Immediate Management of Sport-Related Ocular Emergencies

The American Optometric Association has developed an emergency management protocol to be used by sports medicine professionals in the event a sport-related ocular injury is sustained in practice or during a game. Many sport-related eye injuries could be serious and require immediate medical attention. The sports medicine professional must recognize the signs of a severe eye injury, administer first aid, make return-to-play decisions, and refer the athlete for appropriate follow-up care.

An athlete who has sustained an apparent sport-related ocular injury should be evaluated first for a concussion, as many of the same injury mechanisms that cause eye trauma may also cause a concussion. Eye injuries and can share some similar signs and symptoms ( Boxes 7.2 and 7.3 ). These include blurred vision; unequal, dilated, or nonreactive pupils; and headache or head-related pain. If an athlete has sustained a concussion, the National Athletic Trainers’ Association guidelines should be followed. If the athlete meets any of the criteria listed in Box 7.3 , immediately refer the athlete to a local emergency department. A secondary assessment may be performed, including evaluation for any potential eye injuries, once the primary survey for a serious or life-threatening injury has been completed.

Clinical Management of Sport-Related Ocular Injuries

The eye care practitioner has a legal and ethical responsibility to provide a thorough evaluation of the eye and orbit to determine the extent of any damage. A thorough methodic evaluation of an eye injury facilitates appropriate management recommendations. Systematic approaches for assessment of ocular sports injuries have been summarized in the literature and include assessment of visual acuity, ocular motilities, pupillary function, external adnexa, intraocular pressure, and anterior and posterior segment structures. ^,

The practitioner should take a comprehensive case history to determine the nature of the injury and elicit any long-standing conditions that may be present. A detailed account of symptoms should be noted as well as a complete description of how the injury was treated after the incident. The ultimate goal of the patient history is to raise the index of suspicion for eye and vision effects from an injury. Although a thorough eye health evaluation should be performed on all athletes with a history of ocular trauma, an effective case history can be particularly valuable for selecting appropriate assessment procedures for the symptoms reported and the type of injury. For example, a basketball player who was struck with considerable force by an opponent’s elbow presents with the potential for eyelid damage, hemorrhaging and damage to the orbital contents, orbital bone fractures, corneal trauma, angle recession, hyphema, uveal structure damage, vitreous detachment, and retinal and choroidal ruptures. If the athlete reports sudden onset of diplopia after the injury, the practitioner is further alerted to assess extraocular muscle (EOM) function and determine if orbital bone fractures are present.

Before proceeding with any other evaluation procedures, an assessment of visual acuity should be made. Visual acuity information is useful for differential diagnosis and management decisions, but it may also be crucial for medicolegal issues. Practitioners commonly use an anterior-to-posterior approach to ocular health assessment; however, this chapter considers the types of eye injuries that commonly occur in sports. A trauma typically is classified as either a closed-globe or open-globe injury, and the Birmingham Eye Trauma Terminology System (BETTS) was developed to standardize descriptions of damage. This chapter provides brief descriptions of common eye injury mechanisms by sport, followed by consideration of the cause of the injury—blunt trauma, penetrating trauma, or chemical trauma.

Baseball and Softball

There is a high incidence of reported eye injuries from baseballs in the United States, and baseball has been reported as the leading cause of sport-related eye injuries in children. ^{, , , ,} The hardness of the baseball, combined with the forces at which it is thrown and hit, produce potentially devastating damage to the eye and orbit. When the baseball is rotating at a high rate, additional tractional forces can be transferred to the ocular tissues by the raised seam on the ball. Similar patterns of eye injury can be found in cricket. ^{, ,} The incidence of eye injuries with softballs is not well known. The softness of the ball reduces the risk of injury, but the forces of a thrown or hit ball are significant enough to cause substantial damage to the eye. Even a Wiffle ball has been reported to cause significant ocular damage. The risk of ocular foreign body also exists from the playing field environment.

Basketball

Basketball accounts for a large percentage of eye injuries in sport because of the intense contact encountered during play and the large number of people who play the game. It is commonly a leading cause of sport-related eye injury in the United States. ^{, , , , ,} Common injuries include eyelid abrasions or lacerations, orbital contusions and fractures, and corneal abrasions. Eye injuries are rarely caused by the ball, but rather by fingers or elbows.

Boxing

Ocular trauma is a common result of boxing, and the extensive nature of ocular injuries has been well documented in the literature. Most of the ocular injuries are the result of contusion forces on the orbital and periorbital bones and ocular contents. Damage to the lids and soft tissues is common, and more extensive damage to internal ocular structures and EOMs can occur. The thumb is capable of transmitting the largest force to the globe and therefore can result in the most significant damage to the eye. Although some studies have suggested that the prevalence of severe ocular trauma is lower than that reported by others, ^, most studies confirm the serious nature of ocular injuries in boxing.

Fishing

Fishing is an activity pursued by many and injury is periodically expected. Although eye injuries do not occur with high frequency, the reported cases are often quite serious. ^{, ,} The fish hook presents a challenge to remove without increasing tissue damage, and several removal methods have been discussed. ^, The anterior segment structures are most commonly damaged by fish hook penetration, including the cornea, iris, and lens tissues. Bystanders are also at risk for injuries caused by whipped pole tips, lures, weights, and fishing spears. ^, The most common injuries include corneal laceration, hyphema, and globe ruptures.

Football

The incidence of face and eye injuries in football was dramatically reduced with the mandate for face guards. However, standard face guards offer incomplete protection for the eyes; specifically, a finger can enter with enough force to cause significant ocular trauma. ^, The addition of a clear protective visor to the helmet may help reduce the risk of eye injury; however, there is currently no American Society for Testing of Materials (ASTM) standard for this form of sports protection. The risk of ocular foreign body from the playing field environment also exists.

Golf

The golf ball can be struck with considerable force, and this hard sphere can cause considerable ocular damage because it fits inside the bony orbit. Similarly, the golf clubhead is quite hard and can directly transmit a large amount of force to the globe. Golf-related ocular injuries are relatively rare; however, the results are often quite severe. ^, Blunt trauma from a golf ball or golf clubhead that results in a ruptured globe typically has a poor prognosis and the rate of enucleation is high. ^{, , ,} A closed-globe blunt trauma has a better visual outcome potential than open-globe trauma.

Hockey

Because of the mandate for face protection at all levels of ice hockey, except the National Hockey League, eye injuries in hockey have been virtually eliminated. Eye injuries are typically incurred only during unsupervised play, from improper use of face protection, or in the National Hockey League. Beginning with the 2013–14 season, all players who have fewer than 25 games of National Hockey League experience must wear a visor. Although visor use can be discontinued after 25 games, very few players elect to remove them. The most common cause of eye injury is from the hockey stick, followed by the puck or opponent. ^, The tip of the hockey stick can transmit considerable force to the ocular tissues because it fits inside the orbital rim and severe blunt trauma can result. Injuries from the puck and the aggressive play of opponents can also cause considerable damage. A similar risk profile exists for other forms of hockey, such as field hockey, floor hockey, and street hockey.

Lacrosse

Lacrosse has risks for eye injury that are similar to hockey, in which the stick and ball present significant hazards. Men’s lacrosse mandates head and face protector use, thereby minimizing the risk for ocular injury. Women’s lacrosse did not mandate face protection until recently; the incidence and severity of eye injuries had been a contentious issue in the sport. ^, US lacrosse changed the rules to endorse and mandate the use of protective eyewear in 2004, resulting in a significant reduction in eye injuries. Aggressive stick play and ball-related accidents can cause extensive blunt force trauma to the ocular tissues.

Mountaineering

When mountaineers make ascents above approximately 3000 m, high-altitude retinopathy risk increases as climbers become more susceptible to acute mountain sickness. The decrease in atmospheric pressure for those unaccustomed to such heights can lead to observable tortuosity and increases in the diameter of retinal arteries and veins as well as optic disc hyperemia. A faster rate of ascent, a higher altitude reached, and a longer length of time at altitude typically will increase the incidence of retinal hemorrhage, retinal nerve fiber layer defects, and other retinal vasculature changes. The coughing problems commonly experienced with high-altitude climbing and the physical exertion from carrying heavy loads have been suggested to play a role in triggering retinal hemorrhages in the compromised vasculature. Most climbers do not notice any symptoms of altitude retinopathy, although the more severe vasculature problems can produce permanent vision loss. ^{, ,} Because the amount of ultraviolet radiation markedly increases at higher elevations, and snow reflects 85% of the ultraviolet radiation, additional risk of photokeratitis exists when appropriate filters are not used.

Racquet Sports

A significant portion of sport-related eye injuries is caused by racquet sports. ^{, , , , , ,} Racquet sports include badminton, handball, racquetball, squash, and tennis. The ball or shuttlecock is hit with tremendous force and can travel at dramatic speeds (see Table 6.4 ). Even though the balls used in some racquet sports are larger than the average orbital opening, the compression forces can push the ball deep inside the orbit. The shuttlecock has a diameter of 0.75 inches and easily penetrates the orbital opening. Ocular trauma usually results from severe blunt force trauma caused by the racquet or ball, including a high prevalence of hyphema, traumatic glaucoma, commotio retinae, and retinal detachment. ^, In tennis and badminton, doubles play significantly increases the risk of eye injury because of the proximity of the doubles partner. The ocular damage may be increased with inappropriate eyewear (see Chapter 6 ). Many of the ocular injuries require in-hospital care, and the ocular damage may cause permanent vision changes. ^{, , ,} The retinal detachments from squash injuries have been reported to have a worse prognosis than other rhegmatogenous detachments. The experience and expertise level of the athlete have not been shown to reduce the risk of eye injury during racquet sports. ^,

Scuba Diving

The increased ambient pressure encountered in scuba diving must be equalized by exhaling through the nose during descent to avoid mask barotrauma. The increased pressure of the mask pulls the eyes and surrounding tissues into the airspace of the mask unless it is equalized, potentially causing hemorrhaging and edema in the ocular tissues. ^, Fortunately most mask barotrauma is self-resolving, and the only treatment is supportive (e.g., ice packs) with patient reassurance.

Decompression sickness (DCS) can result from surfacing too quickly, causing the rapid release of gas accumulated in the body’s tissues during the period of high compression. Many neurologic ocular manifestations of DCS have been reported in the literature, including nystagmus, diplopia, visual field defects, cortical blindness, central retinal artery occlusion, and optic neuropathy. The ocular manifestations of DCS are successfully managed with recompression therapy and hyperbaric oxygen.

If a diver wears contact lenses, soft lenses are preferred. Rigid lenses, particularly polymethyl methacrylate lenses, can cause corneal edema from nitrogen gas bubble formation under the lens during outgassing of decompression. If a diver has had an ophthalmic surgical procedure, Butler recommends minimal convalescent periods before clearing the patient for diving ( Table 7.2 ). The main risk involves infection from the rich microbial environment of water during wound healing. The increased pressure associated with diving does not pose a significant risk for patients who have undergone corneal or refractive surgery, with glaucoma, or with vitreoretinal disorders.

Soccer

The soccer ball is responsible for most ocular traumas in soccer, although the incidence of eye injuries is relatively low. ^{, , , , ,} Although the soccer ball is significantly larger than the orbital opening, a portion of the ball will deform and enter the orbit during contact with the high velocities at which the ball is kicked. ^, A study found that, although the soccer ball did not penetrate the orbital opening as deeply as smaller sports balls (e.g., baseballs, golf balls, tennis balls, squash balls), the ball remains inside the orbital space considerably longer than the other ball types. An appreciable rebound effect also occurs after the initial compression phase that produces a suction distortion to the globe, potentially increasing the severity of the blunt force trauma (see Fig. 7.1 ). The predilection for retinal lesions in the superotemporal quadrant is proposed to be caused by the more exposed temporal retina when the compression forces expand the globe equatorially; the nose offers some protection from the forces transmitted to the nasal retina.

Soccer ball impact on an artificial orbit. The orbit (anterior plane, small arrow ) is penetrated 8.1 mm by the 18-m/s (40 mph) size 3 soccer ball, which compresses on the steel plate surrounding the orbital fixture ( large arrow ) . The compression phase of the ball, which drives a small knuckle of the ball into the orbit (1–4 ms), is easily seen by studying the dark triangles on the ball. During rebound, the slow orbital exit of the ball compared with the rebound from the plate (5–10 ms) produces a secondary suction effect on the orbital contents.

Courtesy Paul Vinger, MD, Concord, Massachusetts.

Swimming and Water Sports

Swimming and water sports do not present a significant risk of eye trauma; however, water sports can be a significant source of eye infections and chemical burns. Swimming goggles can potentially cause a blunt trauma injury if they slip during removal or when cleared. The elastic band can cause the goggles to snap back and cause severe injuries, including globe ruptures. Water polo presents a risk of blunt trauma from fingers, elbows, or the ball to the improperly protected eye. Other risks include infections in soft contact lens wearers who are not adequately compliant with appropriate lens cleaning and pingueculae and pterygia in outdoor water sports (e.g., surfing, windsurfing, kiteboarding, kayaking). ^,

Paintball

War games with paintball guns present a tremendous risk for ocular injury when proper protection is not used. The paint pellet is shot with sufficient energy to cause severe eye trauma, including corneal lacerations, hyphema, traumatic cataract, and retinal pathology.

Blunt Trauma

Most eye injuries reported from sports and recreational activities result from objects larger than the orbit, producing blunt trauma, and objects smaller than the orbit, resulting in penetrating trauma. ^{, , ,} Blunt trauma to the head can also result in damage to the visual pathway. ^, In cases in which only one eye is injured, the other eye should also be thoroughly assessed for either recent or long-standing damage.

Blunt trauma is produced by significant pressures exerted on the orbital contents. The ocular damage is usually produced by direct injury to the local site of the trauma (coup effects) or the forces transferred through the ocular tissues along the path of the shock waves (contrecoup effects). ^, Ocular damage may also result from the compression forces exerted when the orbital contents are compacted within the bony orbit. ^, In ocular compression injuries, the globe is compressed along the anteroposterior direction and must compensate by expanding equatorially or it will rupture ( Fig. 7.2 ). Each of these mechanisms is capable of causing significant harm to the delicate orbital bones and ocular tissues. Most blunt eye trauma is caused by a ball, stick, finger, or other object or body part during sports participation, as previously described. The examination should also determine whether any penetrating intraocular foreign body injury occurred that was not reported in the trauma history.

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  Sideline management: When evaluating the athlete after a blunt trauma, the sports medicine professional must assess the following regarding the eye: Is the lid swollen shut? Is blood present inside the eye? Is the cornea white or hazy? Is the pupil irregularly shaped, fixed, dilated, or constricted? Is the athlete experiencing problems with vision (e.g., seeing stars, floaters, distortion)? If the athlete has any of these signs or symptoms, then apply a cold compress and immediately refer the athlete to an eye care professional. If eye pain is the only symptom, the injury sustained is usually not emergent. If an immediate referral is not required, then have the athlete apply ice for 15- to 20-minute periods during the first 24 h after injury. The athlete should be referred to an eye care professional within 24–36 h of the event ( Table 7.3 ). Athletes who have sustained a blunt trauma injury should have a dilated fundus examination performed by an eye care professional within 96 h.

  
  
  
  

  Table 7.3

  
  

  Triage of Sport-Related Ocular Injuries.

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Emergency Situation	Treatment
  Foreign object in eye/eye pain
  Visible object, not embedded	Lift object gently with tissue or cotton moistened with sterile eye solution. If solution is not available use water.
  Object not visible	Gently grasp lashes of upper lid and pull lid forward and down. Allow tears to wash out foreign body.
  Visible object that cannot be removed	See eye care professional the same day.
  Possible penetration of the globe of the eye or surrounding tissue by the object	Do not attempt to remove object; see eye care professional the same day.
  Blood seen in the eye	See eye care professional the same day.
  Object possibly trapped behind the upper lid	See eye care professional the same day.
  Vision problems	See eye care professional the same day.
  Eye pain	See eye care professional the same day.
  Blunt trauma
  Patient should have a dilated fundus examination performed by an eye care professional within 96 h of the event because serious internal eye injuries may have occurred. Apply cold compress for the first 24 h unless one of the signs below is present . If no improvement occurs see an eye care professional within 24–36 h of the traumatic event.
  Lid swollen shut	See eye care professional immediately.
  Blood inside the eye	See eye care professional immediately.
  Cornea (front of the eye) white or hazy	See eye care professional immediately.
  Pupil irregularly shaped, fixed, dilated, or constricted	See eye care professional immediately.
  Problem with vision (e.g., stars, floaters, distortion)	See eye care professional immediately.
  Eye pain	See eye care professional the same day.
  Superficial injury to eyelid	Gently apply direct pressure to stop bleeding. Cleanse wound and apply sterile dressing taped in place or apply a bandage encircling the head. See eye care professional immediately.
  Burns
  In the event of a chemical burn do not attempt to neutralize the acid or alkali. Do not use an eye cup. Do not bandage the eye. When irrigating ensure that the chemical does not wash into the other eye. If sterile eye solution is not available use water.
  Ultraviolet burn (most commonly occurs in water and snow sports)	See eye care professional the same day.
  Chemical is a strong base (alkali; e.g., drain cleaner, lime, cement, plaster)	Irrigate 30 min with sterile eye solution and lids forced open. See eye care professional immediately.
  Chemical is a strong acid (e.g., battery acid)	Irrigate at least 15 min with sterile eye solution and lids forced open. See eye care professional immediately.
  Chemical is a mild acid or base (e.g., pool chlorine, bleach, gasoline)	Irrigate at least 15 min with sterile eye solution and lids forced open. See eye care professional the same day.

   
  
  

Mechanism of ocular damage by blunt trauma.

Reprinted from Kanski JJ. Clinical Ophthalmology . 5th ed. Boston: Butterworth Heinemann; 2003.

Bone Structures

Blunt trauma to the bony orbit can cause external fractures to the orbital rim; however, the more fragile internal orbital walls are more prone to fractures. ^{, ,} Lang was the first to postulate the mechanism for what would later be referred to as a blowout fracture. The blunt trauma to the eye forces the globe back into the orbit, and the hydraulic pressure of the compressed globe can break through one or two orbital walls. The term blowout fracture is used to describe fractures of the internal orbital floor (separating the maxillary sinus) without fractures of the external orbital rim. The medial wall (lamina papyracea) separating the ethmoid sinus may also be fractured during a blowout fracture. ^, Medial wall fractures may also cause orbital emphysema from air forced into the orbit from the nasal sinuses ( Fig. 7.3 ), most noticeable when blowing the nose or during a Valsalva maneuver. These fractures are confirmed by a computed tomographic scan or radiograph of the orbit ( Fig. 7.4 ) and often produce pain, EOM restrictions, and eventual enophthalmos. Significant fractures necessitate surgical interventions to minimize enophthalmos and EOM restrictions. ^,

Subcutaneous emphysema in a patient with a medial orbital wall blowout fracture.

Reprinted from Kanski JJ. Clinical Ophthalmology . 5th ed. Boston: Butterworth Heinemann; 2003.

Coronal computed tomographic scan of a right orbital floor blowout fracture.

Reprinted from Kanski JJ. Clinical Ophthalmology . 5th ed. Boston: Butterworth Heinemann; 2003.

Jones reported that one-third of orbital blowout fractures are the result of sports activities, with soccer being the most common sport involved in the United Kingdom. Aggressive play was identified as the most common cause of the fractures, typically through high-energy blows by an opponent’s fingers, fists, elbows, knees, or boots.

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  Sideline management: A blowout fracture can prevent concentric gaze and result in double vision. The athlete will report pain at the site of injury and with movement of the eye. Visual inspection often reveals hyphema, swelling, numbness of the ipsilateral cheek, a protruding or a sunken eye, vertical dystopia, and periorbital hematoma. ^{, ,} An athlete presenting with signs consistent with a blowout fracture should have a sterile eye pad placed over the eye to prevent him or her from looking around. The athlete may require bilateral eye pads to further reduce the chance of eye movement. The use of ice will help with pain modulation while the athlete is transferred to the emergency department.

  
  
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  A retrospective review of National Football League players found the most common signs and symptoms experienced immediately after an orbital fracture included decreased visual acuity, decreased eye movements, hyphema, and infraorbital numbness. The mechanism of injury was either a digital poke or a blunt facial trauma. To highlight the seriousness of orbital fractures, 15 of the 19 cases reviewed required surgical reconstruction. Two of the football players were unable to return to football because of residual visual impairment.

Corneal injuries

The cornea is a frequent site of damage from both blunt and penetrating or foreign body trauma. Injuries to the corneal epithelium are particularly painful because of the high concentration of sensory nerve innervation, leading to photophobia and reflexive tearing. Athletes participating in contact sports are at particular risk for finger injuries, and a fingernail can cause significant harm to the corneal tissues. The practitioner must therefore perform a careful evaluation of the layers of the cornea with a biomicroscope to determine the depth and extent of the damage. Fortunately, epithelial wounds heal rather rapidly without sequelae unless the Bowman layer has been involved. Injuries to Bowman layer increase the incidence of residual scarring, which can affect visual clarity. Athletes whose corneal injuries involved vegetative matter should be carefully monitored for subsequent fungal infections. Corneal lacerations ( Fig. 7.5 ) that are large and not self-sealing require protection with a Fox shield and referral for surgical consultation.

(A) Large corneal laceration through visual axis. Note the linear scar from the wound and around the multiple interrupted nylon sutures of various lengths used to repair the laceration. (B) Corneal laceration demonstrating positive Seidel test result (bright stream of fluorescein around the central suture).

Reprinted from Kaiser PK, Friedman, NJ. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology . 2nd ed. Philadelphia: W.B. Saunders; 2004.

Pressure patching had been the standard approach for the management of corneal abrasions ( Fig. 7.6 ); however, the reduction of oxygen to the epithelium and increased temperature produced by patching can retard healing and increase the risk of infection. ^, A Cochrane review in 2016 did not show any improvement in pain, symptoms, or healing when comparing patching with nonpatching for corneal abrasions. The use of topical antibiotics without patching may yield faster healing rates while protecting from secondary infection. Aggressive use of ocular lubricants can further improve patient comfort and promote healing, especially the use of lubricant ointments at bedtime. Because of the significant pain associated with epithelial injuries, oral nonsteroidal antiinflammatory agents are frequently prescribed. A Cochrane review did not show clinically relevant pain reduction from the use of topical nonsteroidal antiinflammatory drugs in traumatic corneal abrasions, and because antiinflammatory agents can slow tissue healing, their use should be limited to twice daily. The use of topical anesthetics to improve patient comfort is specifically contraindicated because of significant interference with corneal healing and increased risk of infection.

Pressure patching to manage corneal abrasions. (A) The examiner applies an eye pad to the closed eyelids, either lengthwise or folded in half. (B) The examiner places a second patch lengthwise over the first patch. (C) Finally the examiner secures the patches with tape placed from the center of the forehead to the angle of the jaw across the patched eye.

Reprinted from Palay DA, Krachmer JH. Primary Care Ophthalmology . 2nd ed. St Louis: Mosby; 2005.

A bandage contact lens can be an effective management tool for corneal injuries, although the lenses may also slow healing. The lens can protect the epithelium without significantly reducing the oxygen supply or increasing the corneal temperature like traditional pressure patching does. A contact lens offers the additional benefit to the athlete of allowing use of the eye during healing. For the athlete who is already a contact lens wearer, this is an excellent management approach. The athlete should be encouraged to use rewetting drops frequently to maintain good ocular lubrication.

A particular problem with corneal injuries inflicted by fingernails is the chance of recurrent corneal erosions. Most epithelial injuries heal well but 7%–8% of injuries result in recurrent erosions. ^, Management is designed to reestablish the adhesion complex between the epithelium and Bowman layer and includes sequential use of topical hyperosmotic agents, bandage contact lens wear, surgical debridement, stromal micropuncture, and excimer laser phototherapeutic keratectomy. ^, Newer therapies include oral matrix metalloproteinase inhibitors, blood-derived eye drops, amniotic membrane graft application, and topical corticosteroids. However, a review concluded, “well-designed, masked, randomised controlled trials using standardised methods are needed to establish the benefits of new and existing prophylactic and treatment regimens for recurrent corneal erosion.”

The forces generated in many fast ball and contact sports can result in ruptures to all layers of the cornea. Damage to Descemet membrane or the endothelium results in considerable corneal edema and possibly corneal blood staining. The corneal edema and blood staining typically resolves spontaneously; however, the disruption in the endothelial cell junctions can be permanent. ^, Injuries with sufficient force to rupture the deeper corneal layers often result in damage to the adjoining sclera as well. ^, Athletes who have had corneal refractive surgery may be at higher risk for ruptures and should be strongly counseled regarding the use of appropriate protective eyewear.

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  Sideline management: If a foreign object injury is suspected and the athlete has been unable to remove the object on his or her own, the sports medicine professional may be able to assist with the removal. If an object is visible (and not embedded) then lift the object gently with tissue or cotton moistened with sterile eye solution (or water if solution is not available). If the object cannot be seen the eyelid must be everted ( Fig. 7.7 ). Allow tears to wash out the foreign body. If the object is difficult to remove, if the athlete has vision problems or blood in the eye, or if the foreign object has penetrated the globe or surrounding tissue, immediately refer the patient to an eye care professional.

  
  

  
  

  
  

  

  
  

  
  

  Steps to evert the upper eyelid. (A) Ask the athlete to look down while keeping his or her eyes open. Grab the eyelash and the tarsal plate close to the edge of the eyelid and gently pull forward and down. The eyelid should not be pulled up or out (top) . Place a cotton-tipped applicator or lid evertor just above the tarsal plate of the eyelid. While still holding the eyelashes evert the eyelid over the applicator (bottom) . (B) The eye can then be examined with the eyelid held against the superior bony ridge of the orbit (top) . Instruct the athlete to look upward and blink. This will return the lid to its normal position (bottom) .

  
  

  Reprinted from Palay DA, Krachmer JH. Primary Care Ophthalmology . 2nd ed. St Louis: Mosby; 2005.

  
  
  
  
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  Immediate management of suspected corneal injury requires covering or patching the eye, instructing the athlete not to rub the eye, and referring the athlete to an eye care specialist. The use of fluorescein dye and illumination of the eye are necessary to ascertain the extent of damage.

Removing contact lenses

Contact lenses should be removed from the eye in the case of minor injuries such as a corneal abrasion. In cases in which the eye exhibits serious surface trauma, the contact lens should be left in place until the eye can be more thoroughly evaluated by a physician or an eye care specialist.

Anterior chamber and uvea

The pressure forces generated with blunt trauma in sports can result in damage to the iris or ciliary body tissues. Contusion pressure forces the cornea, iris-lens diaphragm, and ciliary body to rapidly expand posteriorly and circumferentially. ^{, , ,} The resulting damage can lead to anterior chamber angle and pupillary effects and traumatic hyphema problems.

A relatively mild trauma may cause injury to the iris stroma, resulting in iritis that spontaneously recovers with time. Topical cycloplegic agents are prescribed to decrease the pain and photophobia produced by the iritis. The iris sphincter may rupture in one or more locations, causing characteristic triangular defects and notched pupillary borders that are permanent ( Fig. 7.8 ). The iris and ciliary body may respond to blunt trauma with temporary miosis, mydriasis, cycloplegia, or spasm of accommodation. More severe trauma may result in iridoschisis (detachment of an anterior mesodermal leaf) or iridodialysis (base of the iris separates from the ciliary body). Iridodialysis typically produces a substantial hyphema that makes the injury difficult to detect until the hyphema clears. Iridodialysis may not require treatment unless it has created monocular diplopia because of an accessory pupil.

Rupture of the iris sphincter.

Reprinted from Kanski JJ. Clinical Ophthalmology . 5th ed. Boston: Butterworth Heinemann; 2003.

The ciliary body is also at risk for damage from blunt trauma, usually producing a cleft in the anterior ciliary body and causing angle recession ( Fig. 7.9 ). ^{, , ,} Angle recession can occur with or without bleeding and affects anterior chamber drainage by damage to the trabecular meshwork. Gonioscopic studies suggest that most injuries that result in traumatic hyphema also produce angle recession. ^, Angle recession is responsible for glaucoma, often unilateral in cases when only one eye received the trauma. A secondary open-angle glaucoma can occur within 2 months to 2 years after the injury or even 10–15 years after the injury. The incidence of secondary glaucoma with angle recession is estimated to be approximately 7%, ^, and eyes with angle recessions larger than 180 degrees are at greater risk of developing glaucoma. Athletes who have angle recession injuries should be frequently monitored throughout life for development of glaucoma. Rarely, a 360-degree ciliary detachment can occur (cyclodialysis) and cause hypotony and phthisis bulbi, requiring surgical managment.

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