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Head and Neurological Conditions

Ocular Injuries in Sports

Cass, Shane P. DO

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doi: 10.1249/JSR.0b013e318240dc06
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Although less common than musculoskeletal injuries, sports-related eye injuries have the potential for major morbidity and loss of function. Sports are responsible for a third of eye injuries in the United States that lead to blindness (29). An estimated 100,000 physician visits per year from sports are reported to cost greater than $175 million (22). Reviewing data from the National Electronic Injury Surveillance System, recent studies show 208,517 cases of sports-related eye injuries were treated in U.S. emergency departments between 2001 and 2009. Per-risk classification by the American Academies of Ophthalmology and Pediatrics (Table 1), high-risk activities contributed 55% of eye injuries, moderate-risk activities contributed 27%, low-risk activities contributed 16%, and eye-safe activities contributed 3%. Although eye injury trends declined from 2001 to 2005, they showed increasing injury rates from 2007 to 2009 (17).

Data from The National Eye Trauma System found that sports account for 13% of all penetrating ocular injuries. The most common sports relating to eye injury in the United States are as follows in descending order: baseball and softball, basketball, racquetball, football, and soccer. Among these injuries, 82% wore no form of eye protection (12).

With injury trends on the rise and the potential for serious functional loss with these injuries, it is important for the sports medicine professional to accurately diagnose, treat, and know when to refer common ocular injuries. With a minimal amount of equipment and a good history and physical examination, these injuries can be managed on the field, in the office, and in the training room. This article will review some of the new literature in the area of sports-related ophthalmology.

Table 1
Table 1:
Selected sports by risk category.

“Eye Tray”

Many eye injuries can initially be diagnosed and managed with a minimum of equipment and should be considered an essential component of any game bag or training room. A slit lamp examination may occasionally be necessary for diagnosis but is often unavailable. Most eye carts should contain the following: ophthalmoscope, a penlight and a light source with a blue filter or cobalt blue, fluorescein dye, cotton-tipped swabs, a vision chart, eye shields, loupes or magnifying glass, 18-gauge needles, sterile saline, and a contact lens remover. Medications include topical anesthetic drops, mydriatic drops, and antibiotic ointment. A tonopen for measuring intraocular pressures may be considered if funding is available (30).


The physician should try and deduce the force and direction of impact. If the physician is not present at the time of injury then a thorough explanation of mechanism of injury is necessary. High-velocity injuries or those dealing with glass should raise the question of a penetrating eye injury. Blunt, forceful injuries may direct one to look for signs of orbital blow out fractures. Symptoms such as foreign body sensation, perception of decreased visual acuity, and diplopia are helpful to direct evaluation.

Physical Examination

A good examination can diagnose many eye injuries but should be systematic to avoid missing specific signs. An assessment of visual acuity should be done first. This can give a baseline for further follow-ups and give clues to more serious problems. This can be obtained with a portable snellen chart. For those with smart phones, many free apps are available. Confrontational visual fields should be checked to evaluate for retinal, optic nerve, or central nervous system injury.

Pupils should be examined with a penlight or other bright source of light. The physician should look for pupil size, reactivity, shape, and extraocular muscles. At this time, one should check for a relative afferent pupillary defect. This can be done with the swinging flashlight test. A relative afferent pupillary defect is present when the eye with the deficit paradoxically dilates when exposed to the light source. This could indicate an optic nerve or retinal injury. An efferent defect loses both direct and consensual constrictions, with both present in the unaffected eye. This is seen with anisocoria (unequal pupils) and could indicate a third nerve palsy or Horner syndrome. The penlight can be used to evaluate the anterior chamber for relative depth and the eyelids for lacerations. Conjunctiva, cornea, and facial and maxillary bones should be examined as well.

Corneal Abrasion

Among some of the most common injuries to present both on the field and in the training room are corneal abrasions. This a defect in the corneal epithelial surface. It is usually traumatic but can occur spontaneously, as in the athlete with dry eyes. This is important to consider in our endurance and running population (10,14). Fingernail scratches to the eyes in contact sports are fairly common. The history usually involves a traumatic insult to the eye with associated irritation or a sharp pain, tearing, photophobia, and an occasional foreign body sensation. Corneal abrasions stain with fluorescein dye.

Recent systematic reviews and Cochrane meta-analysis have shown that treatment with a combination of drops is most effective (10). Treatment with topical antibiotic (chloramphenicol was used in many of the studies) and cycloplegics (cyclopentalate) leads to improved healing. Conversely, eye patching does not improve healing rates or pain 1 d after injury and can lead to a loss of binocular vision (28). It should be noted that this is mainly regarding simple corneal abrasions and that further research is needed on lesions greater that 10 mm. The systematic review by Fraser (16) did demonstrate two studies that gave some evidence that topical diclofenac can be useful for pain alleviation. It may be prudent to refer contact lens wearers to an ophthalmologist for frequent slit lamp examination because this population is more likely to develop secondary infection. Contact lens use should be discontinued until healing and drops are stopped. In addition to the review, Fraser gives referral guidelines. These include a history of significant trauma, worsening symptoms despite treatment, infiltrates around the edge of abrasion that may suggest secondary infection, and recurrent erosion syndrome.

Corneal Foreign Body

Symptoms of a retained corneal foreign body are similar to symptoms of abrasions. Diagnosis of corneal foreign body requires a high index of suspicion to rule out. Commonly missed foreign bodies are under the upper lid in the tarsal plate. A full evaluation to rule out foreign bodies should include inversion of the upper and lower lid. Foreign bodies should be irrigated. If that fails to dislodge the foreign body, a moistened cotton swab can be used. The tip of an 18-gauge needle can be used with caution, taking care to not damage the cornea further. Although routine use of topical antibiotics in the clinic setting often is not necessary, some recommend its use in wilderness and athletic settings where hygiene may be less than optimal (8).

Blunt Trauma

Blunt trauma makes up a majority of sports-related eye injuries. Size, velocity, and hardness of the object are important for determining the severity of the injury. If an object smaller than the orbit is the source of impact, it causes rapid compression and dilation of the middle of the globe, which may transmit more force to the internal ocular structures. A blow from an object larger than the orbits transmits force to the medial wall or the orbital floor, resulting in fractures of thin bones. This can cause a pressure release that may lead to soft tissue entrapment.

Orbital Fractures

Orbital fractures and other maxillofacial injuries, although less common, are increasing in incidence in sports. A recent study showed that orbital floor fractures accounted for 17% of all maxillofacial injuries in sports, with sports accounting for 21% of all the fractures surveyed (3). Typically, the orbital floor, on occasion the medial wall, is fractured owing to increased intraorbital pressure, which causes the orbital bones to break at their weakest point. Signs of an orbital floor fracture include periorbital edema, ecchymosis, and painful extraocular movements. A step off can be seen if the orbital rim is fractured. Injury to the infraorbital nerve can cause hypesthesia or dysthesia. Proptosis or enophthalmos (abnormal protrusion of eyeball) also can be seen. A limitation of vertical gaze is suggestive of an inferior rectus entrapment (15).

There is a subtype of orbital fracture that is present in children known as a trapdoor fracture or white-eyed blow-out fracture (WOBF). This is the orbital equivalent of a green stick fracture and is due to the elasticity of pediatric bones. Soft tissue gets entrapped in the fracture as the elastic pediatric bones snap back into place. It receives its name because of the relative lack of external ocular trauma. Recent reviews have determined that these trapdoor fractures are the most common type of orbital fracture occurring in children (31). White-eyed blow-out fracture is a clinical diagnosis that consists of vertical diplopia, pain with extraocular movement, gaze restriction (usually vertical), and nausea and/or vomiting in the setting of periorbital trauma. One study found these symptoms present 100%, 100%, 100%, and 75%, respectively, in WOBF (21).

A recent article by Ethunandan and Evans (9) hypothesized that this may be more common in adults than recently thought. Retrospectively sampling 10 patients treated for orbital fractures, 7 had no subconjunctival hemorrhage or bruising (white eyed). All of these patients had orbital fractures and entrapment of soft tissue. Of them, 60% had autonomic symptoms such as nausea and vomiting. On review, they all demonstrated fracture on imaging.

Computed tomography (CT) is the gold standard for diagnosing orbital floor fractures. Keep in mind that, with WOBF, the CT scan may read as negative for a fracture. Therefore, in children with the above symptoms, an ophthalmologist should be consulted in the case of a normal CT scan. Children with WOBF fair better with surgical treatment if done within the first 2 to 5 d, so accurate diagnosis is important (31). Treatment for adults includes advising patients to avoid blowing their nose for several weeks after the injury to prevent orbital emphysema, which could affect vision. Surgical treatment is controversial and often debated among ophthalmologists but follows certain guidelines such as diplopia, enophthalmos, and fracture size (15).

Globe Rupture

Globe rupture should be considered with blunt trauma, especially high-velocity trauma from a flying object, such as a racquet ball. Lack of appropriate recognition and treatment can lead to endophthalmitis — a serious intraocular infection that can lead to blindness (4). Pain, visual loss, hyphema, anterior chamber depth loss, pupil irregularity, and subconjunctival hemorrhage involving 360° around the cornea are very suspicious for globe rupture (23). Other more obvious signs would include signs such as leakage of vitreous material.

Once globe rupture is suspected, prompt referral to an ophthalmologist is mandatory. An eye shield should immediately be placed, and manipulation of the eye is deferred to avoid direct pressure and further damage. Scheduled analgesics and antiemetics should be provided to avoid Valsalva maneuvers that may accompany pain and emesis from the injury and further damage intraocular or extruded tissue. Given a high-velocity trauma history, an ophthalmologist should be consulted, despite potentially normal findings in the physical examination (27).

The astute physician should be aware of a condition known as sympathetic ophthalmia. This is bilateral eye inflammation that threatens blindness in both eyes after an initial penetrating injury to one eye. It has been seen in globe ruptures and orbital fractures. It typically follows a latent period after initial injury to the eye. The time course is variable, but 70% to 80% occur in the first 3 months after injury (6). Early signs, in a patient with a history of traumatic globe injury, include changes in accommodation strength, photophobia, and tearing. Prompt referral is critical.


Hyphema is a common result of blunt trauma to the eye. Direct trauma causes shearing forces on the blood vessels of the iris. A hyphema is the end result of these vessels rupturing. This is commonly seen by examining the anterior chamber where layering of gross blood or clot can be observed. Traditional acute management of a traumatic hyphema includes shielding the eye, bed rest with head of the bed elevated, cycloplegic drops, and avoidance of any aspirin-containing products. A recent Cochrane review found inconclusive evidence for the use of cycloplegics and corticosteroids because of a small number of participants in the studies. The review also demonstrated inconclusive evidence for wearing a patch on one versus both eyes, bed rest versus moderate activity, and elevation of the head of bed versus lying flat (11). Because it is inconclusive evidence, it is still prudent to restrict all athletes from competition and training who present with a hyphema until cleared by an ophthalmologist. All cases of hyphema should be referred to an ophthalmologist because rebleeding may affect vision and is a major cause of concern (11,13).

Retrobulbar Hemorrhage

A devastating consequence of blunt eye trauma is retrobulbar hemorrhage leading to compartment syndrome. The orbital space is an enclosed area; acute rises in intraorbital pressures can lead to decreased perfusion and ischemia, similar to other compartment syndromes. Raised pressures for longer than 60 min can lead to permanent visual loss (18). Because orbital compartment syndrome is a clinical diagnosis, a high index of suspicion should be held for patients with periorbital bruising, visual impairment, proptosis, and pupillary defects in the setting of blunt trauma.

Retinal Injury

Traumatic retinal tears are usually caused by blunt trauma to the globe. The pathophysiology attributed to this phenomena is compression of the globe, which may result in a traction between the vitreous tissue and retina. Subsequent tearing may ensue if great-enough force is achieved. The only symptoms specific to retinal tears are flashes of lights and floaters, which may not always be present (24). Evaluation should include visual acuity, extraocular function, and pupil and retina evaluation. Symptoms of severe pain and dulled vision, in the setting of decreased acuity and trauma, should prompt ophthalmology treatment.

The literature also includes cases of visual loss and retinopathy in nontraumatic cases of athletes (20). This has been reported in endurance athletes, and the proposed mechanism is related to individuals who are more prone to clotting and thrombosis. As strenuous exercise increases activated platelets and other clotting factors, thrombosis can ensue. Also, the risk for retinal detachment is much higher in athletes with severe myopia.

Penetrating Eyelid Injuries or Laceration

Penetrating eye injuries are much less common than blunt injury. Eyeglass breakage can cause injury that penetrates the globe. Assessment and treatment should proceed as outlined before. Lacerations of the eyelid are not uncommon and can be seen with penetrating eye injuries and even forceful blunt trauma. If underlying globe injury has been ruled out, simple upper and lower eyelid lacerations can be managed by the sports physician. Time to primary closure should be 12 to 36 h. It is necessary to refer injuries that involve the upper or lower lid margins or injuries that involve the lacrimal sac or duct. These will require microsurgical technique (5). It is also necessary to refer lacerations that expose the orbital fat because this may indicate damage or extension to the underlying levator palpebrae superioris muscle. If there is question of lacrimal system involvement, fluorescein may be placed in the eye and observed for dye in the wound. Many providers may have lack of experience in the area of eyelid laceration repair and should only proceed with primary closure if clinical expertise is appropriate.

Burns and Radiation Exposure

Many athletes are exposed to high levels of ultraviolet light, namely, UVB and UVA. Because sunscreen cannot be applied close to the eye, the eyelid margins are particularly at risk and should be monitored (14). UV burns tend to damage the conjunctiva and cornea and can happen in water or snow sports as well as mountaineering and athletics at high altitudes. Classic signs include intense pain, photophobia and delay in symptom onset, tearing, and lid spasms (8,25). Fluorescein dye will show fine punctate staining. Treatment involves systemic analgesics and topical antibiotics. The best prevention for radiation exposure of the eye is the use of sunglasses that absorb all forms of UV radiation. In sports where there is a risk of eye trauma and potential risk of broken lenses, shatter-resistant polycarbonate lenses should be used for protection.

National Collegiate Athletic Association Regulations

The National Collegiate Athletic Association (NCAA) has few regulations regarding mandatory eye protection and athletic participation. In 2005, they did mandate that all field players in women’s lacrosse shall wear protective eyewear that meets current American Society for Testing and Materials (ASTM) lacrosse standards (19). There are now a number of manufacturers that provide eye protection that meets ASTM standards (2). Currently, the NCAA does not mandate eye protection for any other collegiate sport.

Return-to-Play Guidelines

There are no set or published guidelines for return to play from eye injuries. The determination to return is a clinical call that must take into account the athlete’s ability to play his or her given sport at his or her previous level. Table 2 provides some suggestions for return to play. Essentially, if there is no functional or binocular loss of vision, then play can resume. Obviously, eye injuries necessitating specialty consultations should be cleared by the specialist prior to return.

Table 2
Table 2:
Return-to-play guidelines.


Sadly, a large majority of sports ocular injuries could have been prevented with appropriate eye wear. Recent studies show that more than 90% of these injuries are preventable (12). A joint policy from the American Academy of Pediatrics and the American Academy of Ophthalmology set forth specific recommendations. They recommend eyewear specific to the sport that meet ASTM standards, protection for contact lens wearers, and ASTM-standardized lenses for those requiring correction and that all functional one-eyed athletes should wear protection. In addition, they recommend all functional one-eyed athletes not to participate in boxing or full-contact martial arts (1). A functional one-eyed athlete is that individual with a corrected visual acuity of less than 20/40 in the eye with the defect. ASTM standards can be reviewed at the following Web site:

Getting players to wear eye protection that is not mandated is a challenge. In 2002, a National Health Interview Survey showed that only 15% of children in organized sports wore appropriate protective eyewear (12). A survey of 1,163 squash players in Australia demonstrated that 1,072 of them did not wear eye protection. Of them, 51% reported this was due to the eyewear being uncomfortable or restricting their vision. Of those using protective eyewear, 91 (53%) claimed this was because of the proper knowledge of eye injuries. Of all those surveyed, 71.7% of them agreed that protective eyewear would significantly reduce their risk of sustaining injury (7).

A recent Cochrane review looked at the evidence of educational effectiveness for the prevention of eye injuries. Unfortunately, owing to poor study quality, reliable evidence was not provided for the effectiveness of educational interventions. More studies with high-quality randomized controlled trials that include longer follow-up periods are needed (26). These findings should not discourage providers from giving proper education and anticipatory guidance for proper eye protection because evidence is, at this point, mainly lacking.


Eye injuries are common in organized sports. With an appropriate examination and history, the sideline or training room physician should be able to initially manage and triage/refer most cases of eye injury. Eye protection does decrease eye injuries. Although good trials are lacking on educational interventions, physicians should encourage proper eye wear appropriate for the sport at hand and continue to advocate for appropriate eye protection policy.

The author declares no conflict of interest and does not have any financial disclosures.


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© 2012 American College of Sports Medicine