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Head, Neck, and Spine

Evaluation and Management of Sports-Related Eye Injuries

Toldi, James P. DO; Thomas, Justin L. MD

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Current Sports Medicine Reports: January 2020 - Volume 19 - Issue 1 - p 29-34
doi: 10.1249/JSR.0000000000000677
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Abstract

Epidemiology of Sports-Related Eye Injuries

Musculoskeletal injuries may be the most common sports-related injuries, but eye injuries carry a high risk of morbidity and lifelong sequalae. Ocular injuries disproportionately affect younger males compared with the general population according to the Nationwide Emergency Department Sample. These data from more than 900 hospitals and approximately 30 million emergency department (ED) patient visits per year showed 81.3% of patients with sports-related ocular trauma were males with a mean age of 20.1 years (1). More than half of the patients presenting, males and females included, were younger than 18 years. Traumatic eye injuries are the leading cause of noncongenital blindness in those younger than 20 years. Despite the lack of literature over the past 20 years on sports-related ocular injuries, there has been a notable 26% decrease in the incidence of pediatric ocular injuries from 2006 to 2014 (2). This is likely in part due to improved safety technology and improved return to play guidelines. It should be noted that the pediatric age group is disproportionately affected by sports-related eye injuries likely due to the high percentage of this age group participating in sports.

Different sports can be risk stratified based on low-risk, high-risk, and very high-risk classification schemes. Low-risk sports are those that do not utilize equipment that could potentially cause blunt or penetrating trauma (i.e., a ball, puck, bat, stick, racquet) and no body contact. Lower-risk sports include swimming, track and field, and gymnastics. High-risk sports use the aforementioned equipment that increases the risk for ocular injury. Basketball, baseball, soccer, lacrosse, tennis, racquetball, hockey are all examples of high-risk sports. Very high-risk sports include boxing, martial arts, and wrestling, where ocular injuries occur at a relatively high rate due to the violent nature of the sport. Basketball was shown to be the leading cause of sports-related ocular injuries among ED patients sampled between 2010 and 2013 (1). Overall, open wounds of the adnexa (i.e., eyebrows, eyelids and lacrimal apparatus) were the most common injury followed by contusions of the eye and superficial wounds (1). The trend remained the same in basketball with open adnexal wounds being most common followed by superficial wounds (1).

Ocular Anatomy

The anatomy of the eye is very complex with many integral working parts that are prone to injury in the athlete. The complete detailed anatomy of the globe, orbit, and vascular and lymphatic supplies are out of the scope of this article, but a general description of the major components will be described here to review the major anatomy. Figure 1 depicts a general description of ocular anatomy which the sports medicine physician should be familiar with.

Figure 1
Figure 1:
Schematic diagram of the human eye. Available from: https://commons.wikimedia.org/w/index.php?curid=1597930.

In terms of injury patterns, the eye can be divided into the anterior and posterior segments. Each segment lends itself to different examination techniques for the suspected injuries. Vascular supply to the eye is provided by branches of the ophthalmic artery which originates off the internal carotid artery.

The anterior chamber is composed of a thin transparent mucous membrane (conjunctiva), a protective fibrous membrane (sclera), the transparent cornea, the aqueous humor, and the iris. Since the eye is globular in nature the sclera and choroid are parts of both the anterior and posterior chambers. The conjunctiva is contiguous with the posterior surface of the eye lid (palpebral) conjunctiva and is prone to both injury and infection (3). The sclera is a protective fibrous outer layer that is contiguous with the cornea anteriorly and the optic nerve posteriorly. It is composed entirely of collagen and makes up the white part of the eye. The cornea acts as the eye's outermost lens as well as a protective layer. The iris is positioned in front of the lens and separates the anterior and posterior chambers. It is responsible for controlling the amount of light entering the eye.

The posterior chamber is composed of the lens anteriorly, retina posteriorly, and jelly-like vitreous humor which helps maintain the globe like structure of the eye (3). Light refraction and accommodation are the main functions of the lens (3). This focusing is accomplished by a muscular structure known as the ciliary body which changes the shape of the lens by contracting and relaxing. The retina is responsible for processing light information and sending it to the brain via the optic nerve.

Supplies

The basic “eye kit” is something that sideline physicians should carry with them and helps with the initial diagnosis and management of eye injuries. An ophthalmoscope, vision chart, light source with cobalt blue light, cotton swabs, eye shield, sterile saline, contact lens remover, fluorescein dye, and loupes or magnifying glass are examples of the equipment one should have at his/her disposal (4). Ringside equipment for lateral canthotomy and cantholysis may be considered for the boxing or mixed martial arts (MMA) events.

History

Firsthand observation of the event is the most helpful part of the injury history; this helps determine velocity and direction of the inciting blow. If the physician is not present, focused questions of the sport and any projectiles help aid in determining extent of damage and diagnosis. Video review and a history from the athletic trainer, if available, also aid in history and diagnosis. Instances where glasses or goggles have broken may be concerning for penetrating injury. Foreign body sensation, tearing or photophobia may indicate a corneal abrasion or foreign body. Contact with organic matter may increase risk for infection. High velocity, blunt trauma from balls, pucks, or bats may clue the clinician into the possibility of an orbital fracture and/or retrobulbar hematoma. Pain with extraocular movement, epistaxis, or diplopia may be indicative of an orbital fracture with muscle entrapment. The most common mechanism of injury is blunt trauma to the eye (1). It is important to always inquire about tetanus immunization history.

Physical Examination

A focused eye examination will facilitate proper diagnosis and management in the setting of eye injury. First, visually examine for any obvious deformity, foreign bodies, eyelid lacerations, facial bone deformity, erythema, or hematomas. Visual acuity should be done first as this is considered the vital sign of the eye (5). This can be done using a hand-held Snellen chart. Confrontational visual fields should be tested in all four quadrants which can help diagnose injuries to the retina, optic nerve or central optic pathways. Test extraocular movements through the six cardinal positions to help determine ocular muscle or cranial nerve injury. An entrapped inferior rectus muscle from an orbital floor fracture can result in limited vertical range of motion. It is important to ask the patient about diplopia since this can sometimes be a subtle finding. If diplopia is present, it is typically worse when looking toward the affected side (5). Eye pain, decreased visual acuity, loss of anterior chamber depth, or a teardrop-shaped pupil in the context of penetrating trauma should raise concern for the possibility of globe rupture or traumatic lens dislocation (5,6). If this is suspected, the examiner should be careful to avoid placing pressure on the globe. The patient should be given precautions against straining and Valsalva pressure and an eye shield should be placed to protect the eye from further injury.

A penlight is used to test pupil reactivity and to test for a relative afferent pupillary defect (RAPD). A RAPD is when the affected eye paradoxically dilates when exposed to light but constricts when the contralateral eye is exposed to light. This is indicative of a retinal or optic nerve injury. A light source can help to quickly examine the anterior chamber for blood (hyphema) and foreign bodies which can lead to globe rupture. If either is suspected, then a more thorough examination should be done with a slit lamp. When using a basic light source to examine the eye be sure to direct the light perpendicular to the globe, illuminating the anterior chamber. This will help visualize a potential hyphema. Palpate for step-offs or subcutaneous crepitus which may occur secondary to orbital rim or facial fractures. Table 1 gives a brief overview of signs and symptoms that would require immediate ophthalmologic consultation.

Table 1
Table 1:
Signs and symptoms of vision threatening injuries that require immediate Referral (4).

Corneal Abrasion

Corneal abrasions are one of the most common eye injuries encountered. Recent data show that approximately 27% of U.S. pediatric-related ocular injuries presenting to the ED are secondary to corneal abrasions (7,8). Symptoms include pain, foreign body or gritty sensation, and photophobia or tearing. They can be diagnosed using a cobalt blue light or woods lamp and fluorescein dye. With fluorescein staining, an abrasion will appear yellow under normal light and green under cobalt blue light (9).

Goals of treatment include prevention of infection, pain control, and speed of healing (9). First-line treatment is erythromycin ointment as it provides antibacterial coverage, serves as a physical barrier, and provides lubrication to the eye. It is important to educate the patient that this will blur his/her vision, but his/her vision will likely already be compromised from the abrasion. Pain management can best be achieved with topical nonsteroidal anti-inflammatory drugs (NSAIDs) or oral narcotics for larger abrasions and occasionally topical cycloplegics. Evidence does not support the use of cycloplegics for uncomplicated corneal abrasions, but they may be considered for traumatic iritis to help reduce the pain from ciliary muscle spasm (9). Antibiotics should be used for 3 to 5 d depending on response. Choice of antibiotic selection will be based on whether or not the patient wears contact lenses. Erythromycin ointment is first line for noncontact lens wearers, followed by Polytrim drops or sulfacetamide (9). For contact lens wearers, Pseudomonas and other gram-negative coverage are needed since lenses are usually colonized (9). As Pseudomonas are frequently found in the environment, individuals coming into contact with organic matter should be covered as well. This is accomplished with fluoroquinolones or aminoglycosides. Ciprofloxacin, ofloxacin, and gentamicin are commonly used and are both available in ointment and drops. Antibiotic regimens are usually dosed four times daily until the patient is asymptomatic for 24 h (9). Topical NSAIDs should not be used for more than 1 to 2 d as they may be associated with corneal toxicity (9). A recent Cochrane review by Wakai et al. (10) for topical NSAIDs use in traumatic corneal abrasions did not show clinically relevant pain reduction, which should be taken into consideration as topical NSAIDs are expensive. It should be noted that topical anesthetics should not be used as they slow healing, are toxic to the corneal epithelium, and mask worsening symptoms (11).

A recent Cochrane Review in 2016 on patching for corneal abrasions did not show any improvement in pain, symptoms, or healing when compared with nonpatched individuals (12). Evidence also shows that there may be an increased risk of having temporary monocular vision loss. If there is concern for recurrent eye rubbing or exposure, then patching may be considered. Based on clinical experience, large corneal abrasions or shearing injuries, where the epithelium separates from the basement membrane, may warrant eye pressure patching to limit the mechanical irritation and agitation from the underside of the lid. This should be applied only until the athlete can get to a higher level of care and should never remain longer than 24 h. Bandage contact lenses can be used in the same manner but are not part of the usual sideline supplies.

Corneal Foreign Body

Foreign bodies can cause a multitude of problems, including corneal abrasions, globe rupture, conjunctivitis, and iritis. Carefully inspect the eye, including everting the upper and lower lids. Point-of-care ultrasound may be of benefit for detecting corneal foreign bodies or substances that may have penetrated the cornea or globe. If copious amounts of dirt are in the eye, judiciously irrigate with sterile saline, preferably using a Morgan Lens and topical anesthetic, such as proparacaine and tetracaine, if available. A Morgan Lens is a device that is placed over the globe and within the lids to provide a continuous lavage to the cornea and conjunctiva, while floating on a layer of irrigation solution and never physically touching the cornea. Only a physician with experience using a Morgan Lens should be utilizing this device on the sideline. A moistened cotton swab helps to remove debris as well. If the concern for a retained foreign body remains after the initial examination, a slit lamp examination should be performed to more thoroughly evaluate the eye and guide definitive treatment. After removal of penetrating foreign bodies, treatment is the same as for a corneal abrasion. If the foreign body is metal, a rust ring may result if left in for too long. A burr drill may be used for attempted removal of the rust ring by a skilled physician. This is not typically performed on the sideline.

Subconjunctival Hemorrhage

Subconjunctival hemorrhages are one of the most common ocular problems seen in the ED or physician's office. They are usually asymptomatic and occur spontaneously; therefore they can be more visually alarming to patients than they actually are. Minor eye trauma (i.e., rubbing) or Valsalva maneuvers, such as coughing, sneezing, or straining are the usual causes. They usually spontaneously resolve within 2 to 3 wk. However, if the hemorrhage involves the entire sclera or hemorrhagic chemosis is present, there should be a high index of suspicion for globe rupture (5), and immediate referral is required. Hemorrhagic chemosis is a collection of blood within the substance of the conjunctiva. These also can occur from a small laceration to the conjunctiva, such as from a fingernail to the eye. With this finding, visual acuity should be checked in addition to a thorough examination looking for any signs or symptoms of a ruptured globe (see below for further discussion).

Hyphema

Commonly caused by blunt trauma, hyphemas are anterior chamber hemorrhages caused by microvascular damage to the iris (13). Examination of the eye will show a layer of gross blood in the anterior chamber. Figure 2 shows the layering of blood in the anterior chamber. Spontaneous hyphemas can also occur in patients with bleeding diathesis and sickle cell anemia. Since these usually occur in high force injuries, there should be concern for penetrating trauma, orbital fracture, abrasion, and/or retinal injury (13). Initial management includes elevating the head of the bed above 45 degrees, discontinuing all NSAIDs or anticoagulants, and bed rest for 4 d (11). Urgent ophthalmology consult is warranted due to the risk of extensive bleeding that may result in glaucoma or corneal staining (11). If complications, such as glaucoma, do occur, pressure-lowering medications (i.e., topical beta-blockers, IV mannitol, topical alpha agonists and oral, IV or topical carbonic anhydrase inhibitors) (5) should be used under the ophthalmologist’s care.

Figure 2
Figure 2:
Layering of blood seen in the inferior portion of the anterior chamber.

Orbital Fracture

In a recent study by Harling et al., the epidemiology of eye injuries in 85,000 patients was analyzed to quantify and characterize sports-related eye injuries. Orbital fractures accounted for approximately 9.5% of all sports-related ocular trauma from January 2010 to December 2013. Despite ocular fractures being a small proportion of ocular injury, they are a significant injury with a high risk of morbidity and vision loss. Most orbital fractures are secondary to blunt trauma from sports equipment, with the highest risk coming from a ball that is smaller than the orbital rim, such as a racquetball. The inferior orbital floor, and less commonly the medial wall, is usually fractured secondary to increased pressure within the orbit causing the orbital bones to break at their weakest points. Signs and symptoms include enophthalmos (posterior displacement of the globe in relation to the orbit), periorbital ecchymosis, painful extraocular movements, upward gaze restriction, and diplopia caused by inferior rectus muscle entrapment. Hypoesthesia in the distribution of the infraorbital nerve also may be seen. Sensation can be tested just below the lower eyelid to see if this has occurred. Advise the patient to avoid blowing his/her nose as this can result in significant subcutaneous emphysema. All patients with suspected orbital fracture should be evaluated in the ED for a more thorough evaluation and definitive treatment. Computed tomography with thin cuts is gold standard for diagnosis.

Due to the force that is usually associated with these injuries, the clinician should have a high degree of suspicion for other possible sustained ocular injuries. Approximately one third of orbital fractures also are associated with other significant ocular trauma such as abrasions, traumatic iritis, hyphema, lens dislocation, retinal tear or detachment, and vitreous tear. All fractures should be referred to an otolaryngologist, oral-maxillofacial surgeon, or ophthalmologist for more definitive surgical treatment. Surgery is usually determined on a case-by-case basis. Immediate repair is warranted for fractures with nonresolving oculocardiac reflex, pediatric “white-eyed” blowout fracture, evoked diplopia with gaze, and early enopthalmos or hypoglobus (14,15). Others can be monitored until the swelling decreases before deciding on surgical management.

Retrobulbar Hematoma

Suspicion for a retrobulbar hemorrhage should always be present in the setting of blunt ocular trauma, in the athlete with bleeding diathesis, sickle cell anemia, or on anticoagulant therapy. Anytime there is facial trauma, retrobulbar hemorrhage should be included in the differential diagnosis. Signs and symptoms concerning for retrobulbar hemorrhage include eye pain, proptosis, decreased visual acuity, increased intraocular pressure (IOP), and a RAPD. Because of the enclosed space, there is a risk for compartment syndrome that can lead to blindness. This is an ophthalmological emergency and needs immediate consultation for lateral canthotomy and cantholysis to prevent compartment syndrome. Decompression should occur within 2 h of decreased visual acuity to prevent permanent vision loss (14). Increased IOP can progress to irreversible optic nerve and retinal ischemia, resulting in blindness (5). The ring-side clinician should strongly consider carrying equipment for such a procedure to boxing or MMA events because the transport time to the ED alone may result in permanent vision loss. We suggest ringside physicians be competent in this skill. If there is an associated orbital floor fracture, the risk of vision loss drastically decreases from the resulting pressure relief through the fracture site.

Retinal Injury

Traumatic retinal tears usually occur after blunt force to the orbit or globe, causing a transient increase in IOP from globe compression. This may result in traction between the vitreous and retina leading to separation of the retina from the choroid. Endurance athletes (secondary to sustained increased IOP) and persons with myopia (traction injury due to the increased length of the globe) are at increased risk of retinal tears. Retinal vessel disruption can occur, leading to retinal and/or vitreous hemorrhages.

Signs and symptoms include flashes of lights, floaters, a curtain in the field of vision, and decreased peripheral and/or central visual acuity (11,15). Floaters can be described as fine dots, veils, cobwebs, clouds, or strings (16). If available, point-of-care ultrasound is a helpful tool to diagnose a retinal tear and/or a vitreous hemorrhage. Emergent evaluation by an ophthalmologist is indicated for retinal repair by a retina specialist.

Globe Rupture

Globe rupture can result from various mechanisms including blunt trauma from a ball, fist, or penetrating trauma from a BB gun or fingers as in basketball. Signs and symptoms concerning for globe rupture would be complete circumferential subconjunctival hemorrhage, hyphema, loss of anterior chamber depth, pain with extraocular movements, decreased visual acuity, irregular or teardrop-shaped pupil, and afferent pupillary defect (5). Protrusion of intraocular contents also may be seen. Immediate management would be to place a metal eye shield or a hard barrier over the eye, such as the bottom of a paper cup, and seek immediate ophthalmological care. Any protruding foreign bodies should not be removed in the field. Avoid placing topical anesthetic or fluorescein in the eye if globe rupture is suspected as these can be toxic to the retina and intraocular contents. Care should be made to not apply any pressure over the orbit when securing the shield. If using tape, make sure it is adhered to bony prominences such as the forehead and maxillary prominences. Antiemetics and analgesics should be scheduled to prevent Valsalva and further herniation of ocular contents. Tetanus vaccine also should be administered.

Consideration must always be made for a condition called sympathetic ophthalmia. This is a rare condition that results in bilateral acute anterior uveitis days to years after penetrating ocular trauma. Inflammation of the injured eye begins first, followed by the sympathizing eye, secondarily (16,17). Symptoms include floaters, photophobia, redness, or blurry vision (18). Urgent consultation is warranted with initial treatment consisting of systemic and topical corticosteroids with most requiring long-term steroid-sparing immunosuppressive agents (19). Older references recommend enucleation or evisceration of the eye with prior trauma as part of the management, but recent literature generally discourages this practice (19).

Eyelid Lacerations

Laceration of the upper and lower eyelids, as well as the lacrimal duct or sac, is not uncommon (4). Injuries may be sustained following blunt trauma but also may be seen with penetrating injuries. A competitor wearing glasses with an impact to the face puts them at risk for such injuries. The astute clinician should always be concerned for other injuries, such as globe rupture, corneal injuries or foreign bodies in such situations. The laceration can be a sign of a penetrating injury which can be easily missed if the primary focus is on the laceration only.

Many sports medicine physicians do not have the experience or expertise to manage complicated lacerations. Specialty referral is needed for lacerations involving the lid margin, the lacrimal duct or sac, involving the under surface of the lid, or within 6 mm to 8 mm of the medial canthus. Wounds associated with ptosis, orbital fat prolapse, the tarsal plate, or levator palpebrae also should be referred (5). Time to primary closure is 12 h to 36 h which allows the sports medicine physician optimal time for referral if other vision-threatening emergencies have been ruled out (20). Many partial thickness lacerations involving less than 25% of the lid can be left to heal through secondary intention along with judicial use of topical antibiotic ointment (20). The ointment also helps prevent exposure keratitis which can lead to corneal ulcers and permanent vision loss. Large lacerations can be closed with 6-0 or 7-0 chromic gut absorbable sutures using a buried mattress technique. This technique simplifies postoperative care and reduces potential complications (20). We recommend against repairing the lid margins on the sideline to avoid poor cosmetic outcomes.

UV Exposure

Certain sports such as long-distance running, hiking, snow, or water sports can predispose the individual to excessive UV light, increasing the risk of UV-related eye damage. Sunlight is divided into long wave ultraviolet (UVA) and short wave ultraviolet (UVB) wavelengths; UVB is stronger and has more damaging effects to the eye (21). Excessive exposure to UV light is implicated in age-related cataracts, pterygium, skin cancer adjacent to the orbit, photokeratitis, and corneal degenerative changes. It also may contribute to the development of macular degeneration (21). Acute ocular burns may occur secondary to prolonged sun exposure in snow or water sports, as well as from the reflective nature of the snow and water. Classic signs are photophobia, intense pain, and a delay in symptom onset (7). Fluorescein staining will show fine punctate lesions (11). Treatment includes systemic pain relievers and topical antibiotics (5–8). Referral is indicated if there is a corneal epithelial defect (5). Preventing acute and chronic injuries from UV light is as simple as wearing sunglasses that absorb all forms of UV light. In sports with an increased risk of damage to sunglasses, shatter-resistant, polycarbonate lenses should be used.

Prevention and Regulations

The National Collegiate Athletic Association (NCAA) recommends athletes use protective eye wear in high risk sports but official rules differ between sports. In 2005, it was mandated that protective goggles be worn in women's lacrosse (4). Starting with the 2013 to 2014 season, the National Hockey League (NHL) mandated all players with less than 25 games of NHL experience wear a visor affixed to their helmet, but players commonly do not wear face or eye protection if not enforced (22). It is a requirement by the NCAA to wear full-face cages in collegiate hockey. There is a standard to manufacturers developing and producing athletic eye protection that must comply with the American Society for Testing Materials or the National Operating Committee on Standards for Athletic Equipment (23). For many years, The American Academy of Pediatrics and American Academy of Ophthalmologist have set forth a joint policy for protective eyewear in young athletes. The most recent policy, published in 2013, states that functionally one-eyed athletes should wear protective eyewear during all sports, regardless of risk. A functionally one-eyed athlete has a corrected visual acuity of 20/40 or worse in the affected eye (24).

Return to Play Guidelines

There are no set guidelines or standards for determining when the athlete is allowed to return to activity. Corneal abrasions and foreign body injuries are tolerated relatively well. If there is no functional or binocular vision loss, then the athlete may return to play. In general, the eye should feel comfortable and have adequate vision (7). Most other injuries require consultation with a specialist who will determine when the athlete can return. Table 2 gives an overview about return to play recommendations based on condition.

Table 2
Table 2:
Return to Play Recommendations Following Ocular Injury.

Conclusions

Overall, ocular injuries are common in sports, and the sideline physician should be prepared and adept at initial evaluation and treatment. The physician also should have a full understanding of the physical examination of the eyes and surrounding structures and be able to recognize the features of an injury that mandate more urgent ophthalmological evaluation. It is prudent that all athletes participating in very high-risk sports, and even special situations in high-risk sports, wear protective eye equipment because ocular injuries can have devastating long-term sequalae.

Neither of the authors, J.P.T. nor J.L.T., have any financial relationships to disclose.

References

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