Sports and recreational activities are becoming increasingly popular and account for more than 40,000 eye injuries each year in the United States. About 90 percent of sports-related ocular injuries are considered preventable.^1–5 Athletes should be educated by team physicians about proper eye and facial protection and encouraged to use protective devices.

Thirty percent of ocular injuries among children younger than 16 years are sports related. Basketball, water sports, baseball, and racquet sports account for most injuries.¹ Among young persons five to 14 years of age, baseball is most frequently associated with ocular injury, while among persons 15 to 64 years of age, basketball is the leading cause of eye injuries.^1,2,6–10

Sport Classification and Risk

The American Medical Association classifies sports as collision (football, rugby, hockey, lacrosse), contact (baseball, soccer, basketball, wrestling), noncontact (cross-country running, track, tennis, crew, swimming), and other (bowling, golf, archery, field events). These classifications may be misleading because golf and racquet sports, for instance, have a great potential for eye injury but may not be considered hazardous for the monocular athlete if these classifications are followed. Conversely, these classifications may be overly restrictive with regard to contact sports such as hockey, for which adequate eye protection is available.⁷

When considering the potential for eye injury, it may be more appropriate to categorize sports as low risk, high risk, and very high risk. Low risk indicates no use of a ball, puck, bat, stick, or racquet, and no body contact. Examples include track/field, swimming, gymnastics, and cycling. High-risk sports involve the use of a ball, puck, bat, stick, or racquet, and/or body contact. Examples of high-risk sports include baseball, hockey, football, basketball, lacrosse, racquet sports, tennis, fencing, golf, and water polo. Very-high-risk sports, such as boxing, wrestling, and contact martial arts, are those in which eye protectors typically are not worn.^2,10

Preparticipation Examination

A complete eye examination should be part of any sports physical. With each athlete, physicians should obtain an ocular history, paying special attention to prior conditions such as a high degree of myopia, surgical aphakia, retinal detachment, eye surgery, and injury or infection. Athletes with any of these conditions may be at increased risk for serious eye injury.^2,11,12 It also is important to assess athletes who have a strong family history of retinal detachment, retinal tears, and diabetic retinopathy.¹² Athletes with such risk factors should be evaluated by an eye care professional before engaging in any high-risk or very-high-risk sport.¹³

Most Common Mechanisms of Eye Injuries

The most common mechanisms of eye trauma involve blunt, penetrating, and radiation injuries. Blunt trauma accounts for most sports-related eye injuries.^5,14 The extent of ocular damage depends on the size, hardness, and velocity of the blunt object, and the force imparted directly to the eye. A direct blow to the globe from a blunt object smaller than the eye's orbital opening causes rapid anteroposterior compression and dilation of the middle of the globe, transmitting a great force to the internal ocular structures. A blunt object larger than the orbital opening exerts force on the floor of the orbit or the medial wall, resulting in fractures of the thin bones. This “pressure-release valve” may prevent rupture of the globe. However, there is a high incidence of occult internal ocular injuries^1,7 (Figure 1).

Examples of blunt injuries include orbital blowout fracture, orbital and lid contusions, iris injury, ruptured globe (Figure 2), traumatic iritis, subconjunctival hemorrhage (Figure 3), hyphema—blood in the anterior chamber—(Figure 4), retinal hemorrhage, commotio retinae (Figure 5), vitreous hemorrhage, choroidal rupture (Figure 6), retinal tears, and retinal detachment.^{3,7,8,12,15–18}

Penetrating injuries are relatively uncommon but may occur even with large projectiles. Eyeglass breakage also can cause penetrating injury.¹ Such injuries range from mild abrasions to serious lacerations. Canalicular lacerations usually occur because of trauma from a fellow player's finger in the area of the medial canthus.⁸ Fishing hooks have been known to cause penetrating globe injuries (Figure 7). Radiation injuries occur as a result of exposure to ultraviolet light in snow skiing, water skiing, and other water sports.^5,14

Aspects of the Ocular Examination

Sports-related ocular injuries can be evaluated on site with the appropriate medical supplies (Table 1).¹ First, an adequate history should be obtained to determine the force and direction of the impact. For example, the physician should find out whether the injury was from a line drive, a fly ball, a pitched ball, or a hockey “slap shot.”¹⁰ Best-corrected visual acuity is checked using an eye chart. Confrontation visual fields should be checked. Visual field defects suggest a retinal, optic nerve, or central nervous system injury.

Next, the pupils should be examined with a bright light source. The physician should check for anisocoria (unequal pupil size) and for a relative afferent pupillary defect. Normally, the pupils constrict promptly and equally during accommodation and exposure to direct light and to light directed at the other pupil (i.e., consensual light reflex). If light reflex is diminished in one eye, a swinging flashlight test may discriminate between an afferent (retina or optic nerve) lesion and an efferent (third nerve or pupillary muscle) lesion. A deafferented pupil constricts consensually, but not to direct light, paradoxically enlarging when the light is quickly brought from the unaffected side (Marcus Gunn pupil). An efferent lesion prevents direct and consensual constriction while the unaffected eye maintains both. Pupil irregularity is almost always pathologic. A penlight examination of the anterior chamber should be performed to check for foreign bodies, hyphema, abrasions (Figure 8), and lacerations.

Both eyes should have full motility in all positions of gaze. Elevation of gaze may be limited by an orbital floor fracture. Double vision in any gaze position suggests significant injury in one or both eyes.¹

External examination is then performed. Signs of orbital injury include periorbital ecchymosis, edema, proptosis, and bony step-offs of the orbital rim. Trismus, or pain when opening the mouth, often occurs with fractures of the lateral wall of the orbit. Paresthesia in the V2 (infraorbital) distribution of the trigeminal nerve suggests a fracture of the orbital floor (Figure 9).

Finally, funduscopic examination is done to evaluate the red reflex. Even modest bleeding into the ocular media can alter or obscure the red reflex. This may be the only sign of occult rupture of the globe. Any alteration of the red reflex requires immediate ophthalmologic referral.^13,19 Signs and symptoms that warrant immediate referral are outlined in Table 2.^1,3,10,19

When eye trauma occurs, the possibility of a globe rupture must be considered. Perforation and rupture are indicated by darkly pigmented uveal tissue presenting through a laceration.^1,19 A tear-drop–shaped pupil may indicate iris prolapse through a wound at the limbus. Subtle signs of globe rupture include subconjunctival hemorrhage, a deep or shallow anterior chamber, or a conjunctival laceration. If globe rupture is suspected, no further manipulation of the eye should take place. After a protective shield is placed over the eye, the patient should be given nothing by mouth and should be referred immediately for ophthalmic evaluation. Table 3^1,3,10,13,19 outlines treatment of selected eye injuries.

Protective Devices

Eye protection has reduced the number and severity of eye injuries. A protective device should dissipate a potentially harmful force over a larger area. Eye protectors need to shift impact from the eyes and face to the skull without causing intracranial injury. It may be necessary to integrate helmets with eye and face protectors. The American Society for Testing and Materials (ASTM) has established performance standards for selected eyewear in racquet sports, baseball, basketball, women's lacrosse, field hockey, and alpine skiing. ASTM F803–01 standards establish performance requirements for eye-wear that are most appropriate in sports with a risk of ocular injury.⁹ According to these performance standards, force transfer devices must be acceptable to the athlete, not change the appeal of the game, and not generate unacceptable liability.^1,11,13

Protective eyewear often is made of polycarbonate, a highly impact-resistant plastic capable of absorbing ultraviolet light. Because this plastic is eight times stronger than other materials, it is preferred for use in protective glasses. Polycarbonate lenses are available in prescription and nonprescription lenses. Contact lenses offer no eye protection, and eyeglasses provide inadequate protection. Regular eyeglasses have only 4 to 5 percent of the impact resistance of polycarbonate of comparable thickness.^1–3,11,20 Guidelines for protective eyewear are listed in Table 4.^2,3

Functionally One-Eyed Athletes

An athlete is considered monocular when the best corrected visual acuity in the weaker eye is less than 20/40. Such athletes must wear sports eye protectors that meet ASTM racquet sports standards in all sports that carry risks of eye injury, for all games and practices. An eye protector must be worn beneath a face mask in sports that require facial protection (i.e., hockey, football, and lacrosse). The athlete should be instructed to wear protective lenses at all times in case of non–sports-related trauma.^{2,3,7,11,20,21}

Monocular athletes should wear polycarbonate lenses and frames while playing basketball. In hockey, a helmet with a full-face cage, made of either wire or polycarbonate, and sports goggles are needed. While playing football, the monocular athlete should wear a helmet with a face mask, a polycarbonate shield, and sports goggles. Monocular baseball players should wear sports goggles at all times. While batting or running bases, the appropriate helmet with a polycarbonate face guard and sports goggles should be worn. Boxing, wrestling, and full-contact martial arts are contraindicated in monocular athletes because no adequate eye protection is available.^2,11,21 The functionally monocular athlete should be evaluated by an ophthalmologist before being admitted to participation in a particular sport.¹³

Return to Play

Several guidelines for returning to play after an injury should be followed. In patients with significant ocular injury, a full examination and clearance by an ophthalmologist are required. The injured eye should feel comfortable and have adequate return of vision. Eye protectors must be worn. During the game, immediate return to play depends on the athlete's symptoms and the nature of the injury as determined by the team physician. Athletes should never be allowed to use topical anesthetics to prolong play.¹⁰