Treating athletes can create unique challenges for ophthalmologists

Eye doctors should be aware of the categories of injury and know how to treat this special subset of higher-risk patients.

With a higher risk for ocular injury than the average patient and a tendency to expect faster recovery, athletes can pose a unique challenge for ophthalmologists.

Ocular Surgery News spoke to ophthalmologists who have studied and treated athletes to discover what ophthalmologists need to know when approaching these patients.

“Don’t fool yourself into thinking that you’re going to be treating this patient like a normal patient,” said Rolando Toyos, MD, who is the team ophthalmologist for the Memphis Grizzlies of the National Basketball Association. “These people who are playing sports are different. They are very competitive. Whether it’s the 11-year-old playing Little League Baseball or the 28-year-old playing Major League Baseball, they all have that same mindset that they don’t want to accept injury. They want to play through injury, and you have to be their advocate and emphasize what is going on.”

Prevalence

According to the United States Eye Injury Registry, 13% of serious eye injuries occur during sports-related activities. Sharon M. Napier, MD, and colleagues concluded that nearly 25% of reported cases of visual impairment resulting from trauma are due to sports and other recreational activities, and one-third of ocular sports injuries occur in the pediatric population.

In 2000, the U.S. Consumer Product Safety Commission reported that there were more than 42,000 sports-related injuries. Of those, 72% occurred in people younger than 25, 43% were younger than 15 and 8% in children younger than 5.

In addition, a study conducted by Adrian M. Lavina, MD, and colleagues showed that 30% of eye injuries in children younger than 16 are sports-related.

Understanding injury types

Although the types of injuries sustained in sports-related activities are not exclusive to athletes, ophthalmologists should be aware of the most common athletic injuries, how they occur and how to treat them.

Dr. Lavina said a physician must first understand the mechanism of injury and whether it is blunt, penetrating or radiating.

“The mechanism of injury is important,” he said. “Sometimes if they’re hit hard in the forehead, there could be not much outward trauma, but they could have a traumatic optic neuropathy and that can be found with a pupillary exam or visual acuity.”

With blunt trauma, which his study showed is the most common type, the extent of damage depends on the size, hardness and velocity of the blunt object and the force exerted directly to the eye. Possible blunt trauma outcomes can be caused by anteroposterior compression and dilation of the middle of the globe, fracture of thin bones and a rupturing of the globe.

Externally, a physician might observe orbital blowout fracture or contusions of the orbit and lid. Internally, the athlete could suffer from iris injury, traumatic iritis, subconjunctival hemorrhage, hyphema, retinal hemorrhage, commotio retinae, vitreous hemorrhage, choroidal rupture, retinal tears or retinal detachment.

Athletes are also at risk for penetrating injuries to the eye such as scleral lacerations, also known as a ruptured globe. Fishing is considered a competitive sport, and fishing hooks could lodge in one’s eye.

“Look at basketball, the most common injury is corneal abrasions,” Dr. Toyos said. “[Players] get traumatic hyphemas, just from elbows coming and flying into the eye, orbital fractures from elbows flying into the bone of the eye and causing fractures.”

Dr. Toyos also discussed the injuries incurred by other sports.

“Hockey players are also susceptible to eye injuries,” he said. “They too get a lot of orbital fractures, a lot of traumatic hyphemas.

“Football players often get fingers to the eye, especially when they get into pileups,” he added. “When you get into baseball, the most common thing is pitchers hitting batters in the head,” causing orbital fractures or traumatic hyphema.

Although many of these injuries can be prevented with protective eye wear, most athletes still refuse to wear helmets or goggles for fear of hindering their performance. Yet, Dr. Lavina warned that some injuries can appear well after the injury occurs and that any injury can leave an athlete susceptible to future complications.

“You can have a retinal tear or detachment, and you cannot diagnose that on the field. Some of the symptoms, things like floaters and decreased vision, can really happen any time,” he said. “It can be anywhere from days to weeks to even years.”

Dr. Lavina added, “Once the eye has significant trauma, whether it be [through] sports or not, there can be some predisposition to [lifelong] problems in the eye … like glaucoma and retinal detachment.”

On and off the field

Following a strict protocol can help an ophthalmologist or general practitioner accurately identify ocular trauma and to know what steps to take.

“The first is to recognize it and see if there’s any need for a referral outside of the field. Those need to be evaluated by an ophthalmologist and then appropriate care coordinated afterward,” Dr. Lavina said. “You’d want to do at least a basic eye exam on the field, consisting of visual acuity, eye movements, external exam, to see if there’s any swelling or tenderness around the orbit and then the examination of the pupils.”

In their study, Dr. Lavina and his colleagues suggested some steps for proper treatment on the field.

Take an adequate history of the injury, including the mechanism of injury. Check visual acuity and confrontation visual fields.

Then, examine the pupils with a bright light source, checking for unequal pupil size and relative afferent pupillary defect. The study suggested that pupil irregularity is almost always pathologic, pointing toward a foreign body, hyphema, abrasions or lacerations.

Examining the motility of the eyes could reveal an orbital floor fracture, and double vision in any gaze position could mean significant injury in one or both eyes.

“You want to make sure that there are no signs of a ruptured globe,” Dr. Lavina said. “That needs urgent surgical intervention.”

If, in this process, the physician notices darkly pigmented uveal tissue, subconjunctival hemorrhage, a deep or shallow anterior or a conjunctival laceration, he or she should consider the possibility of a globe rupture. If that is the suspected cause, the eye should no longer be manipulated.

For the outer examination, one should look for periorbital ecchymosis, edema and proptosis. The researchers said pain when opening the mouth could indicate fractures of the lateral wall of the orbit.

Lastly, they said the athlete needs a funduscopic examination to evaluate the red reflex and detect any bleeding into the ocular media.

“You’re not realistically going to be able to do a complete exam of the back of the eye on the field,” Dr. Lavina said, although ophthalmologists who care for professional teams sometimes have the necessary equipment.

Dr. Toyos agreed, saying each team in each sport handles its ocular injuries differently.

In the case of an eye injury, Dr. Toyos said, “The trainer will take the player back, and essentially I’m right there. If he thinks it’s something that needs to be seen, he’ll call me into the training room and we’ll take care of it.”

Returning to the field

Rolando Toyos, MD, pitched at the Memphis Redbirds stadium that houses the St. Louis Cardinals’ AAA team during the annual baseball game for supporters of the team. Radio and TV personalities, company presidents, team doctors and local celebrities play in this annual event. Image: Toyos R

After injury, athletic patients should always undergo a full examination and obtain clearance from the ophthalmologist before returning to play.

Before the patient resumes his or her activities, the injured eye should be comfortable and have adequately recovered vision. Eye protectors must be worn, Dr. Lavina and colleagues advised in their study.

Although it is not uncommon for athletes to be given topical anesthetics so they can return to their sport sooner, Dr. Lavina and colleagues say this should be done with extreme caution.

“Generally, for small abrasions, we do not give proparacaine,” Dr. Lavina said. “If it’s a small one, if the athlete is aware of it and is careful, it might be reasonable to get them through the game … with a drop of proparacaine. Sometimes that’s done, although it has to be done with great care.”

Dr. Toyos said this type of decision is often where the line is drawn between professional and amateur athletes, as well as other patients.

“A player got a scratch in his eye during an important game. This was early on in the game, and he couldn’t keep his eye open, and he was one of the starters on the team,” he said. “This is where you would treat an athlete differently than you would treat a regular patient.

“A regular patient, you put some ointment on his eye, put on a patch, dilate, cycloplegia his eye and say, ‘We’ll see you in the morning,’” Dr. Toyos said. “This athlete really wanted to get back out there to play, so I gave him some numbing drops and put a contact lens in so he could play.

“At the end of the game, he made an important three-point shot to win the game,” he said. “Then, after that we took the contact lens off, put the ointment in and patched him for the next morning.”

When athletes return to play with less than 20/40 vision in the weaker eye, they are considered monocular. These patients must wear eye protection that meets certain standards in all sports with risk of ocular injury, including face cages on hockey masks and goggles in baseball and basketball.

“One-eyed athletes really do need to wear protection all of the time,” Dr. Lavina said. “There are specialized helmets that are approved for each sport.”

Boxing, wrestling and other full-contact sports are contraindicated in monocular athletes because there is no adequate protection for the eyes.

What to emphasize

When an athlete wants to return to play too quickly, an ophthalmologist should appeal to his or her athletic sense. The physician can explain the problem, how to fix it and the long-term consequences if medical direction is not followed.

“You really have to be diligent and emphasize exactly what their problem is, how their problem is going to get better and what precautions they are going to have to take to get back on the playing field,” Dr. Toyos said.

He said an athlete might believe that he or she can still play, but not understand that any athletic activity may exacerbate the problem.

In the case of hyphema, for example, Dr. Toyos recommended being specific and saying: “You’re going to have to have bed rest. Keep your eye elevated. You’re not going to be able to practice for a while.

“They may not want to hear it, but you have to emphasize that,” he continued. “Say: ‘You could have the possibility that you’re going to cause some serious damage to your eye and your career if you don’t do X, Y and Z and, when you do come back [to the sport], since you’ve already had this problem, I suggest that you wear goggles, even though for some reason you don’t want to wear goggles. This is something that you’re going to have to do or you risk permanent damage to your eye and permanent damage to your career.’”

Drs. Lavina and Toyos emphasized the need for protection early on, even before injury, and the need to emphasize that again with athletes who have suffered an injury.

“I think in sports you have the opportunity to protect because you know you’re going to be going into something high-risk,” Dr. Lavina said. “In daily life, you don’t know if you’re going to get into a car accident.”

For more information:

• Rolando Toyos, MD, can be reached at Toyos Clinic, 569 Skyline Drive, Suite 200, Jackson, TN 383301; 731-660-3937; e-mail: rostar80@aol.com.
• Adrian M. Lavina, MD, can be reached at 3399 PGA Blvd., Suite 220, Palm Beach Gardens, FL 33410; 561-624-0099; e-mail: adrianlavina@yahoo.com.

• Katrina Altersitz is the Managing Editor of Ocular Surgery News Latin America and India Editions.

Ophthalmologist’s lobbying efforts for increased eye protection pay off by Katrina Altersitz Although many athletes resist ocular protection due to fears of a hindered performance, ophthalmologists insist that it is the best way to prevent injury in high-risk sports. Bernd Kutzscher, MD, began lobbying for eye protection when his daughters played lacrosse in high school more than 5 years ago. “At the time, my eldest daughter was playing lacrosse and, as a spectator, I started noticing that there were an amazing number of close misses, a lot of broken noses, and it was so obvious that this was a disaster waiting to happen,” he said. Ocular Surgery News interviewed Dr. Kutzscher about his lobbying efforts. The following are excerpts of this conversation. OSN: Were you successful in your efforts and how so? Dr. Kutzcher: It was a big effort. I got myself educated about it, and it became obvious that there was a need and then I started inquiring and made contact with a number of people in the national lacrosse groups. It turned out that this topic had been discussed and they were aware of the issues, but it’s such a traditional sport and there was such a tremendous amount of resistance to it. Unfortunately, at the time, there was really nothing reliable in the way of statistics. It was their impression, as an organization, that there wasn’t much of a risk involved, but no one had anything to hang their hats on. … There were a couple of people in the organization who were aware of some serious problems. Like many things, it also came down to some legal concerns. Both the American Academy of Ophthalmology and the American Academy of Pediatrics had actually already published recommendations, [which included] lacrosse. As I searched around, there were a number of serious incidents. There was an incident at the college level where a girl actually lost her vision in one eye from a lacrosse ball. At my local level, I couldn’t get anyone to budge, so I sat down with the president of the high school where my kids are and said, ‘I think you’re really putting the girls at risk, and you’re also putting the school at risk. … If anything happens, it’s going to be a serious problem.’ … Out here in California, the high school where my kids are is the powerhouse of lacrosse, and they unilaterally declared that goggles were mandatory. Then, the other schools in their league quickly came along. Within a year, U.S. lacrosse handed down an edict that both college and high school sanctioned lacrosse was going to require goggles, and it’s been that way ever since. … OSN: What response do you get from athletes when you express this concern? Dr. Kutzscher: [My children] said, ‘Please stay away from my lacrosse.’ They really favored it, but the problem was that no teenager is going to do this if the others don’t. Once it became the school rule, then it became easy for them, and they were very happy to participate. The players took a little bit of grief from the other schools, initially, because they were the only ones doing it. Some of them even objected on the grounds that it was not fair. Now, I think they’re actually rather proud of the fact that I was at least peripherally involved in helping push this through. … I guess what I learned is that if you actually do put your mind to it and put some effort into it, you can make a dent. Unfortunately, the dent that’s easiest to make is the legal argument, but that’s an important one if you actually want to get this pushed through. For more information: Bernd Kutzscher, MD, can be reached at Pacific Eye Specialists, St. Mary’s Medical Center, 2250 Hayes St., Suite 208, San Francisco, CA 94117; 415-387-8887; e-mail: eyemdbk@aol.com. Katrina Altersitz is Managing Editor of OSN Latin America and India Editions.