Management of Sport-Related Ocular Injuries and Concussion

Many reports have been published regarding the incidence of eye injuries occurring during sports and recreational activities. A retrospective analysis of data from the Nationwide Emergency Department Sample (NEDS) utilizing data from over 900 hospitals across the United States over a 4-year period found more than 30,000 individuals per year presented to emergency departments with sport-related ocular trauma. This sample represents only injuries serious enough to warrant attention at a hospital emergency department; the incidence of eye injuries incurred during sports and recreational activities is much greater than the NEDS data estimates because many athletes seek care outside hospitals, if care is sought at all. A better estimate is 2.5 times higher than the amount reported in hospital emergency departments, indicating a more accurate incidence of approximately 75,000 sport-related eye injuries per year in the United States. It was notable that more than 80% of the individuals in the NEDS data were men and that more than half were under the age of 18 years.

Preparticipation Physical Examination

Each year athletes receive a preparticipation physical examination (PPPE) before the start of the sports season. The PPPE is performed to identify athletes at risk of sudden death; identify medical conditions that require further evaluation and treatment; identify at-risk individuals for substance abuse, sexually transmitted diseases, violence, and depression; and satisfy legal requirements of sport-governing bodies (e.g., state high-school athletic associations and the National Collegiate Athletic Association). The Committee on Sports Medicine and Fitness recommends that all youths involved in organized sports should be encouraged to wear appropriate eye protection ( Box 7.1 ). The committee strongly recommends that functionally one-eyed athletes wear appropriate eye protection during all sports, recreational, and work-related activities. , A functionally one-eyed athlete is defined as an individual who has a best corrected visual acuity of worse than 20/40 in the poorer eye. Athletes who have sustained eye trauma or have had eye surgery should also be evaluated by an ophthalmologist or optometrist. , Athletes who fall into this category may need eye protection or should be restricted from particular sports (see Box 7.1 ). , If the provider performing the PPPE fails to identify eye conditions requiring further evaluation, an athletic trainer who is familiar with an athlete’s health history can serve as a backup by referring the athlete to an eye care specialist.

Box 7.1

Recommendations of the Committee on Sports Medicine and Fitness

  • 1.

    All youths involved in organized sports should be encouraged to wear appropriate eye protection.

  • 2.

    The recommended sport-protective eyewear should be prescribed. Proper fit is essential. Because some children have narrow facial features, they may be unable to wear even the smallest sports goggles. These children may be fitted with 3-mm polycarbonate lenses in American National Standards Institute (ANSI) standard Z87.1 frames designed for children. The parents should be informed that this protection is not optimal and the choice of eye-safe sports should be discussed.

  • 3.

    Because contact lenses offer no protection, athletes who wear contact lenses should be strongly encouraged to also wear the appropriate eye protection.

  • 4.

    An athlete who requires prescription spectacles has three options for eye protection: (1) polycarbonate lenses in a sports frame that passes American Society for Testing of Materials (ASTM) standard F803 for the specific sport, (2) contact lenses plus an appropriate protector, or (3) an over-the-glasses eye guard that conforms to the specifications of ASTM standard F803 for sports in which an ASTM standard F803 protector is sufficient.

  • 5.

    All functionally one-eyed athletes should wear appropriate eye protection for all sports.

  • 6.

    Functionally one-eyed athletes and those who have had an eye injury or surgery must not participate in boxing or full-contact martial arts (Eye protection is not practical in boxing or wrestling and is not allowed in full-contact martial arts.). Wrestling has a low incidence of eye injury. Although no standards exist, eye protectors that are firmly fixed to the head have been custom made. The wrestler who has a custom-made eye protector must be aware that the protector design may be insufficient to prevent injury.

  • 7.

    For sports in which a face mask or helmet with an eye protector or shield must be worn, functionally one-eyed athletes are strongly encouraged to also wear sports goggles that conform to the requirements of ASTM standard F803 (for any selected sport). This is to maintain some level of protection if the face guard is elevated or removed, such as for hockey or football players on the bench. The helmet must fit properly and have a chinstrap for optimal protection.

  • 8.

    Athletes should replace sports eye protectors that are damaged or yellowed with age because they may have become weakened and may no longer be protective.

Management of Sport-Related Ocular Injuries

Medical and allied health professionals providing sports medicine care for sports teams (both on the field and in the clinic) may include the team physician, optometrist or ophthalmologist, athletic trainer, and sports physical therapist. The eye care practitioner may see athletes for initial triage and management of sports and recreational eye injuries. Often, an athletic trainer provides the initial triage and first aid for sports eye injuries, and guides follow-up care when necessary. The athlete may not present immediately for healthcare or vision care if an injury seems treatable with basic first-aid measures, so the practitioner may also see the results of long-standing trauma.

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.

Box 7.2

General Mild Traumatic Brain Injury Signs and Symptoms

  • Loss of consciousness

  • Amnesia

  • Balance problems

  • Memory and concentration difficulties

  • Headache

  • Ringing in ears

  • Nausea

Box 7.3

Critical Mild Traumatic Brain Injury Signs

Signs Requiring Immediate Referral to Nearest Emergency Department

  • Deterioration of neurologic function

  • Decreasing level of consciousness

  • Decreased or irregular respiration

  • Decreased or irregular pulse

  • Unequal, dilated, or unreactive pupils

  • Spine or skull fracture; bleeding

  • Mental status changes

  • Seizure activity

Signs Requiring Referral on the Day of Injury

  • Loss of consciousness on the field

  • Amnesia lasting longer than 15 min

  • Increase in blood pressure

  • Cranial nerve deficits

  • Vomiting

  • Motor, sensory, balance, or cranial nerve deficits subsequent to initial field evaluation

  • Postconcussive symptoms that worsen

  • Symptoms at the end of game

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.

Risks of Ocular Injury by Sport Type

Table 7.1 shows sport-related eye injury estimates collected by Prevent Blindness for 2019 by age and sport category. The incidence of eye injuries by sport is influenced by the number of participants in the region or country combined with the risk of sustaining an eye injury in that sport. , Athletes most often at risk for blunt trauma injuries play collision team sports or sports involving projectiles moving at high velocities. For example, basketball is a leading cause of sport-related eye injuries in the United States because of the large number of participants combined with the physicality of the sport. Baseball players and those playing racquet sports are susceptible to direct trauma caused by fast-moving balls, and even balls larger than the bony orbit can cause significant injury.

Table 7.1

Prevent Blindness Table .

Source: Prevent Blindness. Based on statistics provided by the U.S. Consumer Product Safety Commission, Directorate for Epidemiology; National Injury Information Clearinghouse; National Electronic Injury Surveillance System (NEISS). Product Summary Report—Eye Injuries Only—Calendar Year 2019.

Activity Est. Injuries a Age 0–60 Age 7–12 Age 13–22 Age 23+
Basketball 4597 86 523 2263 1725
Pools & Water Sports 4565 927 1003 1113 1523
Non-Powder Guns, Darts, Arrows, Slingshots 3612 308 1109 1129 1066
Bicycles & Accessories 2495 369 282 192 1652
Exercise, Weight-Lifting 2385 104 97 261 1924
Baseball/Softball 2109 90 718 679 623
Soccer 1618 10 362 913 333
Playground Equipment 1195 409 519 139 127
Football 959 0 431 333 194
Other Sports & Recreational Activities 845 264 15 274 292
Racquet Sports 775 10 14 357 394
Golf 765 86 18 18 642
Ball Sports, Unspecified/Other 736 73 242 174 247
Boxing, Martial Arts, Wrestling 683 5 69 277 332
Trampolines 677 487 130 60 0
All-Terrain Vehicles (4 Wheels) 579 87 162 0 330
Fishing 556 5 27 101 423
Misc. Ball Games 535 5 112 286 131
Sports & Recreational Activity Not Elsewhere Classified 491 55 286 95 55
Volleyball 429 55 84 254 36
Scooters, Skateboards, Skating, Go Carts 380 204 19 84 73
Winter Sports 115 0 10 5 101
Total a 31,101 3637 6234 9007 12,223

This publication is copyrighted. This sheet may be reproduced-unaltered in hard print (photocopied) for educational purposes only. The Prevent Blindness name, logo, telephone number and copyright information may not be omitted. Electronic reproduction, other reprint, excerption or use is not permitted without written consent. Because of the time-sensitive nature of the information contained in this publication, contact Prevent Blindness for updates.

FS09 6/20 © 2020 Prevent Blindness All rights reserved.

a Totals may not equal because the injuries are not mutually exclusive.

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 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.


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 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.


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.


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.


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 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.


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.

Table 7.2

Recommended Minimum Convalescent Period Before Diving After Ophthalmic Surgery.

Reprinted from Butler FK. Diving and hyperbaric ophthalmology. Surv Ophthalmol . 1995;39:347.

Procedure Recommended Convalescent Period
Anterior Segment Surgery
Penetrating keratoplasty 6 months
Corneal laceration repair 6 months
Cataract surgery
Noncorneal valve incision 3 months
Corneal valve incisions
Clear corneal 2 months
Scleral tunnel 1 month
Radial keratotomy 3 months
Astigmatic keratotomy 3 months
Glaucoma filtering surgery 2 months (relative contraindication)
Photorefractive keratectomy 2 weeks
Pterygium excision 2 weeks
Conjunctival surgery 2 weeks
Corneal suture removal 1 week
Argon laser trabeculoplasty or iridectomy No wait necessary
YAG laser capsulotomy No wait necessary
Vitreoretinal Surgery
Vitrectomy 2 months (contraindicated until intraocular gas absorbed)
Retinal detachment repair 2 months
Pneumatic retinopexy 2 months (contraindicated until intraocular gas absorbed)
Retinal cryopexy or laser photocoagulation for breaks 2 weeks
Oculoplastic Surgery
Sutured wound 2 weeks
Skin graft or granulating wound Until epithelialization is complete
Enucleation 2 weeks (contraindicated with hollow orbital implants)
Strabismus Surgery 2 weeks

YAG , yttrium-aluminum-garnet.


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.

Fig. 7.1

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). ,


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.

Overview of Ocular Injury Management

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.

  • 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.
    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.

Fig. 7.2

Mechanism of ocular damage by blunt trauma.

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


The eyelids should be assessed for any lacerations or limitation of lid movement or closure. Substantial lacerations typically require surgical repair, and a broad-spectrum topical antibiotic should be applied to prevent secondary infection if possible. Incomplete lid closure may necessitate treatment with ocular lubricants to prevent exposure keratitis until surgical lid repair can be performed. The lids should be specifically assessed for damage to cranial nerves III and VII, the levator muscle, the orbicularis muscle, and the lacrimal system. , A referral to an oculoplastic specialist may be indicated when lid involvement is substantial.

  • Sideline management: In the case of a superficial injury to the eyelid, gently apply direct pressure to stop the bleeding. Cleanse the wound and apply a sterile dressing taped in place or a bandage encircling head. Refer the athlete to an eye care professional for follow-up care of the injury. Mild lacerations sustained at a competition away from the athlete’s hometown may wait to receive medical treatment until the athlete returns home. The laceration should be bandaged and cleaned, with antibiotic coverage.

  • If a corneal abrasion is suspected or the pupil appears irregularly shaped, the athlete should immediately be referred to an ophthalmologist or optometrist. Place a protective pad or shield over the eye. Covering both eyes may be necessary to reduce bilateral eye movement. If the laceration crosses the margin of the lid, suturing by an eye expert is necessary. Lid deformities (ectropion) from scarring may result if the athlete does not receive proper care. Laceration of the upper or lower lacrimal canaliculi (tear duct) also requires suturing by an ophthalmologist. If the tear duct is not repaired, the patient may have permanent epiphora (watering of the eye).

Orbital contents

The athlete may sustain orbital hemorrhaging, leading to ecchymosis, proptosis, and extraocular muscle (EOM) abnormalities. , A simple black eye should be examined as if the eye had sustained serious trauma until proven otherwise. Hematomas can have many ocular sequelae, necessitating a thorough internal health evaluation and assessment of intraocular pressure. Visual acuity, color vision, pupillary responses, and intraocular pressure should be carefully assessed. Additionally, severe proptosis can compromise the function of the optic nerve and retinal vasculature, requiring rapid diagnosis to determine whether orbital decompression or corticosteroid treatment is necessary. Many orbital hemorrhages completely resolve with no direct treatment, but closely monitoring the athlete throughout the recovery period is prudent.

Any head trauma can result in direct damage to the EOMs or cranial nerves III, IV, or VI. The practitioner needs to determine if the muscle abnormality is caused by hemorrhage or edema around the muscle or direct damage such as a muscle tear or disinsertion. Orbital fractures may also entrap EOMs and directly affect muscle function. These direct causes of muscle damage usually produce symptoms of pain, diplopia, and gaze restrictions. , If the damage has occurred to the cranial nerves, the patient will report the same symptoms but is less likely to report any pain. Cranial nerve damage is a sign of significant closed-head trauma or compression of an expanding intracranial hematoma and should immediately be treated.

Differential diagnosis for concomitancy of EOM function is achieved with version testing, alternate cover testing in the diagnostic action fields, Hess-Lancaster test, red lens or Maddox rod testing in the diagnostic action fields, or the Park three-step test. The diagnostic action fields are the gaze positions where the individual action of each EOM is isolated ( Table 7.4 ). Passive and forced duction testing can help determine if mechanical damage of the muscle(s) has occurred or if the damage occurred in the innervation from the cranial nerves. , Management of EOM abnormalities includes monitoring for spontaneous resolution, prism prescriptions, occlusion (usually partial occlusion in the affected field), orthoptic vision therapy to assist recovery of muscle function, botulinum toxin therapy, and surgical interventions.

  • Sideline management: The presence of a black eye is a cue to evaluate the eye and face further, with subsequent referral of the patient to an eye care professional. An orbital hemorrhage may present with proptosis (eyeball bulging) and decreased EOM motility. Furthermore, visual loss may occur as a result of a compromised vascular supply to the retina and optic nerve. Immediate management includes application of an ice pack and referral to an eye care professional.

Table 7.4

Diagnostic Action Fields of Extraocular Muscles.

Eye Position Right Eye Left Eye
Right gaze Lateral rectus Medial rectus
Left gaze Medial rectus Lateral rectus
25 degrees right gaze and up Superior rectus Inferior oblique
25 degrees left gaze and up Inferior oblique Superior rectus
25 degrees right gaze and down Inferior rectus Superior oblique
25 degrees left gaze and down Superior oblique Inferior rectus

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. ,

Fig. 7.3

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

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

Fig. 7.4

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.

  • 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.

  • 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.

Zygomatic fractures

A fracture of the zygomatic bone usually occurs from a powerful force directed at the cheek or from a fall. Signs of a possible zygomatic bone fracture include epistaxis, periorbital ecchymosis, numbness about the cheek, enophthalmos, restriction of upward gaze and diplopia, subconjunctival hemorrhage, a depressed cheekbone, and inability to open the mouth. , Concomitant injury to the infraorbital nerve will cause hypesthesia or anesthesia of the ipsilateral upper lip, lower eyelid, lateral nose, and medial cheek. Palpation of the area often reveals a bony discrepancy or step-off deformity. If a fracture is suspected apply ice to control edema and immediately refer the patient to a physician.

As with other fractures, healing will take a minimum of 6–8 weeks. The athlete should wear protective face equipment or eyewear when returning to sport.

Frontal bone fracture

A frontal bone fracture can occur from a severe blow to the supraorbital region. An example of a potential mechanism for this type of injury is two heads colliding during a soccer match. A visible or palpable depression superior to the frontal sinus should cue the sports medicine specialist to a possible fracture. Crepitus or depression in the frontal sinus may be noted, as well as numbness in the supraorbital region. Immediate management by a physician is necessary.

Conjunctival and Scleral injuries

Fingers commonly cause damage to the conjunctival tissue in contact sports. A simple subconjunctival hemorrhage often is the sole result of such contact, and the condition self-resolves with no long-term consequences. However, determination of whether more extensive scleral lacerations or ruptures may be hidden by the blood and chemosis is important. Small scleral lacerations may be managed with a prophylactic broad-spectrum antibiotic ointment, whereas larger lacerations may require suturing. Examination of the athlete should entail a thorough assessment of the internal structures that may also have sustained damage, including Seidel testing with fluorescein to determine if a rupture or penetrating injury has occurred. Fluorescein leakage near the injury site indicates a rupture or penetrating wound, and a surgical consultation is warranted. The limbus region and EOM insertion areas are most prone to scleral rupture, and previous eye injuries or surgeries make the globe more vulnerable.

  • Sideline management: A subconjunctival hemorrhage will present as a bright red region within the white conjunctiva. The “red eye” may make this form of injury appear serious in nature, but in many cases, this form of hemorrhage will not require medical attention. However, a subconjunctival hemorrhage often accompanies a contusion or corneal abrasion, so if visual impairments, photophobia, or extensive hemorrhaging is apparent, then the athlete should be referred to an eye care specialist.

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.

Fig. 7.5

(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.

Fig. 7.6

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.

  • 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.

    Fig. 7.7

    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.

  • 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.

Fig. 7.8

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.

Oct 30, 2021 | Posted by in OPHTHALMOLOGY | Comments Off on Management of Sport-Related Ocular Injuries and Concussion

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