodies should be irrigated. If that fails to dislodge the for-
Bicycle eign body, a moistened cotton swab can be used. The tip of
an 18-gauge needle can be used with caution, taking care to
Snowboarding
not damage the cornea further. Although routine use of
Eye-safe Exercise (jogging, running, walking, aerobics) topical antibiotics in the clinic setting often is not necessary,
some recommend its use in wilderness and athletic settings
where hygiene may be less than optimal (8).

can be done with the swinging flashlight test. A relative Blunt Trauma
afferent pupillary defect is present when the eye with the Blunt trauma makes up a majority of sports-related eye
deficit paradoxically dilates when exposed to the light injuries. Size, velocity, and hardness of the object are im-
source. This could indicate an optic nerve or retinal injury. portant for determining the severity of the injury. If an
An efferent defect loses both direct and consensual con- object smaller than the orbit is the source of impact, it
strictions, with both present in the unaffected eye. This is causes rapid compression and dilation of the middle of the
seen with anisocoria (unequal pupils) and could indicate a globe, which may transmit more force to the internal ocular
third nerve palsy or Horner syndrome. The penlight can be structures. A blow from an object larger than the orbits
used to evaluate the anterior chamber for relative depth and transmits force to the medial wall or the orbital floor,
the eyelids for lacerations. Conjunctiva, cornea, and facial resulting in fractures of thin bones. This can cause a pres-
and maxillary bones should be examined as well. sure release that may lead to soft tissue entrapment.

Corneal Abrasion Orbital Fractures

Among some of the most common injuries to present Orbital fractures and other maxillofacial injuries, al-
both on the field and in the training room are corneal though less common, are increasing in incidence in sports. A
abrasions. This a defect in the corneal epithelial surface. It recent study showed that orbital floor fractures accounted
is usually traumatic but can occur spontaneously, as in for 17% of all maxillofacial injuries in sports, with sports
the athlete with dry eyes. This is important to consider in accounting for 21% of all the fractures surveyed (3). Typi-
our endurance and running population (10,14). Fingernail cally, the orbital floor, on occasion the medial wall, is frac-
scratches to the eyes in contact sports are fairly common. tured owing to increased intraorbital pressure, which causes
The history usually involves a traumatic insult to the eye the orbital bones to break at their weakest point. Signs of an
with associated irritation or a sharp pain, tearing, photo- orbital floor fracture include periorbital edema, ecchymosis,
phobia, and an occasional foreign body sensation. Corneal and painful extraocular movements. A step off can be seen if
abrasions stain with fluorescein dye. the orbital rim is fractured. Injury to the infraorbital nerve
Recent systematic reviews and Cochrane meta-analysis can cause hypesthesia or dysthesia. Proptosis or enoph-
have shown that treatment with a combination of drops thalmos (abnormal protrusion of eyeball) also can be seen.
is most effective (10). Treatment with topical antibiotic A limitation of vertical gaze is suggestive of an inferior
(chloramphenicol was used in many of the studies) and rectus entrapment (15).
cycloplegics (cyclopentalate) leads to improved healing. There is a subtype of orbital fracture that is present in
Conversely, eye patching does not improve healing rates or children known as a trapdoor fracture or white-eyed blow-
pain 1 d after injury and can lead to a loss of binocular out fracture (WOBF). This is the orbital equivalent of a

12 Volume 11 & Number 1 & January/February 2012 Ocular Injuries in Sports

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 green stick fracture and is due to the elasticity of pediatric is variable, but 70% to 80% occur in the first 3 months after
bones. Soft tissue gets entrapped in the fracture as the elastic injury (6). Early signs, in a patient with a history of traumatic
pediatric bones snap back into place. It receives its name globe injury, include changes in accommodation strength,
because of the relative lack of external ocular trauma. photophobia, and tearing. Prompt referral is critical.
Recent reviews have determined that these trapdoor frac-
tures are the most common type of orbital fracture occur-
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ring in children (31). White-eyed blow-out fracture is a Hyphema

clinical diagnosis that consists of vertical diplopia, pain Hyphema is a common result of blunt trauma to the eye.
with extraocular movement, gaze restriction (usually verti- Direct trauma causes shearing forces on the blood vessels
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cal), and nausea and/or vomiting in the setting of periorbital of the iris. A hyphema is the end result of these vessels
trauma. One study found these symptoms present 100%, rupturing. This is commonly seen by examining the anterior
100%, 100%, and 75%, respectively, in WOBF (21). chamber where layering of gross blood or clot can be
A recent article by Ethunandan and Evans (9) hypothe- observed. Traditional acute management of a traumatic
sized that this may be more common in adults than recently hyphema includes shielding the eye, bed rest with head
thought. Retrospectively sampling 10 patients treated for of the bed elevated, cycloplegic drops, and avoidance of
orbital fractures, 7 had no subconjunctival hemorrhage or any aspirin-containing products. A recent Cochrane review
bruising (white eyed). All of these patients had orbital found inconclusive evidence for the use of cycloplegics and
fractures and entrapment of soft tissue. Of them, 60% had corticosteroids because of a small number of participants in
autonomic symptoms such as nausea and vomiting. On the studies. The review also demonstrated inconclusive
review, they all demonstrated fracture on imaging. evidence for wearing a patch on one versus both eyes, bed
Computed tomography (CT) is the gold standard for rest versus moderate activity, and elevation of the head of
diagnosing orbital floor fractures. Keep in mind that, with bed versus lying flat (11). Because it is inconclusive evi-
WOBF, the CT scan may read as negative for a fracture. dence, it is still prudent to restrict all athletes from com-
Therefore, in children with the above symptoms, an oph- petition and training who present with a hyphema until
thalmologist should be consulted in the case of a normal CT cleared by an ophthalmologist. All cases of hyphema should
scan. Children with WOBF fair better with surgical treat- be referred to an ophthalmologist because rebleeding may
ment if done within the first 2 to 5 d, so accurate diagnosis affect vision and is a major cause of concern (11,13).
is important (31). Treatment for adults includes advising
patients to avoid blowing their nose for several weeks after Retrobulbar Hemorrhage
the injury to prevent orbital emphysema, which could affect A devastating consequence of blunt eye trauma is retro-
vision. Surgical treatment is controversial and often debated bulbar hemorrhage leading to compartment syndrome. The
among ophthalmologists but follows certain guidelines orbital space is an enclosed area; acute rises in intraorbital
such as diplopia, enophthalmos, and fracture size (15). pressures can lead to decreased perfusion and ischemia,
similar to other compartment syndromes. Raised pressures
Globe Rupture for longer than 60 min can lead to permanent visual loss (18).
Globe rupture should be considered with blunt trauma, Because orbital compartment syndrome is a clinical diag-
especially high-velocity trauma from a flying object, such as nosis, a high index of suspicion should be held for patients
a racquet ball. Lack of appropriate recognition and treat- with periorbital bruising, visual impairment, proptosis, and
ment can lead to endophthalmitis V a serious intraocular pupillary defects in the setting of blunt trauma.
infection that can lead to blindness (4). Pain, visual loss,
hyphema, anterior chamber depth loss, pupil irregularity,
and subconjunctival hemorrhage involving 360- around the Retinal Injury
cornea are very suspicious for globe rupture (23). Other Traumatic retinal tears are usually caused by blunt trauma
more obvious signs would include signs such as leakage of to the globe. The pathophysiology attributed to this phe-
vitreous material. nomena is compression of the globe, which may result in a
Once globe rupture is suspected, prompt referral to an traction between the vitreous tissue and retina. Subsequent
ophthalmologist is mandatory. An eye shield should imme- tearing may ensue if great-enough force is achieved. The only
diately be placed, and manipulation of the eye is deferred to symptoms specific to retinal tears are flashes of lights and
avoid direct pressure and further damage. Scheduled anal- floaters, which may not always be present (24). Evaluation
gesics and antiemetics should be provided to avoid Valsalva should include visual acuity, extraocular function, and pupil
maneuvers that may accompany pain and emesis from the and retina evaluation. Symptoms of severe pain and dulled
injury and further damage intraocular or extruded tissue. vision, in the setting of decreased acuity and trauma, should
Given a high-velocity trauma history, an ophthalmologist prompt ophthalmology treatment.
should be consulted, despite potentially normal findings in The literature also includes cases of visual loss and ret-
the physical examination (27). inopathy in nontraumatic cases of athletes (20). This has
The astute physician should be aware of a condition been reported in endurance athletes, and the proposed
known as sympathetic ophthalmia. This is bilateral eye in- mechanism is related to individuals who are more prone to
flammation that threatens blindness in both eyes after an clotting and thrombosis. As strenuous exercise increases
initial penetrating injury to one eye. It has been seen in activated platelets and other clotting factors, thrombosis
globe ruptures and orbital fractures. It typically follows a can ensue. Also, the risk for retinal detachment is much
latent period after initial injury to the eye. The time course higher in athletes with severe myopia.

www.acsm-csmr.org Current Sports Medicine Reports 13

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 Penetrating Eyelid Injuries or Laceration Table 2.
Penetrating eye injuries are much less common than blunt Return-to-play guidelines.
injury. Eyeglass breakage can cause injury that penetrates Eye Injury Return to Play
the globe. Assessment and treatment should proceed as
outlined before. Lacerations of the eyelid are not uncom- Corneal abrasion May return to play if no functional or
mon and can be seen with penetrating eye injuries and even binocular loss of vision.
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forceful blunt trauma. If underlying globe injury has been Corneal foreign Same guidelines as for corneal abrasion
ruled out, simple upper and lower eyelid lacerations can be body
managed by the sports physician. Time to primary closure Blow-out fracture Should not return to competition. Should
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should be 12 to 36 h. It is necessary to refer injuries that be cleared by an ophthalmologist and

involve the upper or lower lid margins or injuries that ENT prior to return.
involve the lacrimal sac or duct. These will require micro-
Globe rupture Should not return to competition. Should
surgical technique (5). It is also necessary to refer lacer-
be cleared by an ophthalmologist prior to
ations that expose the orbital fat because this may indicate return.
damage or extension to the underlying levator palpebrae
superioris muscle. If there is question of lacrimal system Hyphema Should not return to competition. Should
involvement, fluorescein may be placed in the eye and be cleared by an ophthalmologist prior to
return.
observed for dye in the wound. Many providers may have
lack of experience in the area of eyelid laceration repair and Retrobulbar Should not return to competition. Should
should only proceed with primary closure if clinical exper- hemorrhage be cleared by an ophthalmologist prior to
tise is appropriate. return.
Retinal tear or Should not return to competition. Should
Burns and Radiation Exposure detachment be cleared by an ophthalmologist prior to
Many athletes are exposed to high levels of ultraviolet return.
light, namely, UVB and UVA. Because sunscreen cannot be Eyelid laceration May return to play if bleeding controlled
applied close to the eye, the eyelid margins are particularly and no functional or binocular loss of
at risk and should be monitored (14). UV burns tend to vision.
damage the conjunctiva and cornea and can happen in Penetrating eye Should not return to competition. Should
water or snow sports as well as mountaineering and ath- trauma be cleared by an ophthalmologist prior to
letics at high altitudes. Classic signs include intense pain, return.
photophobia and delay in symptom onset, tearing, and lid
Burns and radiation May return to play if no functional or
spasms (8,25). Fluorescein dye will show fine punctate exposure binocular loss of vision.
staining. Treatment involves systemic analgesics and topical
antibiotics. The best prevention for radiation exposure of
the eye is the use of sunglasses that absorb all forms of UV
radiation. In sports where there is a risk of eye trauma and Prevention
potential risk of broken lenses, shatter-resistant polycar- Sadly, a large majority of sports ocular injuries could
bonate lenses should be used for protection. have been prevented with appropriate eye wear. Recent
studies show that more than 90% of these injuries are pre-
ventable (12). A joint policy from the American Academy of
National Collegiate Athletic Association Regulations Pediatrics and the American Academy of Ophthalmology
The National Collegiate Athletic Association (NCAA) set forth specific recommendations. They recommend eye-
has few regulations regarding mandatory eye protection wear specific to the sport that meet ASTM standards, pro-
and athletic participation. In 2005, they did mandate that tection for contact lens wearers, and ASTM-standardized
all field players in women’s lacrosse shall wear protective lenses for those requiring correction and that all func-
eyewear that meets current American Society for Testing tional one-eyed athletes should wear protection. In addi-
and Materials (ASTM) lacrosse standards (19). There are tion, they recommend all functional one-eyed athletes not
now a number of manufacturers that provide eye protection to participate in boxing or full-contact martial arts (1).
that meets ASTM standards (2). Currently, the NCAA does A functional one-eyed athlete is that individual with a
not mandate eye protection for any other collegiate sport. corrected visual acuity of less than 20/40 in the eye with the
defect. ASTM standards can be reviewed at the following
Return-to-Play Guidelines Web site: http://www.astm.org/Standards/F803.htm.
There are no set or published guidelines for return to play Getting players to wear eye protection that is not man-
from eye injuries. The determination to return is a clinical dated is a challenge. In 2002, a National Health Interview
call that must take into account the athlete’s ability to play Survey showed that only 15% of children in organized
his or her given sport at his or her previous level. Table 2 sports wore appropriate protective eyewear (12). A survey
provides some suggestions for return to play. Essentially, if of 1,163 squash players in Australia demonstrated that
there is no functional or binocular loss of vision, then play 1,072 of them did not wear eye protection. Of them, 51%
can resume. Obviously, eye injuries necessitating specialty reported this was due to the eyewear being uncomfortable
consultations should be cleared by the specialist prior to or restricting their vision. Of those using protective eyewear,
return. 91 (53%) claimed this was because of the proper knowledge

14 Volume 11 & Number 1 & January/February 2012 Ocular Injuries in Sports

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 of eye injuries. Of all those surveyed, 71.7% of them agreed national Commission for Mountain Emergency medicine ICAR MEDCOM.
Wilderness Environ. Med. 2009; 20:169Y75.
that protective eyewear would significantly reduce their
9. Ethunandan M, Evans BT. Linear trapdoor or ‘‘white-eye’’ blowout fracture
risk of sustaining injury (7). of the orbit: not restricted to children. Br. J. Oral Maxillofac. Surg. 2010;
A recent Cochrane review looked at the evidence of 49:142Y7.
educational effectiveness for the prevention of eye injuries. 10. Fraser S. Corneal abrasion. Clin. Ophthalmol. 2010; 4:387Y90.
Unfortunately, owing to poor study quality, reliable evi- 11. Gharaibeh A, Savage HI, Scherer RW, Goldberg MF, Lindsley K. Medical
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dence was not provided for the effectiveness of educational interventions for traumatic hyphema. Cochrane Database Syst. Rev. 2011
Jan 19;(1):CD005431.
interventions. More studies with high-quality randomized
12. Goldstein MH, Wee D. Sports injuries: an ounce of prevention and a pound
controlled trials that include longer follow-up periods are of cure. Eye Contact Lens. 2011; 37:160Y3.
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needed (26). These findings should not discourage providers 13. Heimmel MR, Murphy MA. Ocular injuries in basketball and baseball: what
from giving proper education and anticipatory guidance for are the risks and how can we prevent them? Curr. Sports Med. Rep. 2008;
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Conclusions
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triage/refer most cases of eye injury. Eye protection does injuries in the US: 2001Y2009. Graefes Arch. Clin. Exp. Ophthalmol. 2010;
249:1743Y4.
decrease eye injuries. Although good trials are lacking on
18. Kloss BT, Patel R. Orbital compartment syndrome from retrobulbar hem-
educational interventions, physicians should encourage orrhage. Int. J. Emerg. Med. 2010; 3:521Y2.
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continue to advocate for appropriate eye protection policy. ed. Indianapolis (IN): NCAA; 2010. p. 96Y8.
20. Labriola LT, Friberg TR, Hein A. Marathon runners retinopathy. Semin.
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Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.