Ocular injury

Surface anatomy and basic muscle examination of the eye are shown in Treatment note 16.1.

Treatment note 16.1 Surface examination of the eye

The sclera of the eye is the white portion at the side of the iris. It continues as the cornea which is the clear central region of the eye through which the iris (eye colour) and pupil (black centre) may be seen. At the medial corner of the eye is the lacrimal lake in which the tears collect. Tears originate in the lacrimal gland on the upper outer aspect of the orbit and flow downwards and inwards across the eye to hydrate the cornea. Once collected in the lacrimal lake, the tears drain into the nasal cavity. The eye and lacrimal apparatus is shown in Fig. 16.1.

Figure 16.1 Eye and lacrimal apparatus, indicating flow of tears.

From Drake et al. (2010).

Movement of the eye is controlled by the extrinsic or extraocular muscles, and each muscle may be tested by asking the patient to look in a particular direction (Fig. 16.2). This is most commonly carried out by having the patient follow the therapist’s finger while keeping his/her head in a fixed position. The examination highlights abnormality of the third (oculomotor), fourth (trochlear) and sixth (abducent) cranial nerves, which supply the muscles.

Figure 16.2 Functional muscle testing of the extraocular muscles.

From Drake et al. (2010).

The following signs and symptoms are indications for immediate ophthalmology referral (Brukner and Khan, 2007):

severe eye pain

persistent blurred vision or photophobia (light sensitivity)

diplopia (double vision)

markedly impaired vision

loss of part of the visual field

embedded foreign body

hyphemia (blood within the anterior chamber of the eye)

Reference

Brukner Brukner, P., Khan, K., 2007. Clinical Sports Medicine, third edn.

Eye injuries may arise from collisions in which a finger or elbow goes into the eye. Small balls (squash balls, shuttlecock) may cause ocular damage, while larger balls (cricket or hockey) are more likely to cause orbital fractures. Mud, grit or stone chips can enter the eye and cause both irritation and damage. It is interesting to note the speed at which a ball may move. In squash, the ball can travel at 140 m.p.h., in cricket at 110 m.p.h. and in football 35–75 m.p.h. (Reid, 1992). A small object travelling at these speeds obviously creates considerable force and potential for damage. This is borne out by the sad fact that over 10% of eye injuries in sport result in blindness in that eye (Pashby, 1986).

Where a foreign body is in the eye, quantities of water should be used to irrigate the eye and wash the object out (a squeeze bottle is particularly useful). Sit the athlete down and get him or her to look up, right, left and then down as sterile/clean water is poured into the inner corner of the eye. No attempt should be made to probe the eye as this may cause the object to scratch the cornea.

In some instances, particularly if the foreign body is an eyelash, the eyelid may be rolled back on itself. This procedure is carried out by first asking the athlete to look down. The practitioner then grasps the lashes of the upper lid, pulling them gently down and out, away from the eye. A cotton swab is placed on the outside of the lid level with the lid crease. The lashes are then folded upwards over the swab to reveal the inside of the eyelid, and the foreign body is washed away. The eyelid goes back to its normal position when the athlete looks up and blinks.

A foreign body is one of the most common eye problems on the sports field. The reaction is usually pain and tear production. If the object is not removed, blinking may cause corneal abrasion and extreme pain for about 48 hours. It is important not to allow the athlete to touch the foreign body as this will simply increase the area of abrasion. If the object cannot be washed out easily, cover the eye with a sterile dressing and take the athlete to hospital. Encourage the athlete to keep the eyes still as movement of the uninjured eye will also move the injured one increasing tissue damage.

Contact lenses can cause problems. Hard lenses may break or become scratched or roughened causing corneal damage. Soft lenses are easily torn. When the eye has been injured or infected, a contact lens should never be reinserted until the eye has healed completely for at least 24 hours.

When contact lenses become dislodged, the wearer, with the aid of a mirror, is often the person most capable of removing them. Hard lenses may be removed with a small suction cup available from an optician, and persistent soft lenses may be dislodged by water from a squeeze bottle, or by gently wiping with a cotton swab.

Following injury, basic vision assessment should be carried out and if any abnormalities are detected the athlete should be referred to an ophthalmologist. A distance chart (placed 6 m from the subject) and a near vision chart (35 cm from the eyes) should be used. Failure to read the 20/40 line on either chart is a reason for referral (Ellis, 1987). Visual fields are tested in all four quadrants. One eye is covered, and the athlete should look into the examiner’s eyes. The examiner moves a finger to the edge of the visual field in both horizontal and vertical directions until the athlete loses sight of it. Decreased visual acuity or loss of the visual field in one area warrants referral (Ellis, 1987).

Pupil reaction may be tested with a small pen torch. Pupil size, shape and speed of reaction are noted. Pupil dilation in reaction to illumination requires immediate referral, as does any irregularity in pupil shape and an inability to clear blurring of vision by blinking. A number of common eye symptoms and possible causes are listed in Table 16.1.

Table 16.1 Common eye symptoms encountered in sport

Adapted from Magee (2002).

Dental injury

The simplest form of tooth injury is a concussion in which the anterior teeth are knocked against something. This may occur from a head butt, a punch, or someone running into a piece of apparatus. There is only minor soft tissue damage and the teeth and mouth are sore. The front teeth may be painful on eating, so the athlete should avoid eating hard foods until the pain subsides.

Tooth subluxation occurs when a tooth becomes mobile after a direct injury, but is not displaced. On examination, the tooth may be loose and tender, and there may be some gum damage. It is usual for the teeth to tighten up and heal within a week, but the athlete should see his or her dentist. A subluxed tooth may have damaged its dental artery or vein. When this happens the venous blood can stagnate in the tooth and the haemoglobin seeps into the dentine turning the tooth dull yellow and eventually grey.

Displacement of a tooth is more common when a gum shield is not worn. The displaced tooth should be washed in tepid water and replaced in the socket, taking care to put the tooth back the right way round. The athlete may hold the tooth in place by biting on a cloth or handkerchief until specialist advice can be sought. In children, a displaced tooth may be soaked in whole milk (Mackie and Warren, 1988) until help is available. The tooth should be handled by the crown to avoid further damage to the cells at its root. Good results may be expected if reimplantation is carried out within 30 minutes of trauma, but after 2 hours the prognosis is poor.

Examination of the tooth after an impact injury initially is by a pressure test. The biting edge of the tooth is gently pressed inwards towards the tongue and then outwards towards the lips. If the tooth is painless (but not numb) and moves only as much as its neighbours, injury is normally restricted to the gums alone. If the tooth is numb, painful, mobile, or depressed below the level of the other teeth, the athlete requires dental referral.

Related posts:

The ankle The elbow The cervical spine The thorax and thoracic spine The shin The shoulder

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