Ocular trauma in athletes can have devastating consequences. Incidence of eye injuries from sporting events has ranged over the years from 4.1% to 13.7%.1–3 These injuries may be minor, such as a periorbital contusion, but can also involve severe injuries, such as hyphema and globe rupture. Different sports have different inherent risks, and some require eye protection equipment for competition, also altering their risk patterns.

Each year in the United States more than 40,000 eye injuries occur from sports.⁴ Sports with small, hard, fast projectiles and sticks have the highest risk of injury, including rifle, paintball, squash, lacrosse, and racquetball. Additionally, boxing and contact martial arts have a very high risk. Soccer, water polo, and football have a moderate risk, and swimming and bicycling have a low risk.

A decade-long retrospective study from 1988 to 1999 in Norway showed that 13.7% of eye injuries presenting to the ophthalmology department were associated with a sport.¹ The mechanism of injury was most often from a ball (71.1%) or a club (13.2%). They reported that the highest incidence was noted in soccer (35.5%). A similar study performed in Scotland showed that 12.5% of ocular injuries admitted to the hospital were sport-related.² This study also found that soccer had the highest number of injuries at 32.5% but that all racquet sports combined accounted for 47.5% of injuries. Capao Filipe and colleagues³ reviewed sports-related eye injuries and found that 8.3% of injuries presenting to an eye emergency department were caused by modern sports, such as paintball and motocross. These studies were all performed in high-acuity settings, inpatient settings, and emergency departments. Thus, they likely underestimate the full scope of injuries that occur and never reach such a level of care.

Sport-specific injuries

The incidence and risk pattern of blunt visual trauma can vary based on the different sporting events. Type of play, rules of the game, and protective eyewear requirements can all change the numbers and types of injuries seen. A few examples are listed herein.

Soccer

It is interesting that soccer should have one of the highest incidences of ocular injury, because the ball is very large compared with the diameter of the orbit. Capao Felipe ⁵ describes the unique mechanism of injury caused by the soccer ball itself: “orbital penetration is lower, but the time in the orbit is longer and, during rebound, a secondary suction effect is produced on the orbital contents.” In a separate study, Capao Felipe and colleagues⁶ found that the most common initial diagnosis of an eye injury in soccer was eyelid or orbital contusion and hyphema, followed by retinal hemorrhage, vitreous hemorrhage, and uveitis. At follow-up, the most frequent diagnosis was angle recession and retinal tears. This finding suggests that some injuries may either be missed at initial diagnosis or have a delayed presentation. With any severe visual trauma, follow-up is important.

Boxing

Ophthalmologic examination of 956 Italian Boxing Federation boxers was compared with 80 male controls to evaluate the prevalence and nature of ocular injuries in boxers over almost 2 decades, from 1982 to 1998.⁷ The boxers did have a higher prevalence of milder ocular injury (40.9%) compared with controls (3.1%); however, they did not have a significantly higher prevalence of severe lesions compared with controls (5.6% vs 3.1%). Other studies have shown that a higher percentage of boxers actually do have pronounced or vision-threatening ocular injuries, as high as 21% to 58%.⁸

Giovinazzo and colleagues ⁸ found a linear correlation between number of fights lost and the incidence of retinal tears. The probability of retinal tear additionally increased with the number of bouts, showing a 90% probability after 75 bouts. Previously, thumbing injuries such as optic nerve avulsion, carried a greater concern. However, with the advent of thumbless gloves, the incidence of thumbing injuries has decreased.⁹

Golf

Although golf does not contribute a large overall number of ocular injuries to sport-related eye trauma, it does have a significantly higher proportion of severe or catastrophic injuries. Weitgasser and colleagues ¹⁰ performed a retrospective study from 1993 to 2000 and identified only 7 golf-related eye injuries: 6 were from the golf ball and 1 from a club. Of the patients, 4 had an open globe injury, 2 required orbital floor fracture surgery, and 3 enucleations had to be performed. In a review of pediatric patients, 11 total injuries occurred over a 15-year period: 10 injuries from the club and 1 from a ball.¹¹ These severe injuries included orbital fracture, hyphema, and traumatic optic neuropathy. Of these children, 9 required surgical intervention and 3 had permanent deficits, including blindness, decreased vision, and anophthalmia.

Preparticipation examination

The PPE Preparticipation Physical Evaluation, 4th Edition, asks 4 historical questions regarding the eyes:

1. Have you had any problems with your eyes or vision?

2. Have you had any eye injuries?

3. Do you wear glasses or contact lenses?

4. Do you wear protective eyewear, such as goggles or a face shield?

The physical examination consists of checking visual acuity and evaluating for equal pupils.¹²

The American Academy of Pediatrics (AAP) and the American Academy of Ophthalmology (AAO) issued a joint statement in 2004 recommending that athletes who are functionally one-eyed wear protective eyewear during all sports and should not participate in boxing or full-contact martial arts.¹³ A functionally one-eyed athlete has a best-corrected visual acuity of worse than 20/40 in the poorer-seeing eye. The concern is that if the better eye becomes injured, the athlete may essentially lose all vision or become severely limited in sight.

Protective eyewear

There is much debate across different sports regarding the use and benefit of protective eyewear. The AAP and AAO joint statement on protective eyewear recommends that all youths involved in sports be encouraged to wear appropriate eye protection, and provides a list of recommended eye protectors for specific sports.¹³ They additionally stress that contact lenses do not protect the eye or vision and that athletes who wear contacts also need to wear protective eyewear.

Squash carries a high risk of eye injuries and has a fair amount of literature regarding the use of protective eyewear and general attitudes toward eye protection. A survey of Australian squash players, performed in 1989, 1995, and 2000, showed an increase over time in the self-reported use of eyewear; however, only half of the players who used eye protection used appropriate eyewear.¹⁴ Attitudes toward eye protection also improved over time, with an increasing number of players feeling that squash players should use some type of eyewear and that eye protection should be mandatory for juniors. When reviewing beliefs and attitudes of venue operators, some did believe that more players should use protective eyewear; however, most believed that players with more experience did not need the protection.¹⁵ Additionally, very few venues had eyewear available for borrow or purchase. A protective eyewear promotion strategy was shown to be effective in increasing the odds that a player would wear appropriate eyewear.¹⁶

Attitudes toward protective eyewear are improving, and work is being done to test equipment. Baker and colleagues ¹⁷ performed a study to evaluate the optical and impact performance of football protective faceshields. They were able to show that the faceshields did not fracture, even with impact velocities up to 66.4 m/s, and had good optical quality. However, the study was not designed to evaluate for a possible decreased risk of eye injury in a sport in which almost 20% of injuries are caused by fingers penetrating helmets to the eyes. In soccer, data exist showing that protective eyewear that complies with standard ASTM F803 can prevent contact of the ball to the eye.¹⁸

As rules requiring the use of protective eyewear in sports are being mandated, outcomes data regarding injury-prevention efficacy are following behind. Retrospective data from Australian women’s lacrosse, in which eye gear is not mandatory, indicate that eye injuries account for 12.2% of all injuries to the head.¹⁹ In the United States, US Lacrosse mandated the use of protective eyewear in women’s lacrosse during the 2004–2005 season. Lincoln and colleagues performed a cohort study comparing eye injury rates before and after implementation of the protective eyewear mandate and found that the rate of eye injuries decreased from 0.10 to 0.016 injuries per 1000 athlete exposures.²⁰

In the sport of hurling, outcomes data show a significant reduction in eye injuries after sporting rules were changed requiring protective head gear and face masks for all players aged 18 years and younger.²¹ In the sport of ice hockey, National Hockey League players who wear a facemask have a significantly decreased risk of eye injury compared with those who choose not to use a facemask.²²

Although outcomes data are still fairly limited, those that have been collected seem to show a benefit to using protective eyewear in sports.

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