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© 2010 Human Kinetics - ATT 15(5), pp. 14-18

Eye injury has become increasingly common as the popularity of sports activities among the general populace has burgeoned. It is important to note that certain sports, such as racquet sports, baseball, water sports, and basketball present risk for eye injury. Radiation may cause eye injury, as well as the more common instances of blunt force and penetration. The severity and frequency of eye injury can be greatly reduced by use of

proper protective eye-wear. Eyewear that has been approved by the American Society for Testing and Materials is best suited for sports use. An athlete who has only one functional eye should be advised to exercise caution during participation in sports, particularly those that present high risk for

an eye injury. The risk for eye injury should always be considered during preparticipation physical exams. On-site treatment is only appropriate for a minor eye injury. Return to play and ophthalmology referral are issues that are best managed by team physicians, in collaboration with athletic trainers and therapists.

Determination of Eye Injury RiskEye injury is most common in collision sports, such as lacrosse, hockey, rugby, and football.1 Eye injuries also occur during participation in noncontact sports, such as swimming, crew

rowing, tennis, track, and cross-country run-ning, however. For an athlete with one func-tional eye (the “monocular athlete”), the risk of eye injury from noncontact racquet sports and golf may be substantial. In any sport, the use of protective eye wear appears to significantly decrease the risk of eye injury.1

Sports may be categorized as “low risk,” “high risk,” and “very high risk” for eye injury.2 Noncontact sports that do not involve a racquet, stick, bat, puck, or ball are con-sidered low-risk. Cycling, gymnastics, swim-ming, and track and field are considered “low-risk” for eye injury. Contact sports, and sports that involve implements and objects that are thrown or hit, are considered “high-risk” for eye injury. Water polo, golf, fencing, tennis, racquet sports, lacrosse, basketball, football, hockey, and baseball are examples of high-risk sports. The leading cause of sport-related eye injury in children who are 5 to 14 years of age is baseball.3 Full-contact martial arts, wrestling, and boxing are con-sidered “very high risk” sports because they involve contact and are conducted without eye protection,2,4-5 A study on sports that have become increasingly popular in recent years, such as war games, radical and adventure sports, fantasy military maneuvers, capoeira, yoseikan budo, and motocross documented that ocular injuries in these sports can be severe, often involving retinal breaks.6

A recent study reported that the rate of ocular injury is very low among college athletes who participate in volleyball, soft-ball, water polo, track and field, swimming, diving, soccer, golf, football, cross-country, basketball, and baseball.7 The report’s

Verle Valentine, MD, Report Editor

Eye Injuries in Sports

PHYSICIAN PERSPECTIVE

George Guntur A. Pujalte, MD, CAQSM • Pennsylvania State University

The severity and frequency of sports eye injuries can be decreased by use of eye protection.

Athletes who have only one functional eye must be protected.

Immediate on-site treatment is appropriate only for minor sport-related eye injuries.

Key PointsKey Points

AThlETic ThERAPy TodAy SEPTEMBER 2010 15

authors suggested that an athlete’s past ocular history is a more important factor to consider than the sport the athlete plays for assessment of injury risk.

Specific Aspects of History AcquisitionPreparticipation physical examinations should always include an eye examination. Specific information that should be obtained during history taking includes past eye infections, injuries, surgeries, retinal detachment, surgical aphakia (i.e., absence of the lens of an eye), or a high degree of myopia. Serious eye injuries have been known to occur in individuals with such condi-tions.4,8-9 A strong family history of diabetic retinopathy, retinal tears, and retinal detachment should initiate a focused assessment of the athlete’s eyes.9 Participation in “high-risk” or “very high-risk” sports should be only allowed with an ophthalmologist’s approval.10

Mechanisms of Sport-Related Eye InjuryMost eye injuries among the general population include superficial injuries, foreign bodies, contusions, and open wounds.11-12 Among athletes, eye radiation inju-ries, penetrating injuries, and blunt force injuries are most common. Most sport-related eye injuries result from blunt force.13-14 The magnitude of the object impact force (which is proportional to the velocity and mass of the object) and the object’s hardness and size determine the extent of eye damage.2 A large amount of force may be transmitted to inner eye structures by any blunt object that is smaller than the orbital opening, thereby contacting the globe, which pro-duces antero-posterior compression and middle globe dilatation. For example, paintball impact can produce significant retinal trauma and may lead to severe long-term visual morbidity.15-16

Fracture of the orbital walls may result from the impact of a blunt object that is larger than the orbital opening. In such cases, the globe may not be ruptured, but occult inner eye injury may be present.17-18 For example, a soccer player at any skill level can develop a severe ocular lesion without any obvious symptoms.19 Although rare, pediatric golf injuries can be devastating to the eye, visual system, and periocular adnexa (i.e., eyelids, muscles, conjunctiva, lacrimal apparatus).20 Blunt force can cause such injuries as retinal tear and detachment, choroidal rupture, vitreous hemorrhage, commotio retinae, retinal hemorrhage, hyphema (Figure 1), subconjunctival hemorrhage (Figure 2),

traumatic iritis, ruptured globe (Figure 3), iris injury, lid and orbital contusion (Figure 4), and orbital blowout fracture (Figure 5).21-28 Large projectiles are unlikely to

Figure 1 hyphema.

Figure 2 Subconjunctival hemorrhage.

Figure 3 Ruptured globe.

Figure 5 orbital blowout fracture presentation.

Figure 4 orbital contusion.

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cause penetrating injury, but they sometimes occur. Penetrating injuries can range from mild abrasions to serious lacerations (e.g., broken eyeglasses).29 Impact from another player’s finger over the area of the medial canthus (i.e., the angle formed by the meeting of the upper and lower eyelids at either side of the eye) can cause a canalicular laceration.30 Penetrating globe inju-ries are often caused by fishing hooks. Water sports and snow skiing can cause radiation eye injuries.31-32

Physical ExaminationImmediate evaluation at the site of injury is crucial for most sport-related ocular injuries.17 The magnitude and direction of impact can determine the extent of injury. A hockey slap shot will cause a different injury than a pitched ball, a fly ball, or a line-drive.5 An eye chart can be used to test visual acuity. Visual fields can be tested by confrontation. Injury to the central nervous system, optic nerve damage, or retinal tears can lead to visual field defects.

A bright light source should be used to examine the pupils. The possible presence of pupil defects or anisocoria (i.e., unequal pupil sizes) should be assessed. Light directed at one pupil should also cause constric-tion of the contralateral pupil. Bilateral pupil constric-tion is also expected during light accommodation. A lesion of the third cranial nerve or a pupillary muscle problem will prevent accommodation constriction, whereas an optic nerve or retinal problem will prevent constriction during a swinging light test.2 Irregularity of the pupil is almost always pathologic. Lacerations, abra-sions, hyphema, and foreign bodies can be detected by a penlight examination of the anterior chamber.

Full motility on all positions of gaze should be evident for both eyes. An orbital floor fracture can limit the elevation of gaze. A serious injury may exist if the athlete reports doubling of vision.17 Orbital rim step-off, proptosis (i.e., anterior bulging of the eye out of the orbit), edema, and periorbital ecchymosis are signs of orbital injury. Fracture of the lateral wall of the orbit may cause trismus (i.e., prolonged spasm of the jaw muscles). A fracture of the orbital floor may cause paresthesia within the infraorbital nerve distribution (second division of the fifth cranial nerve [V2]) that includes the lower eyelid and upper lip.

The red reflex (i.e., reddish-orange reflection form the eye’s retina) should be evaluated through a fundu-scopic examination. The red reflex may be obscured by blood in the ocular media. An occult rupture of the

globe can cause such bleeding. An ophthalmologic referral is essential when there is any alteration of the red reflex.10,33 Ophthalmologic referral is also recom-mended for globe perforations, broken contact lens, shattered eyeglasses, subconjunctival hemorrhage, medial canthus (i.e., lid margin) laceration, corneal edema, appearance of halos around lights, hyphema, eye inflammation, foreign bodies, irregular pupil, float-ers, light flashes, proptosis, diplopia, photophobia, pain with eye movement, visual field loss, or sudden decrease or loss of vision.5,17,21,33

Globe rupture must be ruled out with any eye trauma. Darkly-pigmented tissue of the uvea (i.e., the vascular middle layer of the eye constituting the iris, ciliary body, and choroid) going through a laceration indicates rupture and perforation.17,33 Prolapse of the iris through a limbus wound (i.e., at the edge of the cornea where it joins the sclera) may be manifested by a teardrop-shaped pupil. A conjunctival lacera-tion, shallow or deep within the anterior chamber, or subconjunctival hemorrhage, may an indication of a subtle globe rupture. No manipulation of the eye should be performed when there is any suspicion of a globe rupture. A protective eye shield should be applied; the patient should not be given anything by mouth.

Immediate Treatment for Simple Eye Injuries

Before administering treatment for any eye injury, consider whether or not an ophthalmologic referral is needed. For a burn of the eye, or a burn around the eye, apply a topical antibiotic and administer a systemic analgesic. For hyphema, application of an eye shield is appropriate after removal from participation, which should be worn until an ophthalmologic evaluation is performed. For blunt trauma to the eye, with no signs of optic nerve injury or bony abnormality, administra-tion of an analgesic and a cold compress is appropriate. For a superficial eyelid laceration, sterile skin closure may be attempted when no direct injury to the eye is evident. For the uncomplicated presence of a foreign object, irrigate the eye with a sterile solution, or use a moistened swab for its removal; a topical anesthetic may be helpful, and an antibiotic ointment should be used. For superficial corneal abrasions, apply a topical anesthetic and use fluorescein strips with blue light to reveal the abrasions and then apply an antibiotic ointment.5,10,17,21,33

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Eye Protection During Sport Participation

The number and severity of eye injuries can be reduced through the use of proper eye protection.34-37 Preven-tion is the most efficient and cost-effective approach to eye trauma management.38 For example, education regarding proper eye protection during participation in paintball, along with improved safety features of paintball equipment, has reduced the incidence of severe ocular injuries.38 Eye injuries in youth baseball can be minimized by the use of protective eyewear;18 such eyewear distributes potentially harmful forces over a large surface area. Intracranial injury is highly unlikely to result from the redistribution of any force from the eyes to the face. Eye and face protectors may be more effective when used in conjunction with a helmet. The performance characteristics of eyewear used in alpine skiing, field hockey, women’s lacrosse, basketball, baseball, and racquet sports should be established by the American Society for Testing and Materials (ASTM). A recent study documented that soc-cer-related eye injuries have been increasing in Europe and North America, suggesting the need to make eye protection mandatory for soccer participation in the future.39 Protective eyewear should not create a liability or change the appeal of the game and must be accept-able to the athlete.8,10,17 Lacrosse, baseball, football, and hockey are sports that require a facemask to be attached to the helmet. Polycarbonate is a plastic that is capable of absorbing ultraviolet light and resisting high-energy impact. It is the preferred material for pro-tective glasses, because it is eight times stronger than most alternative materials. Prescription polycarbonate lenses are available, and they are recommended for athletes with refractive problems. Regular eyeglasses offer inadequate eye protection, because they provide only 4 to 5 percent of the impact resistance of poly-carbonate material of the similar thickness.4,8,17,21,40 Athletes who wear contact lenses should wear eye protection. Moderate-risk to high-risk sports require polycarbonate lenses that are 3 mm in thickness. Par-ticipation in low-risk sports with polycarbonate lenses that are 2 mm in thickness is acceptable (i.e., standard worn for normal everyday activities).4,21

Monocular Athletes

The weaker eye of a monocular (i.e., one functional eye) athlete has a visual acuity less than 20/40. For all games and practices, such athletes must wear

protective eyewear that is approved by ASTM at the racquet sports standard. For hockey, football, lacrosse, and other sports that utilize a helmet and facemask combination, an eye protector must be worn beneath the facemask. Protective lenses should be worn at all times to prevent trauma during routine activities of daily living.4-5,8,21-22,41

Polycarbonate lenses and frames are recom-mended for monocular athletes. A wire or polycarbon-ate full-face cage and sport goggles are recommended for monocular hockey players. Sport goggles and a poly-carbonate shield (integrated with the helmet facemask) are recommended for monocular football players. Sport goggles are recommended for monocular baseball play-ers, who should also wear helmet with a polycarbonate face guard when batting or running bases. Monocular athletes should not participate in full-contact martial arts, wrestling, or boxing.4,8,41 Medical clearance of the monocular athlete for sport participation should include any restrictions or conditions specified by an ophthalmologist.10

Return to PlayClearance from an ophthalmologist must be obtained before allowing an athlete to return to play after a significant ocular injury. Return of vision must be adequate and eye protection is recommended. The team physician should make the return-to-play deci-sion based on the nature of the eye injury and the athlete’s symptoms. Application of a topical anesthetic to permit continued game play is not recommended.5 The strongest predictors of final visual acuity for an open-globe injury are the grade of injury, defined by the visual acuity in the injured eye during the initial examination, and the presence or absence of a rela-tive afferent pupillary defect.42 A positive outcome is possible for a severe injury if treatment is specifically tailored to the patient and the injury.43

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Jaeger EA, eds. Duane’s Clinical Ophthalmology. Philadelphia: Lippin-cott; 1994: 1-51.

2. Rodriguez JO, Lavina AM, Agarwal A. Prevention and treatment of common eye injuries in sports. Amer Fam Phys. 2003;67(7):1481-1488.

3. Washington RL, Bernhardt DT, Gomez J, et al. Risk of injury from baseball and softball in children. Pediatr. 2001;107(4):782-784.

4. Jeffers JB. An ongoing tragedy: pediatric sports-related eye injuries. Semin Ophthalmol. 1990;5:216-223.

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6. Filipe JA, Roucha-Sousa A, Falcao-Reis F, et al. Modern sports eye injuries. Br J Ophthalmol. 2003;87:1336-1339.

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9. Locke S, Colquhuon D, Briner M, et al. Squash racquets. A review of physiology and medicine. Sports Med. 1997;23:130-138.

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13. Cassen JH. Ocular trauma. Hawaii Med J. 1997;56:292-294.

14. Pardhan S, Shacklock P, Weatherill J. Sport-related eye trauma: a survey of the presentation of eye injuries to a casualty clinic and the use of protective eye-wear. Eye. 1995;9(Pt 6 Suppl):50-53.

15. Baath J, Ells AL, Kherani A. Severe retinal injuries from paintball projectiles. Can J Ophthalmol. 2007;42:620-623.

16. Taban M, Taban M, Sears JE. Ocular findings following trauma from paintball sports. Eye. 2008;22:930-934.

17. Erie JC. Eye injuries: prevention, evaluation, and treatment. Phys Sportsmed. 1991;19:108-122.

18. Vinger PF, Duma SM, Crandall J. Baseball hardness as a risk factor for eye injuries. Arch Ophthalmol. 1999;117:354-358.

19. Filipe JA, Fernandes VL, Barros H, et al. Soccer-related ocular injuries. Arch Ophthalmol. 2003;121:687-694.

20. Hink EM, Oliver SC, Drack AV. Pediatric golf-related ophthalmic inju-ries. Arch Ophthalmol. 2008;126(9):1252-1256.

21. Napier SM, Baker RS, Sanford DG, et al. Eye injuries in athletics and recreation. Surv Ophthalmol. 1996;41:229-244.

22. Vinger PF. The eye and sports medicine. In: Duane TD, Tasman W, Jaeger EA, Eds. Duane’s Clinical Ophthalmology. Philadelphia: Lippin-cott; 1994: 1-51.

23. Larrison WI, Hersh PS, Kunzweiler T, et al. Sports-related ocular trauma. Ophthalmol. 1990;97:1265-1269.

24. Locke S, Colquhoun D, Briner M, et al. Squash rackets. A review of physiology and medicine. Sports Med. 1997;23:130-138.

25. Cavallerano AA. A dose of prevention. J Am Optom Assoc. 1998;69:345-346.

26. Drolsum L. Eye injuries in sports. Scand J Med Sci Sports. 1999;9:53-56.

27. Filipe JA, Barros H, Castro-Correia J. Sports-related ocular injuries. A three-year follow-up study. Ophthalmol. 1997;104:313-318.

28. Orlando RG, Doty JH. Ocular sports trauma: a private practice study. J Am Optom Assoc. 1996;67:77-80.

29. Erie JC. Eye injuries: prevention, evaluation, and treatment. Phys Sportsmed. 1991;19:108-122.

30. Larrison WI, Hersh PS, Kunzweiler T, et al. Sports-related ocular trauma. Ophthalmol. 1990;97:1265-1269.

31. Cassen JH. Ocular trauma. Hawaii Med J. 1997;56:292-294.

32. Pardhan S, Shacklock P, Weatherill J. Sport-related eye trauma: a survey of the presentation of eye injuries to a casualty clinic and the use of protective eye-wear. Eye. 1995;9(Pt 6 Suppl):50-53.

33. Tucker AM. Common soccer injuries. Diagnosis, treatment and reha-bilitation. Sports Med. 1997;23:21-32.

34. Andreotti G, Lange JL, Brundage JF. The nature, incidence, and impact of eye injuries among US military personnel: implications for preven-tion. Arch Ophthalmol. 2001;119:1693-1697.

35. Khan MI, Flynn T, O’Connell E. The impact of new regulations on the incidence and severity of ocular injury sustained in hurling. Eye. 2008;22:475-478.

36. Leivo T, Puusaari I, Makitie T. Sports-related eye injuries: floor-ball endangers the eyes of young players. Scand J Med Sci Sports. 2007;17:556-563.

37. Vinger PF. Understanding eye trauma through computer modeling. Arch Ophthalmol. 2005;123:833-834.

38. Pahk PJ, Adelman RA. Ocular trauma resulting from paintball injury. Graefe’s Arch Clin Exp Ophthalmol. 2009;247:469-475.

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40. Jeffers JB. Pediatric eye safety. In: Cibis GW, Tongue AC, Stass-isern ML, eds. Decision Making in Pediatric Ophthalmology. St. Louis: Decker; 1993:226,269.

41. Wichmann S, Martin DR. Single-organ patients: balancing sports with safety. Phys Sportsmed. 1992;20:176-182.

42. Pieramici DJ, Kah-Guan AE, Sternberg P, et al. The prognostic signifi-cance of a system for classifying mechanical injuries of the eye (globe) in open-globe injuries. J Trauma. 2003;54:750-754.

43. Zoumalan CI, Blumenkranz MS, McCulley TJ, et al. Severe surfing-related ocular injuries: the Stanford Northern Californian experience. Br J Sports Med. 2008;42:855-857.

Dr. Pujalte is with the Primary Care Sports Medicine Interest Group of The Pennsylvania State University, Family and Community Medicine, Hershey, PA.

The American Medical Society for Sports Medicine (AMSSM) is an organization founded in 1991. Its 900 + sports physician members are trained to provide “cutting edge” care in all aspects of sports medicine, from evaluation of orthopedic and medical problems to nutritional and psy-chosocial issues. AMSSM members treat all ages and athletic abilities—from grade school to senior citizen, recreational to professional. Learn more at www.AMSSM.org.