Ophthalmology
Ronica Martinez
BACKGROUND
The emphasis in medicine is changing to preventive care, and more people are taking part in athletics and sport activities.
Primary care providers are going to see a significant amount of injuries that occur during sports.
Eye injuries account for a relatively small number of injuries when including all sport injuries, but an eye injury can have a significant impact especially if vision is lost.
It is estimated that eye injuries from sports account for more than 100,000 visits to a physician each year, making the cost greater than $175 million (17).
EPIDEMIOLOGY
Approximately 72% of sports-related eye injuries occur in people less than 25 years old, and approximately 43% occur in children younger than 15 years old (10).
In the United States, baseball and basketball are associated with the most eye injuries in people between 5 and 24 years old (8,23,24).
Another study showed that hockey, baseball, and racquet sports account for the majority of injuries (17).
There are a significant number of ocular injuries in Europe and South America due to soccer, and the number is rising in the United States due to increased participation in soccer (2,3,4).
A study over a 10-year span showed that 75% of severe eye injuries are due to squash, paintball, bungee jumping, and soccer (4).
CLASSIFICATIONS OF SPORTS FOR OCULAR INJURY RISK
Generally, sports that involve a ball, racquet, or stick are considered high risk for eye injuries. Other sports that are high risk include boxing and full-contact martial arts (11).
Moderate-risk sports include golf, fishing, football, tennis, badminton, soccer, water polo, and volleyball.
Low-risk sports include diving, swimming, bicycling, noncontact martial arts, skiing, and wrestling.
Eye-safe sports include gymnastics and track and field.
PREPARTICIPATION
The eye exam is a very important part of the preparticipation exam. A thorough ocular history should be performed, paying close attention to prior injuries or surgeries and the presence of severe myopia, infection, and any retinal detachments. All these may predispose the athlete to a more severe or vision-threatening injury (16,20,25). Any athlete found to have a positive ocular history should be evaluated by an ophthalmologist or eye care professional prior to clearance for participation of a high-risk sport (16,20).
OCULAR EVALUATION OF THE INJURED ATHLETE
History
A detailed description of the mechanism of injury should be obtained.
The visual acuity needs to be measured on both the injured eye and noninjured eye immediately following the injury. Ideally, this should be compared to baseline.
The history of the timing of any visual loss must also be obtained.
Ask the athlete if there is any photophobia, diplopia, floaters, pain, flashing lights, tearing, nausea, or headache.
Physical Exam
It is critical that a thorough eye exam be done and that it not just focus on the obvious area involved. Ideally, it should be done on site.
Exam should be done in an orderly fashion, using the unaffected eye as baseline for comparison. If asymmetry is noted, further investigation is needed.
Remove contact from the affected eye.
Visual acuity: This is the most important part of any eye exam and should be done first using either a Snellen card or other text source. If an athlete is not able to read text, light perception or finger count should be documented.
Visual fields: A defect could suggest an injury to the optic nerve, retina, or central nervous system.
Pupils: Evaluate the pupils using a bright light. Pupils should be round, reactive, and symmetric. Normally, the pupils will constrict equally and quickly to accommodation and light directed to the affected eye and uninjured eye (consensual light reflex). If a diminished light reflex is found, a swinging flashlight test can be done to better determine if the problem is due to an efferent (pupillary muscle or third nerve) lesion or an afferent (optic nerve or retina) lesion. Pupillary irregularity is almost always pathologic.
Anterior chamber: The anterior chamber can be examined with a penlight to check for any hyphema, foreign bodies, lacerations, or abrasions. Look closely for any blood in the anterior chamber, being sure to compare to the unaffected side.
Extraocular range of motion: Both eyes should ensure full motility in all positions of gaze. An orbital floor fracture may exhibit limitation in gaze elevation. Double vision may suggest a serious problem in one or both eyes.
External examination: Palpate and examine the bony orbits and eyelids. Closely examine the adnexal structures, periorbital skin, cornea, conjunctiva, and iris. Make note of any bony step-offs of the orbital rim, proptosis, edema, or periorbital ecchymosis. Pain with opening the mouth (trismus) often occurs with a fracture of the lateral orbital wall. A fracture of the inferior orbital floor can be suggested if there is paresthesia in the V2 distribution of the trigeminal nerve (20).
Sclera and conjunctiva: Pay close attention to signs that suggest a ruptured globe. These include a 360-degree subconjunctival hemorrhage, lacerations, or extruding pigment (uveal tissue) or gel (vitreous humor).
Cornea: The cornea needs to be examined for clarity. Apply fluorescein to identify any foreign bodies or epithelial defects. A pocket Wood’s light or ophthalmoscope with blue light is an appropriate light source for this exam.
Funduscopic examination: A funduscopic exam is required for all eye exams to evaluate the red reflex. Asymmetry of the red reflex may be the only subtle finding that is seen on exam if the athlete has a ruptured globe. Even a small amount of bleeding into the ocular media can obscure the red reflex. Any abnormality must be referred to an ophthalmologist immediately. Other ocular signs and symptoms that require an ophthalmology referral are found in Table 30.1.Related posts:
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