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

Figure 7-11. Subcutaneous emphysema in a patient with a medial orbital wall blowout fracture. (Reprinted from Kanski JJ:

Clinical ophthalmology, ed 5, Boston, 2003, Butterworth-Heinemann.)

unless Bowman’s layer has been involved. Injuries to Bowman’s layer increase the incidence of residual scarring, which can affect visual clarity. Athletes whose corneal injuries involved vegetative matter should be carefully monitored for subsequent fungal infections. Corneal lacerations (Fig. 7-13) that are large and not self-sealing require protection with a Fox shield and referral for surgical consultation.

Pressure patching has been the standard approach to management of corneal abrasions (Fig. 7-14); however, the reduction of oxygen to the epithelium and increased temperature produced by patching can retard healing and increase the risk of infection.166,183 The use of topical antibiotics and cycloplegics without patching may yield faster healing rates while improving patient comfort and protecting from secondary infection.184 Aggressive use of ocular lubricants can improve patient comfort and promote healing, especially the use of lubricant ointments at bedtime. Because of the significant pain associated with epithelial

Figure 7-14. Pressure patching to manage corneal abrasions. The examiner applies an eye pad to the closed eyelids, either lengthwise or folded in half (A). The examiner places a second patch lengthwise over the first patch (B). Finally the examiner secures the patches with tape placed from the center of the forehead to the angle of the jaw across the patched eye.

excellent management approach. The athlete should be encouraged to use rewetting drops frequently to maintain good ocular lubrication.

A particular problem with corneal injuries inflicted by fingernails is the chance of recurrent corneal erosions. Most epithelial injuries heal well, but 7% to 8% of injuries result in recurrent erosions.185,186 Management is designed to reestablish the adhesion complex between the epithelium and Bowman’s layer and includes sequential use of topical hyperosmotic agents, bandage contact lens wear, surgical debridement, stromal micropuncture, and excimer laser ablation.166,186-191

The forces generated in many fast ball and contact sports can result in ruptures to all layers of the cornea. Damage to Descemet’s membrane or the endothelium results in considerable corneal edema and possibly corneal blood staining. The corneal edema and blood staining typically resolve spontaneously; however, the disruption in the endothelial cell junctions can be permanent.70,192 Injuries with sufficient force to rupture the deeper corneal layers often result in damage to the adjoining sclera as well.193,194 Athletes who have had corneal refractive surgery may be at higher risk for ruptures and should be strongly counseled regarding the use of appropriate protective eyewear.

Anterior Chamber and Uvea

The pressure forces generated with blunt trauma in sports can result in damage to the iris or ciliary body tissues. Contusion pressure forces the cornea, iris-lens diaphragm, and ciliary body to rapidly expand posteriorly and circumferentially.64,166,195,196 The resulting damage can lead to anterior chamber angle and pupillary effects and traumatic hyphema problems.

A relatively mild trauma may cause injury to the iris stroma, resulting in iritis that spontaneously recovers with time. Topical cycloplegic agents are prescribed to decrease the pain and photophobia produced by the iritis. The iris sphincter may rupture in one or more locations, causing characteristic triangular defects and notched pupillary borders that are permanent (Fig. 7-15). The iris and ciliary body may respond to blunt trauma with temporary miosis, mydriasis, cycloplegia, or spasm of accommodation. More severe trauma may

168 CHAPTER 7 OCULAR INJURIES IN SPORTS: ASSESSMENT AND MANAGEMENT

Grade 1: Layered blood occupying less than one third of the anterior chamber Grade 2: Blood filling one third to one half of the anterior chamber

Grade 3: Layered blood filling one half to less than total

Grade 4: Total clotted hyphemas, often referred to as “black ball” or “eight ball” hyphema

to be approximately 7%,195 and eyes with angle recessions larger than 180 degrees are at greater risk of developing glaucoma.199,200 Athletes who have angle recession injuries should be frequently monitored throughout life for development of glaucoma. Rarely, a 360-degree ciliary detachment can occur (cyclodialysis) and cause hypotony and phthisis bulbi, requiring surgical managment.166

Damage to the iris and ciliary body tissues often results in bleeding in the anterior chamber, and the resulting hyphema presents a considerable diagnostic and management challenge. The hyphema can obscure the clinician’s view of the internal ocular structures, making evaluation of the extent of damage quite difficult. Nevertheless, a thorough case history and evaluation should be performed to the degree possible. The extent of the hyphema should be carefully noted, including notation of the presence and location of a clot. A grading system for traumatic hyphema is useful for recording and communicating the extent of the bleeding (see Box 7-5).195

Traumatic hyphema has many consequences, including elevated intraocular pressure during the acute phase of the hyphema, secondary hemorrhage, anterior and posterior synechiae formation, corneal blood staining, and optic atrophy. Transient elevated intraocular pressure is presumably caused by blockage of the trabecular meshwork and typically returns to normal quickly as the hyphema resolves. This mechanism is similar to the exercise-induced elevations in intraocular pressure found with pigmentary dispersion syndrome.201 Athletes with sickle cell disease, and undiagnosed athletes of African or Hispanic descent, are at a higher risk for elevated intraocular pressure and subsequent central retinal artery obstruction because the sickled erythrocytes cannot pass through the trabecular meshwork.202-206 Secondary bleeding presents a significantly worse prognosis for vision recovery198,206,207 and secondary glaucoma.206,208,209 Synechiae formation in traumatic hyphema is often caused by associated iritis and angle closure, and changes in pupillary responses may be noted.198,207 Optic atrophy can result from the trauma itself or from prolonged periods of significantly elevated intraocular pressure.198,207

All these complications, along with the absence of a definitive treatment approach, present a complex and difficult clinical problem.206,210 Many medical and surgical treatment options must be carefully considered. Conventional initial treatment of traumatic hyphema has included strict bed rest, bilateral patching, sedation, and hospitalization. Medical management is most appropriate for patients with grade 3 or less hyphema and surgical intervention considered for grade 4 hyphemas that do not respond to medical management within approximately 4 days.195

Crystalline Lens

The crystalline lens can be damaged from both coup and contrecoup effects of the trauma. If the globe is compressed enough to push the cornea posteriorly until it makes contact with

the lens, a permanent Vossius ring may result from the contact between the iris pupillary ruff and anterior lens surface.25,64,68 More significant force can produce a transient rosette cataract, although the cataract often remains and can become progressively worse. Removal of the cataract can be complicated by the presence of hyphema and damage to other structures, especially the zonules. If the lens capsule has been ruptured, further complications of uveitis and phacolytic glaucoma may result.

In more severe cases of ocular trauma, the lens can become subluxated or completely dislocated. The pressure of the injury may rupture the zonules and cause the lens to tilt anteriorly or posteriorly, potentially leading to fluctuations in vision and diplopia. If this patient requires dilation, care must be taken to preclude having the subluxated lens shift into the anterior chamber. If the displaced lens is in contact with the iris, or if the vitreous has prolapsed into the anterior chamber, it often requires surgical intervention. In the rare occasion when the zonules have been completely severed, the lens can be dislocated internally into the anterior chamber or the vitreous, or suprachoroidally.166,211-213 The lens may also dislocate externally in severe trauma, especially in globe rupture. In addition to the poor vision resulting from lens dislocation, the clinician may also observe iridodonesis (quivering of the iris).68 A dislocated lens presents a poor prognosis, and the ensuing complications increase if the capsule has ruptured. The best treatment for lens dislocation is removal of the lens with a complete pars plana vitrectomy.166

Vitreous Body

The vitreous body can be directly affected in ocular trauma by vitreous base avulsion or posterior vitreous detachment or indirectly affected by hemorrhaging into the vitreous. Many uveal and retinal sites of possible bleeding exist, which highlights the need for a thorough posterior segment evaluation. If the views of the retina are obscured by blood in the vitreous, B-scan ultrasonography may be necessary to evaluate the integrity of the retina. Vitreal hemorrhaging can spontaneously resolve after several weeks; however, indications for vitrectomy may be present. The cells of the hemorrhage can migrate into the anterior chamber to produce ghost cell glaucoma, often requiring treatment with a vitrectomy.166,196,214

Vitreous traction can produce tears from the locations where the vitreous is attached. Most commonly, the vitreous base can be torn away along the anterior retina and pars plana and is pathognomonic for blunt trauma.70 The vitreous base avulsion can cause the vitreous base to hang over the peripheral retina, creating a “bucket handle” appearance.64,166 The vitreous base avulsion can often cause detachment of the peripheral retina as well. The vitreous is also strongly attached to the retina around the optic nerve, macula, and retinal vessels. Traction from blunt trauma can produce posterior vitreous detachment and subsequent retinal detachment. Detachment of the anterior or posterior vitreous can be monitored unless the traction on the retina necessitates surgical intervention.166

Retinal Injuries

The retina is often affected by ocular trauma. Many effects are possible, several of which cause permanent loss of visual function and require surgical treatment. Athletes with high myopia or otherwise compromised retinas are at particular risk of retinal damage from trauma.

Commotio retinae is a fairly common contrecoup injury first described by Berlin in 1873.215 The contusion causes a white, opaque appearance to the damaged retina (Fig. 7-17)

Figure 7-17. Peripheral commotio retinae. (From Kanski JJ: Clinical ophthalmology, ed 5, Boston, 2003, Butterworth-Heinemann.)

that often resolves without intervention unless permanent damage to the photoreceptors or retinal pigment epithelium occurs.70,166,196,214 Commotio retinae can occur to peripheral retina or the central macular region (known as Berlin’s edema) and have varying effects on visual acuity. Considerable damage to the retinal pigment epithelium can occur, eventually leading to granular pigmentation and bone corpuscular appearance of the affected retina resembling retinitis pigmentosa.216-218 The athlete should also be evaluated for serous retinal detachment, which also diminishes the prognosis for vision recovery.219

Traumatic macular holes are relatively common with blunt trauma, and the possible mechanisms include necrosis, vitreous traction, and subfoveal hemorrhage.166,196,220,221 The vision is usually poor with a full-thickness macular hole, and it is frequently associated with injuries to other internal ocular tissues.222 Surgical success for recovering vision lost to traumatic macular holes, especially in younger patients, has recently improved.221,223-232

Retinal dialysis, a separation at the anterior edge of the ora serrata with the vitreous remaining attached to the posterior edge, is the most common traumatic retinal break.233 The dialysis frequently occurs during the trauma,234,235 and the vitreous attachment is most likely responsible for the gradual development of retinal detachment. Retinal dialysis may be difficult to observe and diagnose; however, prophylactic surgical treatment can prevent progression to retinal detachment.166

Many varieties of retinal tears and detachments can result from ocular trauma. The clinician should be skilled at identifying horseshoe tears, holes with operculum, stretch tears, giant retinal tears, necrotic tears, and rhegmatogenous retinal detachments.70,166 Retinal detachment may not present immediately after the trauma; therefore frequent monitoring and athlete education regarding detachment symptoms is strongly recommended after trauma. Most tears and detachments require surgical treatment to prevent progression of retinal damage; however, no evidence exists that surgically induced adhesions offer protection against retinal detachment in high-contact sports such as boxing or martial arts.236

Optic Nerve

The optic nerve can be damaged by many direct and indirect causes. The most common form of optic nerve injury is from indirect contrecoup forces damaging the nerve itself or the supply vasculature for the nerve or through edematous compression (e.g., orbital emphysema).* In more rare cases, the optic nerve can be directly damaged by intraocular foreign bodies or bone fragments from orbital fractures, or a partial or complete avulsion of the optic nerve may occur from shearing or compression forces.29,165,166,239,240 Athletes are at particular risk for finger injuries in the orbit, which have been reported to cause optic nerve avulsion.241-243 As previously discussed, prolonged elevation of intraocular pressure can also produce damage to the optic nerve. Imaging is essential in trauma affecting the optic nerve to determine the nature of the damage.

Many treatment options have been promoted for traumatic optic neuropathy. High-dose corticosteroids and surgical decompression are the most common approaches, either separately or in combination.165,166,170 Although vision recovery has been reported to occur spontaneously,244 treatment is recommended to improve the chances of recovery. Optic nerve avulsion has a poor prognosis for visual recovery, although some suggest high-dose intravenous corticosteroid treatment.166

Choroid

Ruptures to the choroidal vasculature, Bruch’s membrane, or the overlying retinal pigment epithelium can result from blunt trauma. Choroidal ruptures most often occur as a contrecoup injury from compression in the posterior pole, and ruptures of the choriocapillaris often produce significant subretinal hemorrhages in the optic disc and macular areas (Fig. 7-18). The hemorrhage may take weeks to resolve, and a yellow-white scar may result (Fig. 7-19).

*References 25, 70, 165, 166, 237, 238.

Figure 7-18. Acute chorodial rupture scar. (Reprinted from Kanski JJ: Clinical opthalmology, ed 5, Boston, 2003, Butterworth-

Heinemann.)

Figure 7-19. Old choroidal rupture scar. (Reprinted from Kanski JJ: Clinical ophthalmology, ed 5, Boston, 2003, Butterworth-Heinemann.)

The visual prognosis can be relatively good unless hemorrhaging has occurred under the fovea. If Bruch’s membrane has been ruptured, choroidal vessels can develop under the retina.245-247 Photocoagulation therapy may be useful for prevention of retinal detachments and subretinal neovascular membrane formation that can even occur many years after the choroidal rupture.70,196

Direct trauma to the choroid commonly produces damage more anteriorly and can affect the uveal structures as well. The location of anterior choroidal ruptures makes visualization of the damage difficult; therefore the practitioner must be purposeful in the assessment of the posterior segment. If a large area of the choroid detaches, extreme secondary glaucoma can result that is resistant to treatment.195

Visual Fields

The forces that cause eye injuries can also result in closed-head trauma.25 Closed-head injuries involving cerebral edema, hemorrhaging, compression, or ischemia can damage the visual pathway. Visual field, pupillary reflex, visual acuity, and color testing can be useful adjunct information for other health professionals in determining the nature and extent of the damage.

Penetrating Trauma

A penetrating intraocular injury is relatively rare in sports, particularly when protective eyewear is worn by the athlete. Common penetrating objects include fish hooks, darts, weapon-related objects (e.g., BBs), and inappropriate spectacle lenses and frames.248 Although glass is generally well tolerated inside the eye, the sharp edges of shattered glass can cause considerable secondary progressive damage.248 A detailed case history is crucial for determining the exact nature of the injury and potential intraocular foreign object. In cases of small, fast objects such as BBs, signs of external damage may be limited. All ocular tissues should be thoroughly assessed and Seidel testing performed to help detect any entry points.

A computed tomography scan is often essential for locating the presence and position of the foreign object. Penetration of the ocular tissues causes many complications; the cornea may remain scarred, the iris may remain partially impaired, the crystalline lens may need to be removed, the vitreous may need to be removed, and the retina may have long-term problems.64,166

Many metallic and organic foreign bodies have a high risk for causing intraocular infection and inflammation; therefore, prophylactic treatment with broad-spectrum antibiotics is recommended for all foreign bodies.165 The management of intraocular foreign bodies is determined by “the composition of the foreign body, the mechanical effect of the retained foreign body, and the presence of infection.”165 Foreign materials that are not well tolerated in the eye or have potential for causing secondary damage should be removed when possible. Infection, especially from organic foreign materials, is not successfully treated by antibiotics alone; removal of the object is often necessary. The surgeon must consider the location, composition, and infection issues when determining whether to remove the foreign object and how to accomplish the removal with minimal surgical damage to the ocular tissues.

Perforating injuries from blunt trauma often have a worse prognosis than nonperforating contusions or penetrating foreign objects. The extent of damage to ocular tissues and structures typically is significant when blunt trauma force has caused an open-globe injury. In addition, the scarring from perforating injuries can cause even more extensive damage than the initial injury.166 Management with vitrectomy and other medical and surgical options should be initiated as soon as possible.

Chemical Injuries

Chemical burns (Fig. 7-20) are fairly rare in sports. Swimmers may present with chemosis and irritation from swimming pools that have been chemically treated improperly. Occasionally an athlete may get chalk in his or her eyes from field markings in sports such as football and baseball. These chemical injuries are almost always mild, and meticulous irrigation with water may be the only treatment necessary. If the chemical agent is a solid, scrupulous examination of the fornices is recommended to remove any retained substance.

Figure 7-20. Alkali burn demonstrating corneal burns and conjunctival injection on the day of the accident (A) and complete destruction 7 days after the burn (B). (Reprinted from Kaiser PK, Friedman, NJ: The Massachusetts Eye and Ear Infirmary

illustrated manual of ophthalmology, ed 2, Philadelphia, 2004, WB Saunders.)