Ординатура / Офтальмология / Английские материалы / Sports Vision Vision Care for the Enhancement of Sports Performance_Erickson_2007

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Figure 6-2. Goggle-style sports eye protectors: Liberty MAXX frame with temples (A) and Liberty MAXX frame with straps (B). (Courtesy Liberty Optical/Rec Specs, Fairfield, NJ.)

racquetball, and squash mandate the use of appropriate protective eyewear during competition, and many athletic clubs have instituted eye protection requirements for club play.

Ice Hockey

In ice hockey the most common cause of eye injury is from the stick, followed by the puck or opponent.25,47,72-79 With the mandate for face protection in all levels of hockey except the National Hockey League, the incidence of eye injuries has significantly declined.80-84 No eye injuries have been reported with a full-face shield in use; however, significant trauma has been incurred with a half-face shield.84 It is an unfortunate situation that the National Hockey League has resisted issuing a mandate for face protection, and each season produces examples of the ocular effects of this decision. There are many styles of face protection approved for hockey by ASTM (F513 and F1587) and CSA (CAN3-Z262.2-M78) standards: full-face masks for goaltenders and full-face masks or half visors for other positions (Fig. 6-5). Because of the improved eye safety profile, full-face shields are recommended. The ASTM F803 standard is recommended for eye protection in field hockey.

Lacrosse

Lacrosse has risks for eye injury that are similar to hockey in that the stick and ball present significant hazards. Men’s lacrosse mandates head and face protectors, thereby minimizing the risk for ocular injury. Women’s lacrosse did not mandate face protection until recently, and the incidence and severity of eye injuries caused many to advocate for compulsory eye protection.25,85-90 The ASTM F803 standard is recommended for protection in women’s lacrosse, and wire mesh protectors are favored by the athletes (Fig. 6-6). The women’s lacrosse ball is shot at 45 mph at the eyewear during ASTM testing to determine effective

Swimming and Water Sports

Swimming and water sports also do not present a significant risk of eye injury. A study of ocular pathology prevalence in swimmers using goggles for at least 5 years compared with nonswimmers found no significant differences.109 The elastic band tension, however, can cause swim goggles to snap back and cause severe ocular injuries.25 Many swim goggles are commercially available, and many designs are available with prescription lenses.110,111 Most swimmers and divers use a goggle or face mask so that no adjustment is necessary to the habitual prescription to compensate for the difference in the index of refraction of the water medium.41 Some goggle designs have ventilation holes to reduce lens fogging in highly active water sports such as water skiing, surfing, windsurfing, and endurance swimming.111 A variety of dive masks also are available with prescription inserts or corrective lenses affixed to the face plate. The air space of the dive mask eliminates the need to change the habitual prescription; however, the increased vertex distance may necessitate an adjustment to the prescription. Water polo presents a risk of blunt trauma from fingers, elbows, or the ball to the improperly protected eye. Swim goggles for water polo should contain polycarbonate lenses to prevent lens breakage, particularly for goalkeepers, who are at a higher risk for facial injury from the ball.

Soccer

The soccer ball is responsible for most ocular trauma in soccer, although the incidence of eye injuries is relatively low.50,52,112-117 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.116,117 As previously mentioned, a work item for eye protection in soccer (WK1237) is under a committee for F803. Most practitioners recommend use of ASTM F803 standard eyewear for racquet sports with a secure strap for protection in soccer.

Other Sports

Eye protection may be desirable in many other sports and recreational activities, although no standards exist for those activities. Protective eyewear that meets the ASTM standard for squash (F803) often offers the best available protection for the athlete unless customfabricated protective eyewear can be acquired.

Issues with Protective Eyewear

Some of the common issues causing athletes to be resistant to using protective eyewear are eyewear discomfort, adjustment to wearing eyewear, lens fogging, poor vision (especially visual field constriction), cosmetic appearance, and the perception that it is unnecessary. Athletes who do not habitually wear a spectacle prescription have more difficulty adjusting to wearing eyewear. Adjustment can occur quickly if the eyewear is worn for an extended time period (e.g., several hours continuously), and this should be done outside the sport situation to minimize athlete stress during adaptation. This eyewear adaptation training should also help the athlete adjust to the change in peripheral visual field size that may be induced by the frame.

Early studies found that sports protective eyewear constricted the peripheral visual field.118-120 The constricted visual field was perceived by 12.5% of subjects using racquetball protectors118 and was reported to affect visual reaction time (especially with flat lens design eyewear).120 A study of several types of protective eyewear found that all restricted peripheral

vision to some degree but that the restriction did not affect a peripheral reaction task.119 Some fairly recent studies did not find that sports eye protectors constricted visual fields,121,122 whereas a comparison of hockey visor and sports goggles did find field restrictions but no effect on visual acuity, contrast sensitivity, color vision, or foveal threshold.123 The decision to wear eye protection becomes a balance between the cost to peripheral vision versus the risk of vision loss.

For highly active sports in humid conditions, problems with eyewear fogging can occur. All approved protective eyewear has an antifog coating on the lenses, and additional antifog solutions are available for supplemental use. Athletes should remove the eyewear when not actively participating in the sport to prevent the rising body heat from condensing on the lenses.59

Many athletes are concerned about cosmetic appearance, and protective eyewear is not typically appealing to the athlete. Fortunately, protective eyewear has evolved into more fashionable designs and has earned greater acceptability in some sports. There will always be athletes and sports in which a prevailing attitude of machismo impedes the use of appropriate eye protection.

Squash is a sport with a significant risk for eye injury and has received the attention of several studies to determine the issues related to the low rates of protective eyewear use in the sport. Many players believe that prescription dress eyewear offers adequate protection,65-67 and lensless eye guards continue to be sold as protection.61 Of those who do not wear any eyewear during squash, most believed that protective eyewear was unnecessary because of inadequate knowledge of the risks.66,67,124 The misperception that experience and expertise reduce the risk for eye injury in squash also exists124; in fact, the amount of time playing squash and the increased speeds encountered at higher levels of play actually increase the risk for injury.62,125 Some squash players were concerned with poor vision and comfort45; however, studies suggest that education regarding injury risk and prevention is an effective motivator to increase eye protection use (especially because a previous eye injury increases

utilization).61,64,66-68,123,124,126-128

Functionally Monocular Athletes

Some athletes would like to compete in sports but have some level of loss of function in one eye. Best-corrected visual acuity less than 20/40 (6/12) often is used to determine loss of visual function because this level of impairment begins to affect academic and occupational performance, as well as driving privileges. A study of children with an enucleated eye found good compliance with protective eyewear use in sports and that subsequent eye injury to the remaining eye had been successfully averted.35 In the functionally monocular athlete, the main risk is for severe injury to the better eye. The presence of amblyopia increases the risk of blindness by more than 150% in children (1.75/1000 compared with 0.11/1000), and trauma (including sports trauma) accounts for more than 50% of the resulting blindness.129

One-eyed athletes should use protective eyewear that meets relevant standards for participation in all sports activities.33 These same athletes should wear well-built dress eyewear frames containing polycarbonate or Trivex lenses for nonsport activities. Functionally monocular athletes should be discouraged from participating in sports with a risk for serious eye injury in which an effective method of eye protection does not exist, such as boxing, wrestling, and martial arts.33,129a

Athletes who have had eye trauma or eye surgery that has resulted in a weakening of the ocular tissues should be counseled about the risk of eye trauma in sports. Recommendations

for eye protection in sports and recreational activities are similar to those for the one-eyed athlete.21 Specifically, athletes who have undergone radial keratotomy should be adequately counseled because the procedure significantly weakens the corneal integrity.25

Clinicolegal Issues for Protective Eyewear

Eye care providers are in a position that requires appropriate patient counseling regarding eye injury risks and suitable prevention measures. All prescribed or recommended ophthalmic materials are potential sources of legal liability. Legal liability claims can be based on either practitioner negligence or product-based liability resulting from problems with the lenses or frames.130-133 Plano eyewear and plano sun eyewear can also be a source of potential liability for the practitioner if proper counseling is not provided. Contact lens patients also need appropriate counseling regarding supplemental eye protection during sports and recreational activities.134

Good patient counseling begins with a thorough patient history to determine the specific needs and risk profile for the individual. A lack of knowledge regarding a patient’s sports participation does not protect a practitioner in a liability case if an attempt to elicit that information was not made. Any eyewear recommendations must be made with a thorough knowledge of how that eyewear will be used.

A claim of professional negligence is particularly troubling for a practitioner. Negligence claims involving sports and recreational eyewear typically stem from failure to prescribe the appropriate lens material, failure to warn of potential for breakage (especially with non–impact-resistant materials), or failure to inspect and verify the eyewear before dispensing.130,132 Industry standards play an important role in determining legal liability, and practitioners are expected to understand and comply with those standards. As previously mentioned, polycarbonate or Trivex lenses offer increased impact resistance compared with glass or CR-39; therefore these materials clearly are the recommended choice.13-17 The lens material preference should be clearly stated on the prescription provided to the patient; if the patient refuses the recommended lens material, that fact should be adequately documented in the patient record and the patient should be warned of the diminished impact resistance of the alternate material. The impact resistance of a lens material should be discussed without using the words shatterproof or unbreakable, because even polycarbonate material shatters if hit with sufficient force.130 If a practitioner offers ophthalmic dispensing services, the ancillary personnel responsible for verification and dispensing should be properly educated regarding the industry standards. The lenses should be inspected to ensure that the impact resistance is not compromised by surface treatments17 or improper edging.130

Eye care practitioners also are obligated to counsel the patient on suitable frames for sports and recreational activities. The frames should meet any prevailing ASTM performance standards, and the practitioner and dispensing personnel must understand the proper uses for the eyewear and any liability issues. For example, claims have resulted from the recommendation of lensless eye guards for racquetball.131,135 If a patient selects a frame that is not suitable for protection, that fact should be adequately documented in the patient record and the patient should be warned of the diminished impact resistance of both the frame and the lenses (because the frame may not adequately prevent the lenses from displacing back into the eye on impact).