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

supplement current strength and conditioning programs. Eye injuries may also occur in other nonsport recreational pursuits (e.g., paintball).38

Although the sports medicine professional may not be directly involved in the immediate management of any sustained injuries, he or she should recognize that athletes may participate in these sports despite requests from coaches otherwise.

The athletic trainer can serve two important roles to help reduce the risk of eye injuries from nontraditional sports. First, the trainer should work to foster a trusting relationship with the athletes he or she serves. If the athlete believes that he or she can openly share and consult with the athletic trainer without the potential for negative repercussions, then the trainer will be able to educate the athlete about risk behaviors and risk-reduction strategies. Many eye injuries can be prevented if protective eyewear is worn.38 The athletic trainer often serves as the initial medical team member and sometimes the only health care provider with whom the athlete has contact. Recognition and appropriate referral comprise the second role the athletic trainer serves.

CLINICAL MANAGEMENT OF SPORTS OCULAR INJURIES

The eye care practitioner may see athletes for initial triage and management of sports and recreational eye injuries and therefore follow some of the recommendations previously described. Many reports have been published regarding the incidence of eye injuries occurring during sports and recreational activities.1,4,7,39-67 The athlete may not present immediately for health 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. In any case, 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, methodical 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.68,69

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 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 function and determine whether 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.70 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.69 This chapter considers the cause of the injury—blunt trauma, penetrating trauma, or chemical trauma— following brief descriptions of common eye injury mechanisms by sport.

The U.S. Consumer Product Safety Commission created the National Electronic Injury Surveillance system (NEISS) to monitor the incidence of injuries from consumer products, including eye injuries. Currently 100 emergency departments at hospitals of various sizes and geographic locations, including children’s hospitals, participate in the reporting system. The injury rate data from these emergency departments are extrapolated to generate estimates of eye injuries by cause, and the online database is searchable by a variety of factors.71 Table 7-2 shows the data retrieved for 2004 by sport category. An estimated 15,358 sportsand recreation-related eye injuries occurred in the United States in 2004, although this 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 NEISS data estimate, because many athletes seek care outside hospitals, if care is sought at all.62

Sports

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 sports-related eye injuries in children.7,39,58,59,65 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.36 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.64 Similar patterns of eye injury can be found in cricket.64,72,73 The incidence of eye injuries with softballs is not well known.65 The softness of

TABLE 7-2 Summary of NEISS Data on Sports and Recreational Eye Injury Reports (2004)

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

Swimming and Water Sports

Swimming and water sports do not present a significant risk of eye injury. 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.65 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).65,155

Paintball

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.156-164

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.64-67,70,165,166 Blunt trauma to the head can also result in damage to the visual pathway.25,65 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).70,167-169 Ocular damage may also result from the compression forces exerted when the orbital contents are compacted within the bony orbit.64,70 In ocular compression injuries, the globe is compressed along the anterior-posterior direction and must compensate by expanding equatorially or rupture (Fig. 7-10). 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.

Eyelids

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

Figure 7-10. Mechanism of ocular damage by blunt trauma. (Reprinted from Kanski JJ: Clinical ophthalmology, ed 5, Boston, 2003,

Butterworth-Heinemann.)

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.25,170 A referral to an oculoplastic specialist may be indicated when lid involvement is substantial.

Orbital Contents

The athlete may sustain orbital hemorrhaging, leading to ecchymosis, proptosis, and extraocular muscle abnormalities.165,166 A simple black eye should be examined as if the eye had sustained serious trauma until proven otherwise.67 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. In addition, 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 extraocular muscles (EOMs) or cranial nerves III, IV, or VI. The practitioner needs to determine whether 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 extraocular muscles and directly affect muscle function. These direct causes of muscle damage usually produce symptoms of pain, diplopia, and gaze restrictions.25,170 If the damage has occurred to the cranial nerves, the patient will report the same symptom, 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.67

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.171-173 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 whether mechanical damage of the muscle(s) has occurred or whether the damage occurred in the innervation from the cranial nerves.174,175 Management of EOM abnormalities includes monitoring for spontaneous resolution,

TABLE 7-4171 Diagnostic Action Fields of Extraocular Muscles

prism prescriptions, occlusion (usually partial occlusion in the affected field), orthoptic vision therapy to assist recovery of muscle function, botulinum toxin therapy,176-178 and surgical interventions.

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.25,64,165,166,170 Lang179 was the first to postulate the mechanism for what would later be referred to as a blowout fracture.180 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.165,170 Medial wall fractures may also cause orbital emphysema from air forced into the orbit from the nasal sinuses (Fig. 7-11), 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. 7-12) and often produce pain, EOM restrictions, and eventual enophthalmos (see Fig. 7-1). Significant fractures necessitate surgical interventions to minimize enophthalmos and EOM restrictions.165,170

Jones181 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.

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.166 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 whether a rupture or penetrating injury has occurred. Fluorescein leakage near the injury site indicates a rupture of penetrating wound,182 and a surgical consultation is warranted. The limbus region and EOM insertion areas are most prone to scleral rupture,70 and previous eye injuries or surgeries make the globe more vulnerable.67

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