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When Amare Stoudemire, a basketball player for the Phoenix Suns, was poked in the eye by another player, the result was an iris tear. After the injury healed, Mr. Stoudemire was advised to wear protective goggles, but a few games later he discarded them because they were uncomfortable. Then several months later, Mr. Stoudemire was hit again, in the same eye, and this time the injury was more serious. After complaining of flashers and floaters, he was sent to Jay L. Schwartz, DO, the team ophthalmologist for the Phoenix Suns as well as the Arizona Diamondbacks baseball team. “I examined his eye and, as it turned out, he had a detached retina,” said Dr. Schwartz. Luckily, a scleral buckle and, later, drainage of fluid that had accumulated underneath the retina resolved the retinal detachment.
But having the surgery and going through recovery afterward meant that Mr. Stoudemire couldn’t play basketball for part of the season. He now wears eye protection for every game. “He doesn’t take the goggles off at all during a game. But it took that second injury to really drive home the point that eye protection is really important,” Dr. Schwartz said.
The incidence of “Ouch!” Each year more than 40,000 eye injuries from sports are severe enough to require at least an emergency room visit, according to the U.S. Consumer Product Safety Commission. And more than one in 18 college athletes sustains an eye injury each season, according to the Coalition to Prevent Sports Eye Injuries. Most eye injuries from sports are minor—such as corneal abrasions from scratches to the eye, or eyelid lacerations. But others have major consequences, including orbital fractures, retinal detachments, optic nerve avulsion and optic neuropathies, all of which can result in serious or even permanent vision
Eye or Head Wound, or Both?
High-impact sports like boxing, football and paintball are obvious risks for head trauma. But ophthalmologists who treat athletes say both head and eye trauma are possible in a lot of sports, including basketball, hockey, baseball and softball, volleyball, lacrosse and even surfing.
Mass x velocity = danger. “One of the worst injuries I ever saw occurred in golf when the patient suffered a blunt injury after being hit in the orbit with a golf ball. The globe did not rupture, but the optic nerve sustained a severe contusion. The patient lost almost all vision in the affected eye,” said Prem Subramanian, MD, PhD, associate professor of ophthalmology at Johns Hopkins University.
Dr. Schwartz sees several significant eye injuries each year in his role treating the Suns, Diamondbacks and other Arizona sports teams. He recalled a case in which basketball player Joe Johnson, now with the Atlanta Hawks, suffered an orbital fracture after falling and landing flat on his face. A reconstruction of the orbital floor helped stabilize the socket, and Mr. Johnson went on to play with his team without incident. But Dr. Schwartz acknowledges that an eye injury can be serious enough to put an end to an athlete’s career, as well as result in permanent vision loss. “With basketball, you have a lot of big guys playing in a small space and it’s very easy for someone to get poked in the eye. I’m surprised that there aren’t even more eye injuries than those I’ve treated.”
Repeat injuries. Vision deficits that occur from head injuries can be progressive. “The prognosis gets worse with recurrent hits to the head,” said Kimberly Cockerham, MD, an associate clinical professor of ophthalmology at Stanford University. Athletes with mild recurrent head injuries from contact sports typically present with dizziness and an inability to focus and have problems reading, using the computer or even driving, she said.
Often eye injuries are concurrent with head or brain injuries, according to Drs. Cockerham and Subramanian. Concussions and their mild to moderate neurologic sequelae can be temporary or permanent, according to Dr. Subramanian. “Mild traumatic brain injury is unlikely to produce permanent vision problems other than double vision. But in unusual cases you can see problems as serious as vision loss from traumatic optic neuropathies.”
Dr. Subramanian added that high-impact sports have come under increasing scrutiny for their long-term associations with tremors or dementing illness. “Patients with dementia from multiple head injuries may present with nonspecific complaints of difficulty reading. Their visual acuity may be excellent but they can’t read because they cannot understand the text even if they can see the words. Parkinson patients may have double vision because of convergence insufficiency, so eliciting a history of boxing or other sources of repeated head blows, like football, is important.”
When to send for scans. Injuries to the globe can be readily assessed and treated, but those that involve neurological symptoms can be confusing for the ophthalmologist, Dr. Cockerham said. Clinicians should look for motility or visual field problems after sports injuries.
Dr. Subramanian added that CT scans are helpful for assessing the eye and orbital structures for bony trauma, and that patients should have an MRI when an optic nerve injury is suspected.
The Special Price of Pugilism
While most vision deficits from eye injuries sustained during sports are immediately apparent, others emerge after many episodes of battering, such as in boxing. In a paper on eye trauma in boxing published in Clinics in Sports Medicine, Gustavo Corrales, MD, found that boxers are at increased risk for glaucoma years after trauma to the head and eye occurs.1 “Because of the trauma a boxer sustains, there’s damage to the trabecular meshwork and, with time, you can see increases in intraocular pressure. So a boxer who sustains significant trauma might develop glaucoma 10 years later,” said Dr. Corrales, an associate professor at Washington Hospital Center in the District of Columbia.
No one’s keeping track? It’s also sometimes difficult to assess the potential long-term risks to vision for athletes who participate regularly in sports such as boxing, Dr. Corrales said. There is no centralized database that records the actual incidence, nature or outcome of eye injuries in boxing. Assessing incidence and outcomes from boxing trauma is made more difficult by the fact that injuries often affect only one eye, and are thus more easily hidden by the athletes who fear disqualification from the sport. However, Dr. Corrales’ study of boxers found signs of ocular trauma in 66 to 76 percent of asymptomatic boxers, and 21 to 58 percent of boxers have pronounced and vision-threatening ocular injuries, he said.
DOWN FOR THE COUNT: Preventable Trauma
THE ACADEMY'S STAND. The Academy maintains a firmly worded, detailed position statement on trauma prevention in sports. To read or download the statement, go to www.aao.org/about/policy and choose “Protective Eyewear for Young Athletes.” The statement includes charts that rate all popular sports according to their relative risk for ocular injury and the minimum recommendations for eye protection.
THE AMA'S STAND. The American Medical Association has taken a number of positions similar to the Academy’s, with an especially critical perspective on boxing, a sport in which injuries can actually be described as intentional. The AMA positions on boxing include the following (abridged by EyeNet editors for length):
“The AMA encourages the elimination of both amateur and professional boxing, a sport in which the primary objective is to inflict injury . . . It is the policy of the AMA that until such time as boxing is banned in this country, preventive strategies should be pursued to reduce brain and eye injuries in boxers: (a) Ideally, head blows should be prohibited. Otherwise, our AMA should encourage universal use of protective garb such as headgear, and thumbless, impact-absorbing gloves. (b) The World Boxing Council, World Boxing Association, and other regulatory bodies should develop and enforce objective brain injury risk assessment tools to exclude individual boxers from sparring or fighting [and] should develop and enforce standard criteria for referees, ringside officials, and ringside physicians to halt sparring or boxing bouts when a boxer has experienced concussive or subconcussive blows that place him or her at imminent risk of more serious injury.”
Eye Protection Saves Eyes
Head and eye protection can’t completely prevent vision injuries, but they can decrease the severity of vision deficits after a blow above the neck, Dr. Subramanian said. Lenses should be made of polycarbonate and have an American Society of Testing Materials label, indicating they meet the standards of the ASTM for a specific sport.
Athletes, especially young ones, are not eager to use protective eyewear. But children and teenagers are especially at risk for eye injuries from playing sports because they are involved in a wide array of athletics and they tend to play aggressively. If an athlete has had a prior eye injury, eye protection is even more critical, Dr. Schwartz said. “It’s so important to counsel the athletes you treat to wear eye gear and protective goggles. Unfortunately, it’s only after they experience a significant event that they’re likely to make wearing eye protection a priority.”
1 Corrales, G. and A. Curreri. Clin Sports Med 2009;28:591–607.