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

as well as costing the athlete valuable practice or game time. Tearing by the athlete may help remove the object. 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. 7-2). 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 (see Table 7-1).

Superficial Injury to the Eyelid

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 the head. Refer the athlete to an eye care professional for follow-up care of the injury.

Burns

In the event of a chemical burn, do not attempt to neutralize acids or alkalis. In addition, do not use an eyecup or bandage the eye. Chemical burns are initially treated by irrigating the eye for 30 minutes with sterile eye solution or water while the lids are kept opened, making sure the chemical does not wash into the other eye (see Table 7-1). A burn caused by a strong base (e.g., drain cleaner, lime) or acid (e.g., battery acid) is treated by irrigating the eye for 30 minutes with sterile eye solution while the lids are kept opened. The athlete should also be immediately referred to an eye care professional.

Ultraviolet burns occur most often in outdoor water or snow sports. Although sports medicine professionals are not traditionally present in these venues, the athlete should be referred to an eye care professional the day the injury occurs.

Recognition of Specific Eye and Facial Injuries

Facial Fractures

Trauma to the head and face can result in severe, emergent injuries. The sports medicine specialist must be able to identify signs consistent with a facial fracture and immediately remove the athlete from sport. Failure to do so may lead to further injury, including damage to the eye.

As with any head trauma, the patient should immediately be evaluated for potentially life-threatening injuries. Life-threatening injuries take precedence over all other injuries. Once the injuries have been determined to be non–life-threatening, the sports medicine specialist should rule out the presence of an MTBI.

During the secondary survey the sports medicine professional collects information from the athlete regarding symptoms, determines the mechanism of injury, examines the athlete, makes an assessment, treats, and makes the appropriate referral.

If a fracture is suspected, the athlete should be removed from play immediately. Failure to do so may lead to further injury, including damaging the eye. Immediate treatment should include gentle application of a cold compress or ice pack to the injured region to control pain and swelling. If a nosebleed accompanies a fracture, apply digital pressure to control the bleeding. All suspected fractures must be referred to an emergency department for immediate medical attention.

Nasal Fractures

The nose is the most frequently fractured facial bone.23 These fractures occur during collision or fighting sports. An errant elbow during a basketball rebound or a punch thrown during a boxing match can cause a nasal fracture. As many as 15% of nasal fractures are recurring, plaguing the athlete and potentially leading to functional breathing difficulties and changes in cosmetic appearance.23 Nasal fractures usually occur from either a lateral or an anteriorly directed force.23,24

An athlete with a possible nasal fracture will have the following signs: epistaxis, swelling, crepitus and mobility of the nasal bones, bruising around the eyes, and deformity.23,24 Immediate management by the athletic trainer should include controlling the nosebleed with digital pressure to the anterior nose and applying ice to decrease pain and swelling. Nasal fractures will likely be obvious and should immediately be referred to a medical doctor. Any athlete returning to contact sports after a nasal injury should use a protective facial device to reduce the risk of reinjury.

Orbital Fractures

The frontal, zygomatic, nasal, and maxilla bones form the orbital rim. This bony orbit houses and protects the eye. The orbit helps spare the eye from injury from blows caused by large objects such as a basketball. Impact from a smaller object, such as a baseball or an elbow, could potentially fracture any region of the orbital rim. Although a fracture can occur anywhere along the orbital rim, fractures to the inferior rim are the most common (Fig. 7-3).23 Orbital fractures are classified as either internal (orbital wall) or external (orbital rim).25,26 A blowout fracture and medial wall fracture of the orbit are examples of an internal fracture.25 External fractures occur at the orbital rim superiorly and laterally.25

An external or orbital rim fracture is usually caused by a direct blow27,28; the internal or orbital wall fracture is caused by trauma to the eye.26 When an object, such as a baseball, strikes the eye, the eye deforms and a subsequent increase in intraorbital pressure may occur. An increase in pressure may lead to fracturing of the inferior orbit or orbital floor. This fracture, known as a blowout fracture, can entrap the inferior rectus muscle, preventing concentric gaze, and result in double vision (see Fig. 7-1). The athlete will report pain at the site of injury and with movement of the eye. Visual inspection reveals hyphema, swelling, numbness of the ipsilateral cheek, a protruding or a sunken eye, vertical dystopia, and periorbital hematoma.23,24,29

Figure 7-3. Mechanism of an orbital floor blowout fracture. (Reprinted from Kanski JJ: Clinical ophthalmology, ed 5, Boston, 2003,

Butterworth-Heinemann.)

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.26 The mechanism of injury was either a digital poke or a blunt facial trauma.26 To highlight the seriousness of orbital fractures, 15 of the 19 cases reviewed required surgical reconstruction.26 Two of the football players were unable to return to football because of residual visual impairment.26

Protective eyewear or a protective facial device should be used when returning to sport after an eye injury. Many injuries of this type can be prevented by appropriate sport-specific protective eyewear. Any athlete who sustains a significant blow to the bridge of the nose also should refrain from blowing the nose until normal eye movements are restored. If an inferior orbital fracture has occurred, blowing the nose may cause the maxillary sinus to enter the orbit.

Zygomatic Fractures

A fracture of the zygomatic bone usually occurs from a powerful force directed at the cheek or from a fall.24 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 an inability to open the mouth.23,24 Concomitant injury to the infraorbital nerve will cause hypesthesia or anesthesia of the ipsilateral upper lip, lower eyelid, lateral nose, and medial cheek.24 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 to 8 weeks. The athlete should wear protective face equipment or eyewear when returning to sport.23

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.30 A visible or palpable depression superior to the frontal sinus should cue the sports medicine specialist to a possible fracture.30 Crepitus or depression in the frontal sinus may be noted, as well as numbness in the supraorbital region.29 Immediate management by a physician is necessary.

Eye Trauma

Blunt trauma to the eye can result in minor to severe injuries. Athletes most often at risk for blunt trauma injuries play collision team sports or sports involving projectiles moving at high velocities. For example, basketball players may sustain blunt trauma to the eye while playing in the key. With the physical play that occurs in the post, both offensive and defensive players are susceptible to a finger poke in the eye or an errant elbow striking the orbit. Baseball players and those playing racquet sports are susceptible to direct trauma caused by fast-moving balls. Even balls larger than the bony orbit can cause significant injury. Laboratory experiments confirm that a soccer ball can deform on impact with the face, creating a “knuckle” of the ball that can enter the orbit and strike the globe (Fig. 7-4).31,32

Figure 7-4. 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 to 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 to 10 ms) produces a secondary suction effect on the orbital contents.

A secondary suction effect is produced on the eye during the rebound. This suctioning potentially explains why eye injuries sustained in soccer are often more severe than other sports-related eye injuries.31,32

Corneal Injuries

Corneal abrasions frequently occur in sports such as basketball, in which a finger or fingernail can scratch the eye. The cornea also may be abraded when an athlete attempts to remove or rub away a foreign object. Common signs of an abraded cornea include watering of the eye, pain, and photophobia.16 Athletes may report pain with each blink of the eyelid.

Immediate management by the sports medicine specialist includes removing any readily visible foreign bodies (see Table 7-1), 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. Primary providers usually handle small abrasions, whereas larger abrasions require referral to an eye care specialist.16

A less-common corneal injury is an alkali burn caused by contact with chalk line markings. The eye should be irrigated with sterile saline or water for at least 20 minutes and the athlete then referred for medical attention (see Table 7-1).

Removing Contact Lenses. Many individuals forgo the use of glasses and instead use contact lenses to correct visual limitations. Contact lenses should never be used as a form of protective eyewear. The National Collegiate Athletic Association recommends the use of eye protection for all athletes participating in collision and contact sports who use corrective lenses.33 Nonetheless, many will go without appropriate protective wear when wearing contact lenses. Contact lenses should be removed from the eye in the case of minor injuries such as a corneal abrasion.16 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.

Hyphema

A hyphema is a collection of blood within the anterior chamber of the eye (Fig. 7-5). A hyphema can be caused by a tear of the iris, stroma, or ciliary body.25,34 A hyphema occurs in more than 25% of all sport-related eye injuries. Signs of a hyphema include a reddish tinge in the anterior chamber initially after the injury. Visual acuity may be affected with a large bleed. Within a few hours the blood will settle in the inferior eye or fill the

Figure 7-5. Traumatic hyphema (magnified view) with blood pooled in lower portion of the anterior chamber. (Reprinted

from Palay DA, Krachmer JH: Primary care ophthalmology, ed 2, St Louis, 2005, Mosby.)

entire chamber.35 A hyphema is a serious eye injury that requires immediate medical management. Continued bleeding may lead to uncontrollable glaucoma or staining of the cornea.25

The sports medicine professional should recognize the signs of a hyphema and immediately refer the athlete to an optometrist or ophthalmologist.36 The patient should be transported to the emergency department in a sitting or upright position.16 The athletic trainer should advise the family to avoid giving aspirin or other antiinflammatory medication, which may increase the bleeding.

Rupture of the Globe

Blunt trauma to the eye by a small object such as a racquetball can create pressure intense enough to rupture the globe. In this type of injury, the athlete complains of double vision (diplopia), decreased visual acuity, and intense pain.35 Signs of a ruptured globe include leakage around the orbit and irregular pupils.35 Immediately refer the athlete to the emergency department.

Retinal Injury

Hemorrhaging of the retina can occur as a result of a direct blow to the eye, blow or trauma to the back of the head, or a Valsalva maneuver when weightlifting. Peripheral hemorrhaging will likely be asymptomatic, whereas central hemorrhaging causes blurred vision. Athletes who have sustained a concussion should be evaluated for retinal hemorrhaging.

Orbital Hemorrhage

An orbital hemorrhage may present with proptosis (eyeball bulging) and decreased extraocular motility.37 Furthermore, visual loss may occur as a result of a compromised vascular supply to the retina and optic nerve.37 Immediate management includes application of an ice pack and referral to an eye care professional.

Periorbital Contusion

A “black eye” occurs from a rupturing of small blood vessels in the subcutaneous tissue of the eyelid.26 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.

Detached Retina

Retinal detachment is a painless injury caused by blunt trauma to the eye.35 Individuals with myopia are predisposed to retinal detachments.26 The athlete may describe the symptoms as “a curtain falling in front of the eye” or as lights “flashing on and off.”26,35 The athlete may also see black specks floating across the eye. A detached retina is a serious eye injury requiring immediate referral to a physician. The athletic trainer should use a protective eye shield or the base of a paper cup to cover the eye.

Conjunctivitis

An irritant such as dirt, a contact lens, or dust may lead to inflammation of the conjunctiva. The athlete will report pain, swelling of the eyelids, tearing, some discharge, photophobia, and possibly altered vision. Removal of the irritant should rapidly improve symptoms.37

Conjunctivitis can also be caused by viral or bacterial infections, chemicals, or allergies.35 Athletes who experience eyelid swelling or discharge should be treated by an eye care specialist.

Subconjunctival Hemorrhage

A subconjunctival hemorrhage (SH) (Fig. 7-6) is a rupturing of tiny blood vessels within the conjunctiva. This type of hemorrhaging can occur from benign activities such as sneezing or coughing or by a traumatic event such as a blow to the eye. An SH often accompanies a contusion or corneal abrasion. An SH 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. If visual impairments,

Figure 7-6. Examples of subconjunctival hemorrhages. (Reprinted from Palay DA, Krachmer JH: Primary care ophthalmology, ed 2,

St Louis, 2005, Mosby.)