Of the 100,000 eye injuries that occur annually, 40% occur during sports or recreational activities.1 Foreign bodies and lacerations are the most common and generally can be treated by the pediatrician. Globe lacerations, retinal hemorrhage, and retinal detachments can lead to permanent vision loss and should be referred to an ophthalmologist (Box 36-1). Orbital hemorrhage and hyphema can look dramatic but usually resolve with minimal treatment.
Recommended Referral for Eye Injuries in Sports
Visible foreign object not easilyremoved with cotton or tissue
Embedded foreign object
Slit-lamp examination may be required with small spud for removal
Loss of vision
Irregularity of the globe
Laceration of the globe
Surgical repair of the globe
Herniation of viteous of eye
Full thickness laceration of the eyelid
Proptosis interfering with vision
Hemorrhage and swelling
Orbital hemorrhage with increased intraocular pressure
Intraocular pressure measurement
Totally black anterior chamber
Hyphema large or not resolving in 3 days
Hemorrhage aspiration may be necessary
Loss of visual field
Persistent blood in the anterior chamber
Irregularity of retina on ophthalmoscopic exam
May need surgical/laser repair
Loss of part of visual field
Loss of vision in one eye
Irregularity of the pupil
Surgical reduction and repair
Blurred vision with upward gaze only
Inability to gaze upward with involved eye
Fracture of the floor of the orbit
Surgical reduction and repair of sinus
Use of appropriate protective eyewear will decrease the risk of corneal abrasion. Good supervision, equipment of good repair, and rules enforcement can further decrease the risk of these eye injuries. For outdoor sports, the area should be inspected for potential obstacles such as tree branches. Appropriate eye protection should be used in high-risk sports such as hockey, football, baseball, softball, basketball, tennis, racquet sports, lacrosse, and swimming. Regular glasses and contacts are not adequate protection. The eye wear should include lenses of polycarbonate 3 mm thick. Frames should be of polycarbonate and molded to the temples, not hinged. Lens treatment with fog resistance will improve vision under environmental conditions (Table 36-1). Proper fitting by an experienced ophthalmologist may improve compliance. Full face protectors either of polycarbonate shield or wire cage should be used in hockey. Wire cage face protectors are most commonly used in lacrosse and football.
Minimal Eye Protector
Baseball/softball, youth batter or base runner
Face guard attached to helmet
ASTM F803 for baseball
ASTM specifies age ranges
ASTM F803 for basketball
ASTM specifies age ranges
Helmet plus streetwear ANSI Z80, industrial ANSI Z87.1, or sports
Use only polycarbonate lenses; excellent plano industrial spectacles are available that are inexpensive and give good protection from wind and particles
ASTM F803 eyewear
None available; not permitted in sport
Sport contraindicated for functionally one-eyed
Protector with neck bib
Test requirements of the International Federation of Fencing
Field hockey (both sexes)
Goalie: full face mask; others: ASTM F803 for women’s lacrosse
Protectors that pass ASTM F803 for women’s lacrosse also pass for field hockey; should have option to wear helmet with attached face mask
Polycarbonate eye shield attached to helmet-mounted wire face mask
Full-contact martial arts functionally
None available; not permitted in sport
Contraindicated for one-eyed
ASTM F513 face mask on helmet; goaltenders ASTM F1587
HECC or CSA certified full face shield
NOCSAE face mask attached to lacrosse helmet
ASTM F803 for women’s Lacrosse
Should have option to wear helmet with attached face mask
ASTM F1776 for paintball
Racket sports (badminton, tennis, paddle tennis, handball, squash, and racquetball)
ASTM F803 for specific sport
ASTM F803 for any selected sport
No specific standard for soccer; currently, eye protectors that comply with ASTM F803 for any specified sport are recommended
ASTM F513 face mask on helmet
Must be HECC or CSA certified
Track and field
Use only polycarbonate lenses
Swim goggles with polycarbonate lenses
No standard is available
Custom protective eyewear can be fabricated
Specific Eye Injuries
Dust and debris may become trapped in the eye of the athlete. Especially of high risk are outdoor sports, contact sports, and team sports. Foreign body in the eye is the most common sports-related eye injury.
With exposure to environmental elements as well as sports equipment, foreign bodies can lodge in the eye.
The athlete with a foreign body in the eye will complain of pain, irritation, possibly a “gravelly feeling” in the eye. The irritation is made worse with blinking and rubbing. Irritation can result in conjunctival injection. Excessive tearing is a common associated symptom.
The entire eye should be evaluated to locate the foreign body which often lodges under the upper or lower eyelid. The upper eye lid should be everted by gently inverting the closed lid over a cotton tip applicator (Figure 36-1). The foreign body lodged under the lid can lead to corneal abrasions with movement of the eye.
Instilling a topical anesthetic in the eye will help relieve pain and keep the athlete more comfortable during the examination. When the foreign body is located, the corner of a tissue or a wisp of cotton can be used to remove the foreign body. Symptoms usually resolve when the foreign body is removed. The anesthetic should not be administered on a regular basis, as this can lead to damage to the eye.2 If the foreign body cannot be removed or is embedded, the ophthalmologist will need to remove it with a spade and slit lamp. Rarely, a CT scan may be necessary to localize the foreign body. Protective eyewear may be required for a short period of time, but athlete can usually return to activity immediately after removal of the foreign body. Ice may be applied for pain relief.
Blunt trauma, sharp objects, even inferior or improperly worn eyewear can result in lacerations of the eye lid or globe. Superficial lacerations are the most common eye injuries related to sports. Most sports-related trauma does not result in globe laceration.
Blunt trauma from a small sharp object most commonly results in superficial eyelid lacerations. The natural reflex is closure of the eyelids as potential danger to the eye is sensed. With lower-energy trauma the damage may be limited to superficial tissue. High-energy trauma could result in globe lacerations.
The athlete will often recall a specific trauma, usually of a smaller object size. Often there will be pain swelling and hemorrhage present. Anatomic disruption may be subtle on initial inspection. Visual acuity is often decreased with globe lacerations. Obvious anatomic deformity may be readily apparent.
Lacerations of the eyelid can be subtle and may have normal appearing eye. Lacerations of the external surface of the eye lid should be inspected to determine if there is a full-thickness laceration or the lid margin is involved.3 The eye lid which is swollen shut should not be forcibly opened to avoid possible herniation of globe contents. Globe lacerations are associated with decreased acuity and if deep put vision at risk. Referral to the ophthalmologist is recommended.
Corneal abrasions and foreign bodies may be associated with lacerations. Full eye examination including visual acuity, ocular motion, lid motion, and under surface of the lid should be performed. If the trauma is related to a larger object, an orbital fracture should also be considered.
Superficial lid lacerations may be repaired by delicate suturing well-approximated edges while avoiding injury to the globe. Eyelid lacerations usually heal quite well with very little scar. The athlete should be referred to ophthalmology if the laceration involves the full thickness of the lid or the lid margin. The athlete should be referred if a globe laceration is suspected (Box 36-1).
The cornea is the clear covering of the anterior aspect of the eye lens. Defects in the cornea can result in inference of light penetration through the lens and focus on to the retina. A nontransparent cornea will result in decreased vision. The eyes are shielded from large object by the hard bony orbit. The eyes are also protected from smaller particles by eye lashes and eye lids. Racquet sports and baseball, for example, place the eyes at risk from contact with a fast moving ball. In any team sport even limited contact places the eye at risk of corneal abrasions.
In team sports, the most common mechanism of abrasion is the “finger in the eye,” usually from another athlete. Outdoor sports can have added risk of debris blown into the eye. Finally other objects such as balls, bats, sticks, and pucks, can pose a similar risk.
The most common symptom of corneal abrasion is a very painful eye. This may be described as a gritty feeling which is increased with eye movements. These symptoms can be an indication of a foreign body as well. Other associated complaints include headache, blurred vision, photophobia, and watery eyes. Often the athlete will relate a specific ocular trauma; however, there may be no other trauma than rubbing of the eyes.
On inspection, the conjunctiva may appear injected. Instillation of topical anesthetic (e.g., tetracaine) will help to relieve the athlete’s pain and allow full examination of the eye. Full examination of the eye with specific attention to check under the eyelids is important to identify any foreign body. Foreign bodies resting on the eyelid or the cornea may be elevated and removed with a tissue or gauze. Embedded objects are best removed by the ophthalmologist in an appropriate setting. Instillation of flourescein and examination under blue light will identify the extent of the abrasion as dye uptake lights up brightly.
Full healing without complication is the usual prognosis; however, the athlete should be re-examined daily until the abrasion is healed. These usually heal within 3 days. The involved eye should be protected from light exposure during the healing process. Sunglasses to protect the eyes from sunlight exposure are helpful, but patching has not been shown to be effective. Athletes with contact lenses should remove contacts while symptomatic. The athlete diagnosed with a corneal abrasion should be kept out of contact sports or high-risk sports until healed.4 Natural tears or other wetting solution can offer some symptomatic relief. Topical nonsteroidal anti-inflammatories could be used as well. Antibiotic eye drops are generally not required unless there are signs of infection.
Depending on the velocity and size of object involved, trauma to the orbit can result in orbital hemorrhage and edema. More significant trauma may result in orbital fractures. These injuries may occur in any sport because of equipment or other athletes. Contact sports raise the most risk.