‘Extreme sport’ patients present specific set of visual needs

Addressing the refractive needs of athletes generally requires a customized approach, due to the increased demand for visual acuity, comfort and safety.

In the case of so-called “extreme sports” — those that feature a combination of speed, height and danger – the need for crisp vision and comfort is even more crucial, according to practitioners.

“Many practitioners believe that for these athletes who function in unusual environments, you can just reach up on the shelf, and any kind of contact lens will suffice,” said Vincent Zuccaro, OD, FAAO, optometrist for the San Jose Sharks hockey team. “But it doesn’t work that way.”

Altitude and LASIK

One sport with an especially “extreme” impact on the eyes is mountain climbing. Fred Edmunds, OD, FAAO, director of professional and clinical affairs for Bausch & Lomb, told Primary Care Optometry News that he has consulted with mountaineers and presented lectures on extreme sports and contact lenses. “How do you choose what would be best for these athletes?” he said. “Do you go with LASIK, do you with PRK or contact lenses, and how do you make that decision?”

The possibility of refractive shifts at high altitudes with LASIK, in particular, has been examined. Dr. Edmunds cited a study performed in December 2001. “Two practitioners who also were climbers both had LASIK performed within a few weeks of one another,” he said. “And a few weeks later they climbed to the top of Aconcagua.”

Aconcagua, located in Mendoza, Argentina, is the highest mountain in South America, at 22,841 feet. “After reaching the top of the mountain, the two climbers noticed a myopic shift,” Dr. Edmunds said.

According to the Journal of Cataract and Refractive Surgery, both climbers developed a moderate loss of distance uncorrected visual acuity but described normal near and pinhole acuity consistent with a myopic shift. The distance UCVA diminished to 20/100 in the right eye and 20/125 in the left eye of climber A and to 20/160 and 20/30, respectively, of climber B.

The vision loss worsened with increased altitude, duration of exposure and decreased peripheral oxygenation. One week after the climb, a small myopic shift was still apparent in both eyes of climber A; these subsequently resolved.

“It was a temporary shift. What happens is at a high altitude, the atmosphere becomes quite hypoxic,” Dr. Edmunds said. “The cornea doesn’t get as much oxygen as it would normally like, and it swells up a bit. When it swells up, the curvature changes slightly, perhaps more so in a freshly ablated cornea, and this brings about a slight myopic shift.”

The study’s conclusion states that “climbers who have LASIK, particularly those in the early postoperative period, should be prepared for visual acuity fluctuations with high-altitude exposure.”

Dr. Edmunds maintains that the climbers would have benefited from a longer postoperative recovery period prior to undertaking Aconcagua. “They thought they had gone up too early,” he said. “Their corneas had not fully equilibrated, had not fully recovered from these surgeries. They were only about 2 months out.”

Dr. Edmunds said LASIK patients should be advised to wait at least 3 to 6 months before attempting extreme sports such as mountain climbing. “If you haven’t taken enough time to heal properly, you may experience a myopic shift,” he said.

Other recommendations for climbers

Dr. Edmunds also suggested that LASIK should be performed on mountain climbers during the winter season.

“I would say that if you have a climber who is going to be doing some big altitude over the summer, don’t perform the procedure on them in May or June,” he said. “Do it in the downtime, over the winter, to make sure the cornea is equilibrated to its new shape.”

Dr. Edmunds also recommends continuous wear contact lenses for mountain climbers. “It’s basically vision on demand,” he said. “They don’t have to take the lens out during their expedition, so it essentially gives them the same benefits — or even more, potentially — than refractive surgery.”

He said a continuous wear silicone hydrogel lens would require a minimum of upkeep and no handling. “They can put these lenses in, they don’t have to touch them or take them out,” he said. “No cleaning is required. It would be a good idea for them to use drops, in morning and evening, but the less they handle these lenses the better, especially up at high altitudes.”

Dr. Edmunds said, in many ways, continuous wear lenses are ideal for climbers. “You don’t want people messing with their eyes, you don’t want them touching their lenses,” he said. “So continuous wear lenses for that application, especially with the excellent oxygen performance, are a godsend for climbers.”

Although Bausch & Lomb’s PureVision contact lens is currently not available in the United States, Dr. Edmunds said he has had great success with these lenses on mountain climbers in the past.

“When PureVision was on the market, a number of mountaineers were wearing them,” he said. “One of them climbed Mount Everest three times. The first time he climbed Everest in his PureVision lenses he called to say how great they were, and to thank us.”

Hockey players and vision

Dr. Zuccaro discussed the particular set of visual challenges facing professional hockey players. “Most people are not aware of what the environment is like for hockey players,” he told Primary Care Optometry News. “People assume that because they are playing on ice, it must be cold and wet. Actually, it is neither.”

According to Dr. Zuccaro, the humidity at ice level is the same as might be found in an airplane at 35,000 to 40,000 feet, causing the players’ eyes to become very dry. “The humidity is very low; they do that intentionally to keep the ice dry and hard,” he said. “Then you add insult to injury: here are players moving across the ice at speeds of up to 30 miles per hour. So the wind in the eye is a drying effect unto itself.”

Dr. Zuccaro maintains that athletes competing in sports such as hockey should have lenses that meet their specific visual needs. “We have the ability to produce products that are more stable on the eye for this kind of environment and dry out less than other lenses,” he said. “We also have products that meet the demand for higher vision.”

Dr. Zuccaro’s company, Optical Connection, has developed several contact lenses with hockey players and other athletes in mind. “The one lens we are most pleased with actually started with a goaltender named Jeff Hackett, who is now with the Philadelphia Flyers,” Dr. Zuccaro said. “He had a very high prescription with ordinary contact lenses, and in that dry environment, they were shriveling up on his eye.”

In addition, the lenses were not giving the player the kind of vision needed for a goaltender. As a result, Optical Connection developed a lens called Definition AC, which features “aberration control.”

The Definition AC is a soft contact lens with an optimized anterior ellipsoidal surface. When applied to the cornea, this lens reduces many of the higher-order aberrations along with the lower-order aberrations, according to Dr. Zuccaro.

“This lens has a surface that is less dehydrating, and the optics of the lens are excellent,” he said. “What we were looking for is a lens that provides sharp vision, decreases dryness and is immovable. All of these qualities can be found in this lens.”

An ongoing debate

While Dr. Zuccaro has treated many patients with LASIK who are professional athletes, he maintains that hockey may not be the ideal sport for this type of refractive surgery.

“Because the LASIK flap never entirely seals itself down as strongly as it was in the first place, the possibility of dislodging that flap is too serious a complication. Professional hockey players often suffer corneal injuries,” he said. “So for that kind of sport, I don’t recommend it. For others, such as football, it’s outstanding.”

Other practitioners recommend LASIK above other alternatives.

“If you believe in refractive surgery — and I do — I would think that for some of the extreme supports out there, it is better than contact lenses,” said Randall Fuerst, OD, a practitioner based in Citrus Heights, Calif. “It depends on a practitioner’s comfort level. But I would look at both and say that refractive surgery is still a good option over contact lenses.”

Another possibility for extreme sport athletes is called advanced surface ablation, according to Dr. Fuerst. Like PRK, this procedure does not include the cutting of a flap. “Basically, this is a glorified PRK,” he said. “But there are several techniques and several steps along the way that are different from PRK.”

Dr. Fuerst maintained, however, that refractive surgery, whether LASIK or other procedures, is still among the best available options. “The Navy is willing to have SEALs and fighter pilots undergo it,” he said. “I don’t have trouble recommending it over contact lenses.”

For Your Information:

• Vincent Zuccaro, OD, FAAO, is founder and president/CEO of Optical Connection. He can be reached at 3315 Almaden Expressway, San Jose, CA 95118; (408) 265-8644; fax: (408) 265-8639.
• Fred Edmunds, OD, FAAO, is director of professional and clinical affairs for Bausch & Lomb. He can be reached at 1400 N. Goodman St., Rochester, NY 14609; (585) 338-5190; fax: (585) 338-0273; e-mail: fedmunds@bausch.com. Dr. Edmunds has a direct financial interest in PureVision, LASIK and PRK equipment.
• Randall Fuerst, OD, is a practitioner based in Citrus Heights, Calif. He is also CEO of a nine-laser center chain, Pacific Laser Eye Centers. He can be reached at 5959 Greenback Lane #130, Citrus Heights, CA 95621; (916) 969-4141; fax: (916) 726-1822.