Mechanisms of Eye Injuries in Sports

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  The severity of eye injuries can be positively correlated with the total impact force, rate of force onset, and kinetic energy of an impacting object.

  
  
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  Ocular injuries fall into several broad categories ( Table 47.3 ).

  
  
  
  

  TABLE 47.3

  
  

  RELATIVE FREQUENCY OF EYE INJURIES

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Most Common	Relatively Infrequent	Eye Emergencies
  Corneal abrasion	Chemical burns
  Corneal foreign body	Vitreous hemorrhage	Retinal detachment
  Conjunctival foreign body	Retinal hemorrhage	Lens dislocation
  Subconjunctival hemorrhage	Retinal edema	Blowout fracture of the orbit
  Eyelid laceration	Hyphema Injury to the lacrimal system	Optic nerve injury

   
  
  
  
  
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  Open globe injuries are full-thickness wounds to the eye wall (cornea or sclera) and result from a rupture or laceration. Sports that cause ruptured globes typically have a stick or projectile that fits into the orbit. A previous surgery or eye disease increases the risk of an open globe injury.

  
  
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  Lacerations may be caused by objects that “slice” or penetrate the eye, which may lead to open globe injuries.

  
  
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  Closed globe injuries are those that do not completely penetrate the cornea or sclera. These include lamellar lacerations, corneal abrasions, contusions, hyphema, or injury to the choroid, macula, retina, or optic nerve.

  
  
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  Blunt injuries, typically causing contusions, globe rupture, or adnexal injury, account for most sports-related eye injuries. Contusions are usually caused by blunt objects smaller than the orbit (e.g., golf ball or finger). In addition, several objects will deform significantly on impact (e.g., soccer ball), producing a “knuckle” that will impact the eye ( Fig. 47.1 ). With objects smaller than the orbit, there is generally a greater force transmitted to the internal structures of the eye, whereas with larger objects, there is an increased risk of orbital wall fracture and occult internal ocular injuries.

  
  

  
  

  
  

  

  
  

  
  

  Large object causing injury to the globe.

  
  
  
  
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  Radiant energy or UV burn injuries are less common but may occur in activities that take place at a high altitude or on snow.

Principles of Protection From Eye Injuries in Sports

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  Protective devices work by deflecting the impact energy away from the eye and dissipating the energy over time and area. This is typically accomplished with either a lens or a mechanical grid (e.g., wire-framed face guard or mesh-fencing helmet).

  
  
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  Inappropriate fit of protective gear can decrease the protection offered, placing the eye at an increased risk.

  
  
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  The gear must be comfortable and not interfere with the performance of athletes.

  
  
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  Contact lenses offer no protection. Athletes who wear contact lenses should wear one of these three options:

  
  
  
  
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    Contact lenses plus the appropriate protective eyewear

    
    
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    Polycarbonate lenses in sports frames that pass the appropriate ASTM standard

    
    
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    Over-the-glasses protector that conforms to the appropriate ASTM standard

  
  

Certification and Selection of Eyewear

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  Organizations that certify sports protective eyewear include the Protective Eyewear Certification Council (PECC), Canadian Standards Association (CSA), Hockey Equipment Certification Council (HECC), and National Operating Committee on Standards in Athletic Equipment (NOCSAE). The equipment approved by these organizations commonly bears their seal and should be selected when available ( Table 47.4 ).

  
  
  
  

  TABLE 47.4

  
  

  STANDARDS AND CERTIFYING ORGANIZATIONS FOR SELECTED SPORTS

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Sport	Eye Protection	Standards	Certifying Organizations
  Baseball	Polycarbonate or wire face guard attached to a helmet while batting; sports goggles with polycarbonate or TriVex lenses while on the field	ASTM F910	PECC
  Basketball	Sports goggles with polycarbonate or TriVex lenses	ASTM F803	PECC
  Field hockey	Full face mask for the goalie; sports goggles with polycarbonate lenses or wire mesh goggles while on the field	ASTM F803	PECC
  Football	Wire face mask and polycarbonate eye shield attached to the helmet		NOCSAE
  Ice hockey	Helmet with full face protection	ASTM F1587 ASTM F513	CSA/HECC
  Men’s lacrosse	Helmet with full face protection		NOCSAE
  Women’s lacrosse	Full face protection or sports goggles with either polycarbonate lenses or wire mesh goggles	ASTM F803	PECC
  Paintball	Full face protection	ASTM F1776	PECC
  Racket sports	Sports goggles with polycarbonate or TriVex lenses	ASTM F803	CSA/PECC
  Skiing	High impact–resistant eye protector	ASTM F659	PECC

   
  

  From the American Academy of Ophthalmology (AAO) ( www.aao.org ).
  
  
  
  
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  ASTM International has written performance standards based on design and strength, upon which many of these organizations base their certification (see Table 47.4 ).

  
  
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  For sports with no appropriate ASTM standards or certified equipment, the American National Standards Institute (ANSI) should be considered.

Preparticipation Eye Examination

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  Preparticipation eye examinations should include the assessment of visual acuity, visual fields, pupillary size and responsiveness, eye movements, and ophthalmoscopy.

  
  
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  Documentation of anisocoria is imperative in order to determine if it is pre-existing or caused by an acute injury. Up to 20% of the population may have physiologic anisocoria of >0.4 mm. In physiologic cases, there will be no associated visual field defects or diplopia. The afferent and efferent pupillary light reaction will also be normal.

  
  
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  Assess athlete’s history for high degree of myopia, surgical aphakia, retinal detachment, eye surgery, infection, or injury. Also assess family history for retinal detachment, retinal tears, or diabetic retinopathy. All these conditions increase the risk of serious eye injury and thus require ophthalmologic consultation before participation in high- or very-high-risk sports.

Visual Risk Factors

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  Best-corrected visual acuity worse than 20/40 in either eye or spectacle correction for myopia or hyperopia >6 diopters; disease, degeneration, or structural weakness of the eye itself; thin sclera; history of retinal degenerative disease; and history of eye surgery that weakens the outer wall of eye, particularly cataract or refractive surgery. Athletes with such risk factors should be evaluated by an ophthalmologist before engaging in high- or very-high-risk sports.

  
  
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  Disability from high corrective spectacle lenses can sometimes be mitigated by contact lenses; however, contact lenses themselves can be a risk factor.

  
  
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  Functionally one-eyed athletes face an additional risk. A person is functionally one-eyed when loss of the better eye would result in a significant change in lifestyle owing to poor vision in the remaining eye.

  
  
  
  
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    A child with vision worse than 20/40 should be considered functionally one eyed. Assessment of adults is more difficult because their judgment and values determine the visual impairment they are willing to accept. Special considerations are necessary for such athletes.

    
    
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    The only sports absolutely contraindicated for the functionally one-eyed athlete are boxing and full contact martial arts because the risks of serious injury are high and there is a lack of effective eye protection. Wrestling and noncontact martial arts have a lower incidence of eye injury, but also do not have effective eye protection. They should be discouraged for functionally one-eyed athletes and banned for monocular athletes.

  
  

Examination and Functional Testing After Injury