Eye Injury in Sport - Springer Link

Injury Clinic

Spons Medicine 7: 163·181 (1989) 0112.1642/89/0003·0163/$09.50/0 © ADIS Press Limited

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Eye Injury in Sport Nicholas P. Jones Manchester Royal Eye Hospital, Manchester, England

Contents

Summary .................................................................................................................................... 163 I. The Incidence and Importance of Sports Eye Injuries ...................................................... 164 2. The Spectrum of Ocular Trauma ........................................................................................ 165 2.1 Contusional Injury .......................................................................................................... 166 2.1.1 Globe Injury: Anterior Segment ........................................................................... 166 2.1.2 Globe Injury: Posterior Segment .......................................................................... 166 2.1.3 Orbital and Adnexal Injury ................................................................................... 167 2.2 Penetrating Injury ........................................................................................................... 167 3. The Sports Involved ............................................................................................................. 167 3.1 Racquet Sports ................................................................................................................ 168 3.1.1 Squash Racquets .................................................................................................... 168 3.1.2 Racquetball ........ ..................................................................................................... 169 3.1.3 Badminton .................. ............................................................................................ 169 3.1.4 Tennis ..................................................................................................................... 170 3.2 Bat and Stick Sports ....................................................................................................... 170 3.2.1 Baseball ................................................................................................................... 170 3.2.2 Ice Hockey .............................................................................................................. 171 3.2.3 Field Hockey .......................................................................................................... 17I 3.2.4 Cricket ..................................................................................................................... 171 3.2.5 Golf ......................................................................................................................... 172 3.3 Large Ball Sports ........ ..................................................................................................... 172 3.3.1 North American Football ...................................................................................... 172 3.3.2 Soccer ...................................................................................................................... 172 3.3.3 Rugby Football ....................................................................................................... 173 3.3.4 Basketball ................................................................................................................ 173 3.4 Boxing ........................ ...................................................................................................... 173 3.5 Aquatic Sports ................................................................................................................. 174 3.6 Skiing ............................................................................................................................... 175 3.7 Shooting ........................................................................................................................... 175 3.8 Others ............................................................................................................................... 176 4. Principles of Ocular Protection ............................................................................................ 177

Summary

Eye injury sustained during sport is increasing in incidence worldwide. reflecting the rise in popularity ofsport as recreation. It can account for up to 25% of severe eye injuries. This paper considers the historical context and demography of sports injuries. and the physical mechanisms and results of various types of ocular trauma in relation to sport. It reviews the specific problems associated with the sports considered to be most important in the epidemiology of eye injuries today.

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Certain sports. such as boxing. have an intrinsic risk of injury so high that some consider the sport should be banned. The risk of injury in many sports can be mitigated by changes in rules. such as the prevention of high sticking in ice hockey. Other sports with high risk of trauma could be made far safer with the widespread introduction of eye protection. and this applies especially to squash and badminton. The various types of eye protection are discussed. There is an urgent need to increase awareness of the risk of eye injury. to teach safe techniques. and to encourage the use of appropriate ocular protective wear in those at high risk of injury. espeCially the one-eyed.

Eye injuries represent an important part of the work of an ophthalmologist. While his primary function is the management of injuries already sustained, it is also crucial to identify risk factors in the causation of injury and to move to reduce these wherever possible. In no field is this more important than in sport. Sport currently accounts for an increasing number of eye injuries and, of more importance, is responsible for substantial proportion (up to 25%) of severe eye injuries. This paper places the problem into perspective and discusses the main mechanisms of injury and the spectrum of ocular trauma in general. The most important sports worldwide in the aetiology of injury have been discussed in some detail with reference to special risk factors inherent to each, and the need for more widespread and more effective ocular protection has been discussed. Of particular concern recently are the racquet sports, mainly squash, but also badminton, tennis and racquetball. They have a high incidence of injury, are capable of severe eye injury and provide in some centres the bulk of sporting trauma. Ocular protection for these sports is simple, inexpensive and increasingly necessary. The efficacy oflegislative changes in substantially reducing the frequency of severe eye injuries in Canadian ice hockey is a striking example of a success story in preventive medicine and one that could be reflected in many sports with proper organisation. To this end the improved collection and assimilation of data on sporting injuries is mandatory. The accumulated information should lead to realistic discussion by the regulatory bodies of each sport on how best to reduce the upward spiral of unnecessary trauma.

1. The Incidence and Importance of Sports Eye Injuries In 1923 in Glasgow, Garrow presented the first comprehensive survey of eye injuries in the twentieth century. 1000 patients with eye injuries admitted to hospital over a 5-year period included only 7 (0.7%) involved in a sporting activity. More recent studies in the United Kindgom show very significant changes. Lambah (1968), in a similar survey of adult admissions, found that figure had risen to 4.2%. Canavan and co-workers (1980) reported a figure of 7.0%, again for adults, and most recently Jones (1988) reports a figure of 25.1 %. The above surveys apply only to eye injuries severe enough to require admission to hospital. For eye injuries as a whole, Vernon (1983) found that of those attending an eye hospital accident and emergency department, 2.5% of a sample of 3210 injuries were caused by sport. Jones et al. (1986) found this figure to be 2.2% of 3536 injuries. This low proportion is no cause for complacency. Most patients attending an ophthalmic casualty department have injuries which are not severe and can be managed as outpatients. The proportion requiring admission to hospital is extremely small (0.42%, Jones, unpublished data, 1983). However, on reviewing injuries sustained at sport it is immediately apparent that a disproportionate number of these are severe. Gregory (1986) found that 18.5% required admission to hospital, MacEwen (1987) put the figure at 18.7%, and Jones (1987) at 27.4%. Accurate estimations of the incidence of sports eye trauma are difficult to find. Marshall and Sandes (1977) reported a 2-year survey of sports

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Fig. 1. Multiple corneal abrasions caused by a squash ball. Visibility enhanced with fluorescein staining.

injuries in Dunedin and found that of a total of 3894 cases, of which 18% involved the head and neck, only 0.6% affected vision in any way. Glynn and others (1988) performed a true populationbased survey in Massachusetts and found that of a random sample of 3253 adults, 27 eye injuries requiring medical attention had been sustained in the previous year, of which 2 were related to sport. The incidence here is thus 61 sport-related eye injuries per 100,000 population per year. Karlson & Klein (1986), in a hospital-based study in Wisconsin, found the figure to be 44 per 100,000 per year. The difference between these 2 figures may be accounted for by the fact that some patients attend their usual physician rather than a hospital casualty department. Comparisons of the incidence of sports injuries are made difficult because of differences in popularity of certain sports at local, regional or national levels, or because of varying levels of participation in general. There are few baseball players in Australasia, and there is little cricket played in the United States. A sample of recent studies on eye trauma requiring admission to hospital illustrate these differences. IIsar and co-workers (1982) reporting a study of eye injuries in Malawi, found that sport accounted for only 2 of 205 patients (0.97%). In Reykjavik, Thordarson and others (1979) reported that 5 of 105 (4.8%) were so af-

fected. In Israel in a 3-year period, Koval et al. (1988) reported that 5.3% ofa total of 2276 patients injured were involved in sport. Chapman-Smith (1979), in Auckland, found sport the rAluse of 13.8% of218 injuries, and Yinger (198Ia), reporting data from Massachusetts, found that 23% of severe eye injuries were sport-related. Table I compares the sports most commonly causing injury in Great Britain and the United States. Parver (1986) reflected the strong feelings of many ophthalmologists when he described eye trauma as 'the neglected disorder'. In the United States alone, over 2.4 million eye injuries occur each year (National Society Fact Sheet 1980), of which a significant proportion result in permanent effects. It is felt by many that 90% of all eye injuries are preventable, and sport-related injuries must be high on the agenda. They are responsible for a disproportionate number of severe injuries, and this proportion is rising (Bell 1981). There are therefore deserving of special attention.

2. The Spectrum

0/ Ocular Trauma

Ocular trauma can be conveniently considered in 2 broad categories, contusional and penetrating injury, the former being of most importance in relation to sports injuries.

Table I. The sports most frequently causing eye injury in Great Britain and the United States of America in recent years. Taken from amalgamated figures of surveys by Gregory (1986) MacEwen (1987) and Jones (1987) [Great Britainl and National Electronic Injury Surveillance System (1982) [United States) Great Britain

United States

sport

% of total

sport

% of total

Soccer Squash Badminton Rugby Tennis Cricket Hockey

36.0 13.5 10.5 9.0 6.5 3.5 2.5

Baseball Basketball Bicycling American Football Squash & racquetball Tennis & badminton Soccer

30.0 24.5 10.0

7.5 7.0 5.5 5.5

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2.1 Contusional Injury Contusional injury is the result of a blow from a blunt object such as a squash or tennis ball. The damage sustained will depend upon the mass of the object, its velocity, and therefore the force imparted to the eye (Runyan 1986). It will also depend upon the direction of approach of the projectile, its surface characteristics and its size. A small blunt object striking the eye at speed will cause rapid anteroposterior compression and consequent equatorial dilatation (Clayton & Miller 1986; Runyan 1986), followed by successively smaller waves of distortion. The eye will also be moved posteriorly en masse which can affect the integrity ofthe bony orbit by a piston effect (see section 2.1.3). 2.1.1 Globe Injury: Anterior Segment Any object striking the cornea with moderate force will disturb its epithelium, and an abrasion results which is acutely painful (fig. I). The cornea is displaced posteriorly and the intraocular pressure suddenly rises (fig. 2). The pupil is pressed onto the anterior lens surface and hydrostatic pressure is directed into the angle of the anterior cham-

Fig. 2. A typical severe contusional injury caused by a squash ball. Severe globe compression and equatorial dilatation with intraocular haemorrhage and blowout fracture of the orbit floor.

Fig. 3. Severe macular damage and choroidal rupture (arrow) caused by a tennis ban. Visual acuity 6/36.

ber (Runyan 1986). Blood vessel rupture often occurs, causing hyphaema which may be microscopic or macroscopic. Acute glaucoma or secondary haemorrhage may result (Eagling & Roper-Hall 1986). The iris root may be ripped (angle recession) or completely disinserted (dialysis) and the iris sphincter may be temporarily or permanently disturbed (Paulmann 1986), causing a distorted or dilated pupil. Angle recession has implications for visual deterioration in the future as a significant proportion of affected eyes go on to develop chronic glaucoma (Kaufman & Tolpin 1974; Mooney 1973). Traumatic cataract may occur within hours of injury, or the lens may be displaced. The consequences of blunt injury to the anterior segment are discussed by Canavan & Archer (1982) who found that 16.5% of their adult cases were caused by sport. 2.1.2 Globe Injury: Posterior Segment Rapid distortion of the equatorial proportions ofthe globe places the retinal periphery under stress. Vitreous haemorrhage is frequent (fig. 2) and vitreous base traction causes retinal tears which may lead to retinal detachment. Trauma causes 10% of all cases of retinal detachment (Kanski 1986). Particularly implicated in this context has been tennis (Seelenfreund & Freilich 1976). At the macula, retinal and choroidal haemorrhage or disruption may occur (fig. 3) giving severe and permanent visual loss (Eagling & Roper-Hall 1986). Optic nerve con-

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tusional injury may occur. With severe blunt injury, as can be caused for example by cricket ball (Jones & Tullo 1986), golf club (Millar 1967) or hockey stick (Elliott & Jones 1984; Pashby 1985), traumatic rupture of the sclera can occur with loss of intraocular contents, a situation usually leading to loss of the eye. Schein et a!. (1988) found that 9% of all ruptured globes were caused by sport.

2.1.3 Orbital and Adnexal Injury Posterior displacement of the globe into the orbit is more likely to disrupt bone than sclera and this is the mechanism of blowout fracture of the orbit (Pfeiffer 1943), usually involving the posterior part of the floor (figs 2 and 4), less commonly the medial or other walls. Surgical management is complex. A more severe blow can fracture the orbital margins which are also often involved in midfacial fractures. Such complicated blunt facial trauma often leads to eye injuries, many undiagnosed at the time of injury (Holt et a!. 1983). Insertion of fingers or sharp objects into the orbit can avulse muscles or the optic nerve, as has happened in basketball (Chow et a!. 1984) or skiing (Rousseau 1987). The principles of management of orbital trauma is discussed by Hyde and Della Rocca (1988) and Kay and Lendrum (1988).

Fig. 5. A perforating injury involving the posterior segment. showing the exit wound of the projectile below the optic disc.

2.2 Penetrating Injury Sharp injury to the globe in sport is not common (causing 2% of all penetrating injuries in Eagling's series in 1976, and 5% in Cole et a!. 1987) but is often caused by the breakage of glass spectacles (Cole et a!. 1987; Ingram & Lewkonia 1973). In mild cases involving only cornea, prognosis after urgent surgery is good, but where sclera, ciliary body, lens or posterior structures are damaged (fig. 5), visual outcome is much less certain and devastating complications can ensue (Shock & Adams 1985). In some instances defective protective equipment itself, such as swimming goggles (Jonasson 1977), can cause penetrating injury. Where a foreign body such as an airgun pellet remains in the eye the prognosis is extremely poor (de Juan et a!. 1983; Shock & Adams 1985). An account of the acute management of sports eye injuries for the doctor of physiotherapist on site is given by Ellis (1987).

3. The Sports Involved

Fig. 4. Radiograph showing blowout fracture of the left orbit floor with extrusion of orbital contents into maxillary antrum (arrow). A football injury.

Eye injuries have been recorded in most sports at one time or another. The following are considered worthy of special mention, and the principles involved hold good for sport of all types.

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Table II. Potential speed of ball or shuttlecock in racquet sports (after data from Prof. C. Morehouse for the American Society for Testing and Materials) Projectile

Squash ball Badminton shuttlecock Racquetball Tennis ball

Velocity (m/sec) (mph) 62 (140)

57 (130) 48 (110) 48 (110)

3. 1 Racquet Sports Yinger (1985) estimated that over 40 million people in the United States play racquet sports. In recent reports of eye injuries, the racquet sports invariably feature prominently and together cause more injuries than any other sport in Great Britain (Jones 1987). In 1976 racquet sports were estimated to cause 3220 eye injuries in the United States (National Electronic Injury Surveillance System 1976). Although these sports have in common the rapid exchange of a high velocity projectile within a confined space, each has its particular problems. Table II shows measured projectile velocities for each sport.

3.1.1 Squash Racquets In terms of eye injury, squash is the paradigm of racquet sports. A small ball bounces around in a confined space at speeds up to 62 m/sec hotly pursued by 2 players, each brandishing a flailing racquet. The potential for ocular trauma is obvious. The popularity of the sport has risen progressively over the last 20 years. Attention was first drawn to the problem by North (1973) and Ingram and Lewkonia (1973), and other reports have followed (Barrell et al. 1981; Blonstein 1975; Easterbrook 1978, 1980; Mondon et al. 1981; Moore & Worthley 1977; Quere & Pietrini 1986; Sabiston 1976). The size of the problem is now becoming apparent. Gregory (1986) found squash the commonest sporting cause of eye injury in Sussex (26%), and Karlson and Klein (1986) found it the second commonest in Wisconsin (15%), as did Jones (1987)

in Manchester (16%). In terms of severe eye injury, Canavan (1980) found it the second commonest sport causing injury of sufficient severity to require admission to hospital (17%), and this is supported by Jones (1988) [23%]. Littlewood (1982) in Perth found that trauma on the squash court caused more hyphaemas (21%) than any other mode of injury. Injury by the ball itself is most common, and characteristically occurs when a player turns to watch his opponent playa stroke. Kennerley Bankes (1985) found that 69% of 339 injuries were caused by the ball, and this high proportion is supported by others [Barrell et al. (1981), 71 %; Gregory (1986), 71%; MacEwen (1987), 79%; North (1973), 77%]. A squash ball is ideally sized to allow entry into the orbit and cause a compression injury to the globe (Editorial 1973) [fig. 6]. The spectrum of injury was detailed by Kennerley Bankes (1985) and not surprisingly included a large proportion ofhyphaemas (43%). Injury by the racquet is often a more serious matter. A disproportionate number (43%) of severe injuries is caused in this way (Ingram & Lewkonia 1973) and globe rupture has been reported (Jones 1987) with loss of the eye. A blow from squash racquet or ball is a blunt injury. Rarely is such an injury of sufficient force to rupture the globe itself. When glass spectacles are interposed, however, penetration of the eye is facilitated (Christianson et al. 1977; Keeney &

Fig. 6. A severe orbital haematoma caused by a squash ball masks a typical contusional injury including hyphaema and blowout fracture of the orbit.

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rarely worn, despite many writers on the subject exhorting that they are necessary (Easterbrook 1978, 1980; Editorial 1973; Elman 1986; Gregory 1986; Ingram & Lewkonia 1973; Jones 1987, 1988; MacEwen 1987; North 1973; Yinger 1981 b, 1985). These should contain polycarbonate lenses; lensless protectors are inadequate for squash (Easterbrook 1980; Yinger 1985) [fig. 7]. There is little doubt that the enforcement of such protection would virtually eliminate eye injuries from the game.

Fig. 7. Lensless eye protectors are inadequate for use in squash because the ball can still deform enough to penetrate the gap and cause compressive injury.

Renaldo 1975; Moore & Worthley 1977). Ingram and Lewkonia reported that 4 of their 21 patients suffered penetrating injury. All were wearing spectacles, and 3 of the 4 were struck by a racquet. Cole (1987), reporting a large series of penetrating eye injuries, found squash the commonest sport involved, injuring 5 players, all of whom were wearing glasses. Wearing glass spectacles on a squash court is extremely dangerous and must be prevented. How dangerous, then, is squash? Barrell et al. (1981) estimated that squash was the most dangerous sport in the United Kingdom, generating an eye injury rate of 5.2 per 100,000 playing sessions. Clemmett and Fairhurst (1980) reported a population-based survey of 10,658 matches involving 1327 competitive squash players, during I season. There were 64 head injuries, and although in only 2 cases was the eye directly involved, the preponderance of injuries around the ocular area was striking. According to Reif et al. (1981), the regular squash player (3 times per week) over 25 years of play has a 25% risk of significant eye injury. Locke (1985), in his review of injuries at squash, including sudden death, poses the salient question: squash racquets ... deadly or safe? Despite some public awareness of the potential for eye injury in squash, protective spectacles are

3.1.2 Racquetball Although the sport has some similarities to squash, fewer injuries have been reported at racquetball. The sport is certainly increasing in popularity, and Doxanas and Soderstrom (1980) reported a series of 37 injured players, including a large proportion of brow lacerations caused in the follow-through by the racquet. Easterbrook (1980) reported 18 cases, of whom 13 required admission to hospital. Eye protection is certainly necessary for this sport (Vinger 1985). 3.1.3 Badminton The badminton shuttlecock can achieve velocity of 57 m/sec (Vinger 1985) and thus impart considerable energy to the globe (fig. 8). Chandran (1974) and Blonstein (1975) have reported eye injuries in badminton, yet on the whole these have

Fig. 8. Hyphaema (blood in the anterior chamber) caused by a badminton shuttlecOCk.

Eye Injury in Sport

been considered less severe than squash ball injuries (Barrell et al. 1981). Badminton is becoming more popular, however, and was found to be the third commonest sport causing eye injury in the United Kingdom by both Gregory (1986) and Jones (1987), being responsible for 17% and 14% of injuries, respectively. In these studies Kelly (1987) has shown that badminton can and does cause severe injuries (including perforating injury), and Jones (1988) found badminton to be responsible for 19% of severe eye injuries in sport. Certain risk factors for eye injury in badminton have been found. Doubles is more dangerous than singles (Jones 1987; Kelly 1987). As with tennis, players at the net are more at risk than those in the back court, and should protect their faces with the racquet. Badminton is dangerous enough to recommend that protective polycarbonate spectacles should be worn by all players (Vinger 1985).

3.1.4 Tennis Recent interest in squash as a danger to the eye has distracted attention away from tennis, yet Vinger and Tolpin (1978), recording a survey of racquet sport injuries, found tennis to cause as many as 73 of 82 cases (89%). Seelenfreund and Freilich (1976) described a series of patients with contusional eye injuries caused by tennis balls, typically including vitreous haemorrhage and retinal breaks, some with established retinal detachment requiring surgery. In 1976 there were an estimated 12 million tennis players in the United States and in that year 3220 eye injuries were sustained during play (National Electronic Injury Surveillance System 1976). The tennis ball, at 6.25cm in diameter, cannot enter the orbit as readily as the squash ball or shuttlecock, yet can obviously cause severe injury. Although it is capable of a similar velocity to a squash ball, it is generally only volleys and the service that achieve this. It is notable that Seelenfreund and Freilich (1976) identified the player rushing into the net as particularly at risk owing to the greater speed of the ball in this situation. Ramanan (1976) also rightly highlights the danger of turning round to watch one's partner serve, for the same reason.

170

In tennis as in other sports, experience is often thought to protect the player. Yinger and Tolpin (1978) dispute this, and Duke (1976) records the instance of a world class player losing an eye at tennis. Experience is no protection, yet an identification of special risk areas, such as net play, turning back, and doubles play (Stein 1987) must lead to better safety. Stein (1987) considers that the routine use of safety spectacles is not necessary for tennis. It is interesting to note that Yinger and Tolpin (1978) found that ordinary spectacles were a considerable protection against eye injury at tennis, yet of course a shattered lens can have a devastating effect. Seelenfreund and Freilich (1976) recommend routine protection for those at high risk from eye injury (including of course the one-eyed) and illustrate a lensless protector. Certainly all who wear spectacles should wear plastic lenses. 3.2 Bat and Stick Sports The following sports have in common a hard, fast-moving ball or puck struck by a hard stick, bat or club. There the similarities end, as the individual features of each sport affect the likelihood of injury, though not necessarily its clinical features.

3.2.1 Baseball In the United States baseball is estimated to cause 900,000 injuries per year. Of these, 170,000 are to the face, and over 9000 directly involve the eye, making it the most common cause of sport injuries to the eye (Vinger 1985). When considering severe eye injuries alone, Schein et al. (1988) also report that baseball is the leading sport, being responsible for nearly 30%. Hoefle (1987) finds that within the comparatively small professional community, severe eye injuries are rare, but Yinger (1985) estimates that eye trauma is most common in the 5- to 14-year age group, accounting for 45% of all baseball injuries. Injuries are usually caused by the ball (62%), the bat causing 16% (Hoefle 1987). The entire spectrum of blunt injury is possible, including ruptured globe and orbital fracture. Professional players have

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been forced to retire because of eye injury. In the United States moves are beginning to introduce facial protectors, initially for younger players, and the American Society for Testing and Materials has laid down standards for such protectors. With widespread use of these, the Consumer Products Safety Commission estimates that head and face injuries could be reduced by up to 54,000 cases per year (Yinger 1985).

nificant improvement in safety standards, Pashby (1987) stresses that there is yet work to be done; in Canada, 238 eyes have been blinded in 18 seasons, and hockey still accounts for 37% of sporting eye injuries and 56% of blinded eyes. Attention is now focussing on the older age groups, and mandatory facial protection for all seems the likely outcome.

3.2.2 lee Hockey Ice hockey is a popular winter sport in many countries, but predominantly in North America. Injuries are extremely common; Yinger ( 1981 b) says that 7% of unprotected hockey players were injured during their first year, and at high school 60% had had ocular or facial injury. Eye and face injuries accounted for one-third of all injuries in ice hockey (Yinger 1985), and most of these injuries (80%) were caused by the stick (Yinger 1976). In 1974, concern about this problem led to the formation of a committee of the Canadian Ophthalmological Society, to investigate the matter. Pashby and co-workers (1975) recorded the initial surveys of hockey seasons 1972 to 1975, giving a catalogue of severe ophthalmic injury including ruptured globes and orbital fractures. Of all eyes injured, 15% were rendered legally blind. A resume of the types of eye injury sustained in hockey is given by Rousseau (1987). Over the succeeding few years, a dramatic fall in the number of injuries ensued (Pashby 1977, 1979, 1985). There were 4 reasons for the fall. Firstly, a campaign to generate greater awareness of the risks of eye injury led to more widespread use of head and eye protectors. Secondly, such protectors became more trustworthy following stringent trials by the Canadian Standards Association. Thirdly, a rule was introduced forbidding high sticking (the practice of raising the hockey stick above the shoulder) and, fourthly, head protection was made mandatory for young players. The resulting fall in injury rate has been hailed as one of the great successes in preventive ophthalmology, and similar events have occurred in the United States. However, although there has been a sig-

3.2.3 Field Hockey Field hockey has attracted considerably less attention than ice hockey, yet severe injuries do occur (Elliott & Jones 1984). Three globe ruptures were reported, all caused by an opponent's stick in the follow-through. Clearly the problem of illegal high sticking in field hockey must be addressed, and the advisability of facial protection must be discussed. 3.2.4 Cricket Little attention has been paid to eye trauma in cricket, yet it can be responsible for severe injuries. In England, recent studies have found it to account for 5.4% (Gregory 1986) and 4.8% (Jones 1987) of sporting eye injuries. In Australia, Littlewood (1982) found it responsible for 7% of all traumatic hyphaemas. Coroneo (1985) described a series of injuries sustained in indoor cricket, a game played with a softer ball. Jones & Tullo (1986) described several cases of severe eye injury sustained at outdoor cricket, including retinal detachment (fig. 9), orbital fractures, and rupture of the globe. Some common risk factors were identified. Most injured players were struck by a ricochet off the bat edge, and the hook shot placed the batsman at particular risk, owing to body position at impact; the ball tends to strike the eye from below and laterally, and it is blows from this direction that are most likely to cause globe rupture (Warwick 1976). Although the wearing of safety helmets in cricket has quite rightly become commonplace, the provision of a polycarbonate visor or face cage is not common to all helmets. Severe eye injuries would be prevented if full facial protection were to be worn.

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lowing sports also involve a variable degree of body contact, and injuries can be caused by heads, elbows, fists and fingers.

Fig. 9. Retinal detachment caused by multiple retinal tears (arrows). A cricket ball injury.

3.2.5 Golf Golf is an uncommon cause of eye injury. It will, however, be appreciated that both ball and c1ubhead are hard, small, and rapidly moving, thus capable of deep penetration into an orbit. Injuries sustained are therefore frequently severe. Millar (1967) described a series of 7 cases, including 2 globe ruptures, both requiring enucleation. Over a 20-year period in Massachusetts, golf caused 14% of all sports injuries leading to enucleation of the globe (Portis et al. 1981). It is appropriate to mention here that the practice of golf ball dissection is dangerous. The liquid core is under high pressure and subconjunctival injection by a spurt of fluid has been extensively reported, causing characteristic granulomatous inflammation (Lucas et al. 1976). Liquid-core golf balls should carry a clear warning to this effect. Most golfing eye injuries are avoidable by the practice of good etiquette on the tee and fairway. Certainly all clubhead injuries should be prevented by keeping clear of the player's swing. Although protective eye wear should not be necessary, spectacle-wearers should convert to polycarbonate lenses (Vinger 1985). 3.3 Large Ball Sports Objects as large as footballs are less likely to cause ocular damage than squash balls or hockey sticks. Despite this, injuries are often seen. The fol-

3.3.1 North American Football To the unfamiliar, the football player appears protected almost to excess. This misconception is soon dispelled by observing a typical game. Football is estimated to cause 432,000 injuries per year in the United States, 12% of all sporting injuries. Despite protective wear, eye injuries are estimated at 2350 per year, mostly in the 5- to l4-year age group (National Electronic Injury Surveillance System 1982). Helmets incorporating facial cages have been proven effective in reducing facial injuries (Wilson & Rontal 1973), but such cages easily permit the entry of fingers, and ocular injuries produced in this way have been recorded (Helveston 1987), and are probably the commonest cause of eye injury, whether accidental or deliberate. The replacement of facial cages with polycarbonate visors would remove this problem and would also improve the visual field, which tends to be reduced with currently available protectors (Vinger 1985). 3.3.2 Soccer The 3 most recent surveys of sports-related eye injury in Great Britain have found soccer to be responsible for a large number of injuries. Gregory (1986) found it the second most common sport causing eye injury, being responsible for 21 % of the total. Both MacEwen (1987) and Jones (1987) found it the commonest cause of injury, reporting 45% and 27%, respectively. Jones (1988), in a survey of severe eye injuries in sport, found it the commonest cause of an admission to hospital (33% of total). Soccer is rising in popularity in the United States and Burke et al. (1983) report a series of 37 injuries, mostly caused by the ball itself. Although the severity of these injuries compared favourably with injuries sustained at hockey or racquet sports, they included 8 cases of retinal damage and 2 orbital fractures (fig. 10). In view of the fact that a soccer ball is 21cm in diameter, it is somewhat surprising that it is capable of blunt eye injury (Vinger 1985). It must be

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capable of adequate deformation on impact to enter the orbit. Burke and others (1983) recommend the use of eye protection in soccer, though resistance to any such initiative is likely to be strong. Suggestions that young players should be discouraged from heading the ball (Vinger 1985) are unrealistic as this action is intrinsic to the sport. 3.3.3 Rugby Football Rugby compares with American football in terms of physical contact between players, yet traditionally no protective wear is used. Injuries are common, and in Dunedin, New Zealand, between 1974 and 1976 it accounted for 49% of all sports injuries (Marshall & Sandes 1977). Of special concern has been the tendency for cervical spine injuries in scrummages (Burry & Calcinai 1988; Taylor & Coolican 1987). Ocular injury has not been specifically documented, though in recent surveys in the United Kingdom rugby accounted for 6.5% (Gregory 1986), 8.3% (Jones 1987) and 9.8% (MacEwen 1987) of eye injuries in sport. Present knowledge of causes of eye injury in rugby does not allow informed comment on the need for ocular protection. 3.3.4 Basketball Basketball is second only to baseball in the league of eye injuries in sport in the USA (National Electronic Injury Surveillance System 1982), caus-

Fig. 10. Computer-assisted tomograph showing blowout fracture of the left orbit floor with extrusion of orbital contents into the maxillary antrum. A football injury.

ing an estimated 7500 eye injuries, mainly in the 15- to 24-year age group. In Wisconsin the sport was the commonest cause of eye injury, being responsible for 19% of the total (Karlson & Klein 1986). As would be expected from the nature of the game, most injuries are caused by opponent's fingers or elbows rather than the ball itself (Yinger 1985). Karlson and Klein (1986) found that 74% of injuries were caused in this way. Extremely severe injuries can result from forceful insertion of a finger into the orbit, and avulsion of the optic nerve has been reported in basketball (Chow et a1. 1984; Park et al. 1971). Ocular trauma is common enough to recommend universal eye protection for basketball players. 3.4 Boxing Of all sports with an intrinsic risk of injury, pugilism has attracted more medical criticism than any other. This is not surprising. Boxing shares with few other activities the essential prerequisite of damaging one's opponent. Indeed, in a position statement from the International Federation of Sports Medicine (Yinger et al. 1988), boxing alone with full-contact karate shares the distinction of being 'extremely high risk for eye injury'. The debate has raged for many years and will continue to do so. Its very inclusion as a sport would be questioned by many, who would regard it at best as distasteful entertainment, at worst as legalised assault. Conversely, devotees ofthe sport are well able, as Doggart (1955) says, to 'evolve a set of reasons to justify their favorite pleasure'. Despite the emotive arguments, it is important to place into perspective the very real capacity for injury, and, in this context, eye injury. Doggart (1955) and Pizzarello (1987) summarise the various types of ocular or adnexal injury typical of boxing. They enclose the whole spectrum of blunt trauma, though of special importance are anterior chamber angle recession, and retinal damage. Many case reports exist on these subjects. Though Whiteson (1981) felt that according to his anecdotal experience, retinal detachment was not a common problem among boxers, this is in direct

Eye Injury in Sport

contradiction to the evidence presented by Maguire & Benson (1986), who recorded 8 retinal detachments in boxers in 2 years at one hospital. Hospital-based data on eye injuries in boxing are relatively difficult to collect or assess and reports remain largely anecdotal, although in this way Elkington (1985) revealed 210 cases. There are, however, important population-based reports on the frequency and severity of such injuries. McCowan (1959) found eye injuries in less than 0.2% of a large sample of boxers. Palmer (1976) found old anterior segment trauma in 16% of a sample of 55 retired boxers. More recently, Giovinazzo et al. (1986), in New York State, examined in detail the eyes of 74 boxers who were applying for, or applying for the renewal of, a licence to box. They found eye injuries in 66% of boxers. More significantly, injuries felt to be 'vision-threatening' were discovered in as many as 58%. 19% had anterior chamber angle deformities, 19% had traumatic cataracts, 24% had retinal breaks and 2 boxers had established retinal detachment. Both the British Medical Association and the American Medical Association have resolved to campaign for the abolition of boxing as an organised sport. In the United Kingdom, the Board of Science and Education Working Party was set up to investigate the problem. Its report (1984) includes comments on the dangers of eye injury as well as chronic brain damage, a subject also reported elsewhere (Kaste et al. 1982; Ross et al. 1983; Sironi et al. 1983). Occasionally the public eye is directed towards a serious injury in a famous boxer. Such attention is usually short-lived even though blindness may result. This media attention represents the tip of an iceberg. Boxers, compared with controls, are more at risk of eye injury, and more at risk of sightthreatening eye injury, particularly retinal detachment (Giovinazzo et al. 1986). What measures can be taken to lessen the problem? The abolition of boxing as a sport is the aim in several countries. On the assumption that this is unlikely to occur in the near future, certain restrictions would undoubtedly reduce the risk of blindness among boxers, and these are admirably

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dealt with by Giovinazzo et al. (1986), in particular the following: 1. The use of thumbless gloves should become mandatory. The thumb of a boxing glove is much more likely to penetrate the orbit than the fist. 2. Boxers should undergo mandatory ocular examination at stated intervals, and those at special risk should be either suspended from boxing for an appropriate time, or where necessary stopped altogether. 3. Ringside physicians should be better trained in the examination and treatment of eye injuries. 4. Proper records of eye injuries should be kept. 3.5 Aquatic Sports Indoor swimming pools contain a variety of irritants of which the most common is chlorine. Abramson & McDonough (1987) describe the principles of pool disinfection. The presence of a disinfectant in pool water serves to limit transmissible infection, yet epidemics of adenoviral conjunctivitis related to swimming pool water have been reported (d'Angelo et al. 1979). Such irritants have well-recognised effects on the cornea, as described by Haag and Gieser (1983). In a group of 50 swimmers using the pool for an average of 34 minutes, 94% had corneal epithelial damage and 68% had transient corneal oedema affecting visual acuity. Ocular injury is by no means limited to the water itself. The use of goggles to prevent the above effects is widespread, yet on occasion the goggles themselves can cause injury, slipping out of wet hands and being pulled into the eyes by their elastic straps, as described by Jonasson in 1971. High diving can rarely cause eye injury, including optic nerve damage (Jonasson & Cullen 1982). Water polo occasionally leads to ocular trauma, as finger to eye contact is inevitable at times. The comparatively relaxed sport of angling might be thought free of potential for eye injury, yet the impalement of an eye on a barbed fish hook has been reported (Bartholomew & MacDonald 1980, Grand & Lobes 1980). Such injuries are, however, rare.

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175

3.6 Skiing Eye injury in skiing is uncommon, but frequently severe. In Canada between 1973 and 1984, only 10 cases of eye injury were reported to the Canadian Ophthalmological Society but, of these, 6 were blinded in the involved eye (Rousseau 1987). Snow blindness is caused by absorption of ultraviolet light by the cornea, and can be prevented by adequate filter goggles, as specified by the American Society of Testing and Materials. Mechanical injury is most commonly sustained during crosscountry skiing or off-piste downhill skiing through trees (Rousseau 1987), when scratches from twigs can occur. Occasionally blows from tree branches are more severe, and a retained orbital wooden foreign body has been reported (Brock et al. 1980). The skier's own equipment, particularly ski poles or the ski itself, can cause optic nerve avulsion, muscle transsection or perforating injury (Rousseau 1987) and the T-bar lift is capable of similar injury (Amyot 1984). Ultraviolet filter goggles are mandatory for skiing in conditions which are likely to lead to snow blindness, but many of these offer little protection from mechanical injury. They should incorporate polycarbonate lenses (Vinger 1985) and be able to deflect blows of at least moderate force. Where the risk of injury is high, as for downhill racing, helmets incorporating polycarbonate visors should be used. 3.7 Shooting Shooting as an organised sport is time-honoured, and many of its various forms are Olympic sports. Under the most stringent safety controls, injury from the use of firearms is unlikely. However, when injuries do occur they are frequently severe. The ocular disruption caused by a small projectile with a very high velocity is considerable. An airgun or shotgun pellet requires a velocity of greater than 40 metres per second to penetrate the eye. The muzzle velocity of airguns is well in excess of this figure, and for a shotgun it is multiplied 6-fold (Salisbury 1987).

Fig. 11. Lateral skull radiograph showing multiple shotgun pellets including ocular damage.

There are several reports of ocular injuries due to shotgun pellets in the literature (Drummond & Kielar 1976; Morris et al. 1987; Roden et al. 1987). They have in common the findings of frequent poor visual outcome. In addition, owing to the spreading nature of the blast, bilateral injuries are not uncommon. Indeed, Morris et al. (1987) found both eyes to be involved in 59% of cases. In Drummond's series of 20 perforating injuries, only 15% attained a visual acuity of better than Hand Movements. Heimann et al. (1983) found that in a large series of 308 eyes with intraocular foreign bodies, those with the worst prognosis were those caused by gunshot or airgun pellets. In Morris' series in 1987, 29% of eyes required enucleation (fig. II). The ophthalmic and general medical literature has a plethora of reports of injuries caused by airgun projectiles, including fatal wounds (Chandu Lal & Subrahmanyam 1972), and it is distressing that children are so frequently involved (Reid 1974; Spitz 1968). A few large series of ocular airgun injuries have been presented, notably by Bowen and Magauran (1973) [105 cases], Sevel and Atkins (1978) [87 cases] and Moore et aI. (1987) [60 cases]. The appalling prognosis of penetrating injuries caused by airgun pellets has been highlighted by Sternberg and others (1984), when of 22 injured eyes, 19 required enucleation and the remaining 3 retained a visual acuity worse than 2/60 (fig. 12). Airgun injuries are common, and it was estimated

Eye Injury in Sport

176

1981) and at freezing point, a 2.2mm lens was more resistant to penetration than a 3.0mm lens. Polycarbonate is 20 times more resistant than tempered glass to high velocity low mass impact (Novak 1981). Gun Users should be exhorted to wear such spectacles. Yinger (1985) gives comprehensive guidelines for eye wear in shooting. 3.8 Others

Fig. 12. Anteroposterior skull radiograph showing an airgun pellet within the left orbit.

in 1981 that 22,800 injuries were caused in the United States, of which 1255 were ocular (National Electronic Injury Surveillance System 1981). The average age of the injured is in the teens [Bowen & Magauran (1973), 14 years; Moore et at. (1987), 17 years]. Airguns are dangerous weapons. This is a truism, but needs stating, as the fact is clearly not appreciated by a substantial proportion of users. Better education in the proper and supervised use of airguns is required. In the prevention of injuries of all types from firearms, of paramount importance is the education of the user in gun safety techniques. In addition to this, the use of safety eye wear is to be recommended. Apart from the risk of perforating injury from projectiles, the eye is also exposed to powder discharge, and small metallic particles from cartridge cases ejected from the breach (Salisbury 1987). Robertson (1976) conducted experiments on the efficacy of various materials for safety lenses and found none to be completely satisfactory. Simmons and co-workers (1983) found polycarbonate to be extremely efficient in the prevention of penetration by shotgun pellets, and recommended that these be mounted in polyamide frames with 4mm posterior rims to prevent posterior dislocation of the lenses. Standard frames were not found to be adequate. It is important to note that polycarbonate becomes brittle at low temperatures (Keeney

Eye damage has been reported in most sports at some time or another and new sports constantly join the list. Cases of injury occur in such diverse activities as baton twirling (Fern et at. 1987) and war games (Easterbrook & Pashby 1985). Men's lacrosse is known to cause frequent injury, and head injuries account for 10% of these (Mueller & Blyth 1982), despite the use of helmets. The eyes are usually well protected by a face cage, but this will still admit fingers and sometimes the stick, and Yinger (1985) recommends upgrading protector standards to those of ice hockey. The controllers of women's lacrosse have strongly criticised suggestions that facial protection should be used, on the basis of a difference in rules whereby there is less bodily contact than in the men's game. However, the United States Women's Lacrosse Association (USWLA) reports an injury rate to the face (including eyes) of up to 9.9% per player per year. Despite this rate, the USWLA has prohibited the use of facial protection and helmets (Vinger 1985). The game of darts is of some concern, mainly as eye injuries tend to occur in children. Cole and Smerdon (1988) reviewed 19 such injuries during an 8-year period, all perforating, and found that the flight end of the dart was responsible for 6 of the cases. In this survey, the dart injuries accounted for 18% of all perforating injuries occurring in the under 14 years age group, and this disturbing tendency is also reported by Wykes (1988) [25% of all perforating injuries in the under 16 years age group caused by darts). The answer to the problem probably lies in greater supervision rather than protective wear.

Eye Injury in Sport

4. Principles of Ocular Protection Each sport has different requirements for protection, but all have in common the need to take reasonable steps to prevent eye injury. In so doing a structured approach is important (Yinger 1985). I. Data collection identifies the incidence and prevalence of injury for each sport. It provides information on the type of injuries caused and their severity, and identifies risk factors within sports. Over time changes in incidence are shown. As a result action to reduce injury may be required, and this essentially takes 2 forms: changing the pattern of the sport and/or using protective wear. 2. Changes in the pattern of the sport may be voluntary, through education, or mandatory owing to changes in the rules of the sport. For instance, in badminton it has been shown that most injuries occur in doubles (Kelly 1987), by a shuttlecock smashed into the eye of the person at the net. Coaching novices to hold the racquet in front of the face in this position would protect from such injury and would not interfere with play. In ice hockey, the use of the stick above shoulder level was identified as a high risk factor for severe eye injury and in Canada the rules were changed to prevent this. A reduction in injuries ensued (Pashby 1977). 3. The ideal eye protector should prevent eye injury by dissipating force onto a wide area, but in no way should increase the risk of injury by reducing visual field or giving misplaced overconfidence and should not convert an oculofacial injury into an intracranial one. The development and constant updating of performance standards for protectors is crucial and various factors must be taken into consideration for each sport, for instance the size and speed of the projectile, the likelihood of eye contact with the hitting instrument if any, the likelihood of body contact with an opponent and the possible sequelae of all of these. On the basis of these considerations a protector is devised, which should be safe, convenient, cosmetically acceptable and as inexpensive as possible. Where the benefits of such protection are un-

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arguable, widespread use, by legislation ifnecessary, should be the aim. Most sports eye protectors (fig. 13) dissipate energy onto the glabella and supraorbital ridges, and via the lateral orbital margins to the facial bones. For a blow from a squash ball, this is adequate and does not lead to increased likelihood of intracranial injury. A blow from an ice hockey stick, however, may carry sufficient force to cause brain damage if the blow is deflected away from the orbit (normally the eye, though severely damaged, will absorb energy as will the orbit when its walls fracture). Where such injury is possible, helmet protection is necessary and eye protection is mounted within this. Other factors may need to be taken into consideration such as the need to protect from ultraviolet light (in skiing goggles) or from chemical action (swimming goggles). Table III shows suggested protectors for several sports. There is unfortunately often a conflict between optimum safety and acceptability of a protector. It must be considered sensible in some circumstances to sacrifice the former to obtain more widespread usage and in general this means making it more lightweight. Lenses for modern spectacles are made of 3 types of material: glass, which may be heat-treated to aid strength, allyl resin or polycarbonate. Christianson et al. (1977) compared glass, heat-tempered glass and allyl resin lenses by the standard method of

Fig. 13. Typical sports eye protectors with polycarbonate frames and broad, strong nasal bridge and sides, allowing absorption and deflection of force. Plano or prescription polycarbonate lenses are used.

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178

Table III. Risk levels for eye injury in certain sports. and recommendations for protective wear Risk

Sport

Protective wear

Unacceptable

Boxing

Not applicable

Very high

Ice hockey Squash

Helmet with full visor Polycarbonate sports protector Polycarbonate sports protector Polycarbonate sports protector Helmet with full visor

Badminton Basketball Men's lacrosse High

Polycarbonate sports protector Baseball Polycarbonate sports protector Helmet with full visor Cricket Helmet with full visor Feild hockey Rugby football Debatable Soccer Debatable Water polo Polycarbonate goggles Shooting Polycarbonate sports protector Women's lacrosse Helmet with full visor

Moderate

Tennis American football

Plastic lens spectacles Helmet with polycarbonate visor

Low

Golf

Sports protector if oneeyed Sports protector if oneeyed UV filter goggles ± helmet Sports protector ± helmet Polycarbonate protector if one-eyed Goggles if in water for long periods Not feasible None required

Racquetball

Volleyball Skiing Cycling Fishing Swimming High diving Track & field

dropping metal balls onto them from graded heights and found that impact resistance increased in the order; glass, heat-tempered glass and allyl resin. Keeney and Renaldo (1975) found plastic lens frames aid lens strength more than wire frames, and noted that glass lenses most at risk of fracture on impact were those with a minus cylindrical pre-

scription. Robertson (1976) compared heat-tempered glass, chemical-tempered glass and allyl diglycol carbonate lenses and found all to be unsatisfactory when hit by shotgun pellets, whereas Simmons and co-workers (1984) found the performance of polycarbonate resin in similar circumstances to be·dramatically better. In terms of impact resistance, polycarbonate is incomparable (Davis 1987) and is therefore the material of choice for all sports protectors where impact is a risk, whether in spectacle or visor form. Polycarbonate is not a panacea; at low temperature its fragility increases markedly (Simmons et at. 1984) and it is prone to scratch, requiring surface coating. At present, however, it represents by far the best material for lenses and visors for sport protectors. The prevention of future eye injuries can only come from an awareness among sportsmen and women of the possibility of such injury, and a sensible appraisal of the risks. For some, such as the one-eyed, these risks may be unacceptable for some sports. For others, the use of protection is advisable. Unfortunately most sportsmen consider it unnecessary. The belief that 'it will never happen to me' is common and can only be changed by an appreciation of the facts which must come through education by ophthalmologists and sports physicians.

References Abramson DH. McDonough RA. Aquatic sports. In Pizzarello & Haik (Eds) Sports ophthalmology, Charles C. Thomas, Illinois, 1987 American Society of Testing and Materials. Standard specification for eye protective devices (alpine skiing) F659-80, American Society of Testing and Materials, Philadelphia, 1980 Amyot M. L'oeil et Ie ski, condition d'exposition et protection. L'Actualite Medicinale 5 (20): 37-39, 1984 Barrell OV, Cooper PJ, Elkington AR, MacFayden JM, Powell RO, et al. Squash ball to eye ball. British Medical Journal 283: 893-895, 1981 Bartholomew RS, MacDonald M. Fish hook injuries of the eye. British Journal of Ophthalmology 64: 531-533, 1980 Bell JA. Eye trauma in sports: a preventable epidemic. Journal of the American Medical Association 246: 156, 1981 Blonstein JL. Eye injuries in sport with particular reference to SQuash rackets and badminton. Practitioner 215: 208-209, 1975 Board of Science and Education Working Party Report on Boxing. British Medical Association, London, 1984 Bowen 01, Magauran DM. Ocular injuries caused by airgun pel-

Eye Injury in Sport

lets: an analysis of 105 cases. British Medical Journal I: 333337, 1973 Brock L, Tanenbaum HL. Retention of wooden foreign in the orbit. Canadian Journal of Ophthalmology 15: 70-73, 1980 Burke MJ, Sanitato JJ, Yinger PF, Raymond LA, Kulwin DR. Soccerball-induced eye injuries. Journal of the American Medical Association 249: 2682-2685, 1983 Burry HC, Calcinai CJ. The need to make rugby safer. British Medical Journal 296: 149-150, 1988 Canavan YM, Archer DB. Anterior segment consequences of blunt ocular injury. British Journal of Ophthalmology 66: 549-555, 1982 Canavan YM, O'F1aherty MJ, Archer DB. Elwood JH. A IO-year survey of eye injuries in Northern Ireland 1967-76. British Journal of Ophthalmology 64: 618-625. 1980 Chandran S. Ocular hazards of playing badminton. British Journal of Ophthalmology 58: 757-760. 1974 Chandu Lal R. Subrahmanyam BV. Accidental death by air rifle. Forensic Science I: 441-443. 1972 Chapman-Smith JS. Eye injuries: a twelve-month survey. New Zealand Medical Journal 90: 47-49. 1979 Chow AY. Goldberg MF, Frenkel M. Evulsion of the optic nerve in association with basketball injuries. Annals of Ophthalmology 16: 35-37, 1984 Christianson MD. Parker JA. Arndt J. Material and thickness: the important factors in the impact resistance ofspectacle lenses. Canadian Journal of Ophthalmology 12: 300-303. 1977 Clayton T. Miller D. The response of the eye and adjacent structures to injury. In Miller & Stegmann (Eds) Treatment of anterior segment ocular trauma. Medicopoea. Montreal. 1986 Clemett RS. Fairhurst SM. Head injuries from squash: a prospective study. New Zealand Medical Journal 92: 1-3. 1980 Cole MD, C1earkin L. Dabbs T, Smerdon D. The seat belt law and after. British Journal of Ophthalmology 71: 436-440. 1987 Cole MD. Smerdon D. Perforating eye injuries caused by darts. British Journal of Ophthalmology 72: 511-514. 1988 Coroneo MT. An eye for cricket: ocular injuries of indoor cricketers. Medical Journal of Australia 142: 469-471. 1985 d'Angelo U. Hierholzer JC, Keenlyside RA, Anderson U. Martone WJ. Pharyngoconjunctival fever caused by adenovirus type 4: report of a swimming pool related outbreak with recovery of virus from pool water. Journal of Infectious Disease 140: 42-47. 1979 Davis JK. Lenses for sports vision. In Pizzarello & Haik (Eds) Sports ophthalmology. Charles C, Thomas. Illinois. 1987 de Juan E, Sternberg P. Michels RG. Penetrating ocular injuries: types of injury and visual results. Ophthalmology 90: 13181322, 1983 Doggart JH. The impact of boxing upon the visual apparatus. Archives of Ophthalmology 54: 161-169. 1955 Doxanas MT. Soderstrom C. Racquetball as an ocular hazard. Archives of Ophthalmology 98: 1965-1966. 1980 Drummond J. Kielar RA. Perforating ocular shotgun injuries: relationship of ocular findings to pellet ballistics. Southern Medical Journal 69: 1066. 1976 Duke M. Tennis players and eye injuries. Journal of the American Medical Association 236: 2287. 1976 Eagling EM. Perforating injuries of the eye. British Journal of Ophthalmology 60: 732-736. 1976 Eagling EM. Roper-Hall MJ. Eye injuries: an illustrated guide, Gower, London, 1986 Easterbrook M. Eye injuries in squash: preventable disease. Canadian Medical Association Journal 118: 298-305, 1978 Easterbrook M. Eye injuries in racquet sports: a continuing problem. Canadian Medical Association Journal 123: 268-269, 1980 Easterbrook M, Pashby TJ. Eye injuries associated with war games. Canadian Medical Association Journal 133: 415-417, 1985 Editorial. A ball in the eye. British Medical Journal 2: 195-196, 1973

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Elkington AR. Boxing and the eye: results of a questionnaire. Transactions of the Ophthalmological Societies of the United Kingdom 104: 898-902. 1985 Elliott AJ, Jones D. Major ocular trauma: a disturbing trend in field hockey injuries. British Medical Journal 289: 21-22, 1984 Ellis GS. Sports eye injuries: first aid and prevention. In Pizzarello & Haik (Eds) Sports ophthalmology, Charles C. Thomas. Illinois, 1987 Elman MJ. Racket-sports ocular injuries. Archives of Ophthalmology 104: 1453-1454. 1986 Fern AI. Kyle P. Allan D. Baton twirling: another cause of eye injury. British Journal of Ophthalmology 71: 931-932, 1987 Garrow A, A statistical enquiry into 1000 cases of eye injuries. British Journal of Ophthalmology 7: 65-80, 1923 Giovinazzo VJ, Yannuzzi LA, Sorenson JA. Delrowe OJ. Cambell EA. The ocular complications of boxing. Ophthalmology 94: 587-596, 1987 Glynn RJ. Seddon JM, Berlin BM. The incidence of eye injuries in New England adults. Archives of Ophthalmology 106: 785789, 1988 Grand MG. Lobes LA. Technique for removing a fishhook from the posterior segment of the eye. Archives of Ophthalmology 98: 152-153. 1980 Gregory PTS. Sussex Eye Hospital sports injuries. British Journal of Ophthalmology 70: 748-750. 1986 Haag JR, Gieser RG. Effects of swimming pool water on the cornea. Journal of the American Medical Association 249: 25072508, 1983 Heimann K. Paulmann H, Tavakolian U. The intraocular foreign body. International Ophthalmology 6: 235-242, 1983 Helveston EM. Football. In Pizzarello & Haik (Eds) Sports ophthalmology. Charles C. Thomas, Illinois, 1987 Hoefle FB. Baseball ophthalmology. In Pizzarello & Haik (Eds) Sports ophthalmology. Charles C. Thomas. Illinois, 1987 Holt JE. Holt R, Blodgett JM. Ocular injuries sustained during blunt facial trauma. Ophthalmology 90: 14-18. 1983 Hyde KJ. Della Roca RC. The management of acute trauma to the orbit and adnexa. Seminars in Ophthalmology 3: 20-33, 1988 I1sar M. Chirambo M, Belkin M. Ocular injuries in Malawi. British Journal of Ophthalmology 66: 145-148, 1982 Ingram DV, Lewkonia I. Ocular hazards of playing squash racquets. British Journal of Ophthalmology 57: 434-438. 1973 Jonasson F. Swimming goggles causing severe eye injuries. British Medical Journal 2: 881, 1977 Jonasson F. Cullen JF. Axonal transport injury caused by diving. American Journal of Ophthalmology 94: 813-815. 1982 Jones NP. Eye injuries in sport: an increasing problem. British Journal of Sports Medicine 21: 168-170. 1987 Jones NP. One year of severe eye injuries in sport. Eye, in press, 1988 Jones NP, Hayward JM, Khaw PT. C1aoue CMP, Elkington AR. Function of an ophthalmic 'accident and emergency' department: results of a six month survey. British Medical Journal 292: 188-190, 1986 Jones NP, Tullo AB. Severe eye injuries in cricket. British Journal of Sports Medicine 20: 178-179. 1986 Kanski JJ. Pathogenesis: significance of trauma. In Retinal detachment, Butterworths. London, 1986 Karlson T A, Klein BE. The incidence of acute hospital treated eye injuries. Archives of Ophthalmology 104: 1473-1476, 1986 Kaste EM, Vilkki J. Sainio K. Is chronic brain damage in boxing a hazard of the past? Lancet 2: 1186-1188, 1982 Kaufmann JH, Tolpin OW. Glaucoma after traumatic angle recession: a ten-year prospective study. American Journal of Ophthalmology 78: 648-654, 1974 Kay S, Lendrum J. Progress in cranio-orbital surgery. Seminars in Ophthalmology 3: 1-19, 1988 Keeney AH. Ocular sports injuries: standards of protection and

Eye Injury in Sport

prevention. I. Applications of protective principles from industry. International Ophthalmology Clinics 21: 168-169, 1981 Keeney AH, Renaldo DP. Impact resistance of ophthalmic lenses of various strengths and the influence of frame design. Canadian Journal of Ophthalmology 10: 367-376, 1975 Kelly SP. Serious eye injury in badminton players. British Journal of Ophthalmology 71: 746-747, 1987 Kennerley Bankes JL. Squash rackets: a survey of eye injuries in England. British Medical Journal 291: 1539, 1985 Koval R, Teller J, Belkin M, Romem M, Yanko L, et al. The Israeli Ocular Injuries Study. Archives of Ophthalmology 106: 776-780, 1988 Lambah P. Adult eye injuries at Wolverhampton. Transactions of the Ophthalmological Societies of the United Kingdom 88: 661-673, 1968 Littlewood KR. Blunt ocular trauma and hyphaema. Australian Journal of Ophthalmology 10: 263-266, 1982 Locke AS. Squash rackets: a review - deadly or safe? Medical Journal of Australia 143: 565-567, 1985 Lucas DR, Dunham AC, Lee WR, Weir W, Wilkinson FCF. Ocular injuries from liquid golf ball cores. British Journal of Ophthalmology 60: 740-747, 1976 MacEwen CJ. Sport associated eye injury: a casualty department survey. British Journal of Ophthalmology 71: 701-705, 1987 Maguire JI, Benson WE. Retinal injury and detachment in boxers. Journal of the American Medical Association 255: 24512453, 1986 Marshall RN, Sandes H. Dunedin sports injuries 1974-1976. New Zealand Medical Journal 86: 423-427, 1977 McCowan IA. Protecting the boxer. Journal of the American Medical Association 169: 1409-1413, 1959 Millar GT. Golfing eye injuries. American Journal of Ophthalmology 64,741-742, 1967 Mondon H, Lefrancois A, Lai C, Hamard H. Traumatisme ocularie au squash. Bulletin of the Ophthalmological Society of France 81: 303-306, 1981 Mooney D. Angle recession and secondary glaucoma. British Journal of Ophthalmology 57: 608-612, 1973 Moore AT, McCartney A, Cooling RT. Ocular injuries associated with the use of airguns. Eye I: 422-429, 1987 Moore MC, Worthley DA. Ocular injuries in squash players. Australian Journal of Ophthalmology 5: 46-47, 1977 Morris RE, Witherspoon CD, Feist RM, Byrne JB, Ottemiller DE. Bilateral ocular shotgun injury. American Journal of Ophthalmology 103: 695-700, 1987 Mueller FO, Blyth CS. A survey of 1981 college lacrosse injuries. Physician and Sports Medicine 10: 87, 1982 National Electronic Injury Surveillance System. US Consumer Product Safety Commission, 1976 National Electronic Injury Surveillance System. US Consumer Product Safety Commission, 1981 National Electronic Injury Surveillance System. US Consumer Product Safety Commission, 1982 National Society to Prevent Blindness. Fact sheet. New York, 1980 North 1M. Ocular hazards of squash. Medical Journal of Australia I: 165-166, 1973 Novak JF. Discussion on gunshot injuries. Ophthalmology 91: 983, 1984 Palmer E, Lieberman TW, Burns S. Contusion angle deformity in prize fighters. Archives of Ophthalmology 94: 225-228, 1976 Park JH, Frenkel M, Dobbie JG. Evulsion of the optic nerve. American Journal of Ophthalmology 72: 969-971, 1971 Parver LM. Eye trauma: the neglected disorder. Archives ofOphthalmology 104: 1452-1453, 1986 Pashby n. Eye injuries in Canadian hockey: phase II. Canadian Medical Association Journal 117: 671-678, 1977 Pashby TJ. Eye injuries in Canadian hockey: phase III. Older

180

players now at risk. Canadian Medical Association Journal 121: 643-644, 1979 Pashby TJ. Eye injuries in Canadian amateur hockey. Canadian Journal of Ophthalmology 20: 2-4, 1985 Pashby TJ. Eye Injuries in Canadian amateur hockey still a concern. Canadian Journal of Ophthalmology 22: 293-295, 1987 Pashby n, Pashby RC, Chisholm LDJ, Crawford JS. Eye injuries in Canadian hockey. Canadian Medical Association Journal 113: 663-674, 1975 Paul mann H. Blunt trauma injuries to the anterior segment. In Miller & Stegmann (Eds) Treatment of anterior segment ocular trauma, Medicopoea, Montreal, 1986 PfeitTer RL. Traumatic enophthalmos. Archives of Ophthalmology 30: 718-726, 1943 Pizzarello LD, Jordan B. Pugilism. In Pizzarello & Haik (Eds) Sports ophthalmology, Charles C. Thomas, Illinois, 1987 Portis JM, Vassallo SA, Albert DM. Ocular sports injuries: a review of cases on file in the Massachusetts Eye and Ear Infirmary Pathology Laboratory. International Ophthalmology Clinics 21: 4, 1981 Quere MA, Pietrini P. Eye injuries and squash. Bulletin of the Ophthalmological Society of France 86: 1499-1500, 1986 Ramanan SV. Eye injuries from tennis balls. Journal of the American Medical Association 236: 1355, 1976 Reid IS. Airgun injuries in children. Medical Journal of Australia I: 64-66, 1974 Reif AE, Vinger PF, Easterbrook M. New developments in protection against eye injuries. Squash News 4: 10, 1981 Robertson DM. Safety glasses as protection against shotgun pellets. American Journal of Ophthalmology 81: 671, 1976 Roden D, Cleary P, Eustace P. A five-year survey of ocular shotgun injuries in Ireland. British Journal of Ophthalmology 71: 449-453, 1987 Ross RJ, Cole M, Thompson JS, Kim KH. Boxers - computed tomography, electroencephalography, and neurological evaluation. Journal of the American Medical Association 249: 211213, 1983 Rousseau AP, Amyot M, Labelle PF. Winter sports: hockey and skiing. In Pizzarello & Haik (Eds) Sports ophthalmology, Charles C, Thomas, Illinois, 1987 Runyan TE. Physical forces involved in ocular trauma. In Miller & Stegmann (Eds) Treatment of anterior segment ocular trauma, Medicopoea, Montreal, 1986 Sabiston D. Squash and eye injuries. New Zealand Journal of Sports Medicine 4: 3-5, 1976 Salisbury JA. The eye and shooting. In Pizzarello & Haik (Eds) Sports ophthalmology, Charles C. Thomas, Illinois, 1987 Schein OD, Hibberd PL, Shingleton BJ, Kunzweiler T, Frambach DA, et al. The spectrum and burden of ocular injury. Ophthalmology 95: 300-305, 1988 Seelenfreund MH, Freilich DB. Rushing the net and retinal detachment. Journal of the American Medical Association 235: 2723-2726, 1976 Sevel D, Atkins AD. Pellet gun injuries of the eye. South African Medical Journal 54: 566-568, 1978 Shock JP, Adams D. Long term visual acuity after penetrating and perforating ocular injuries. American Journal of Ophthalmology 100: 714-718, 1985 Simmons ST, Kroehl GB, Hay PB. Prevention of ocular gunshot injuries using polycarbonate lenses. Ophthalmology 91: 977982, 1984 Sironi VA, Ravagnati L. Brain damage in boxers. Lancet I: 244, 1983 Spitz L. Air rifle injuries in children. South African Medical Journal 43: 557-560, 1969 Stein H, Slatt B, Stein R. Visual approach to winning tennis. In Pizzarello & Haik (Eds) Sports ophthalmology, Charles C. Thomas, Illinois, 1987

181

Eye Injury in Sport

Sternberg p. de Juan E. Green WR. Hirst LW. Sommer A. Ocular BB injuries. Ophthalmology 91: 1269-1277. 1984 Taylor TKF. Coolican MRJ. Spinal cord injuries in Australian footballers 1960-1985. Medical Journal of Australia 147: 112118.1987 Thordarson V. Ragnarsson AT. Gudbrandsson B. Ocular trauma. Acta Ophthalmologica 57: 922-928. 1979 Vernon SA. Analysis of all new cases seen in a busy regional centre ophthalmic casualty department during 24-week period. Journal of the Royal Society of Medicine 76: 279-282. 1983 Yinger PF. Ocular injuries in hockey. Archives of Ophthalmology 94: 74-76. 1976 Yinger PF. The incidence of eye injuries in sports. International Ophthalmology Clinics 21(4): 37. 1981a Yinger PF. Sports eye injuries. A preventable disease. Ophthalmology 88: 108-112. 1981b Yinger PF. The eye and sports medicine. In Duane TO (Ed.) Clinical ophthalmology. vol 5. Harper & Row. Philadelphia. 1985

Yinger PF. Knuttgen HG. Easterbrook M. Pashby TJ. Schnell D. Eye injuries and eye protection in sports: a position statement. International Federation of Sports Medicine. 1988 Yinger PF. Tolpin OW. Racket sports: an ocular hazard. Journal of the American Medical Association 239: 2575-2577. 1978 Warwick R (Ed). Wolffs anatomy of the eye and orbit. 7th ed .• ch. 2. HK Lewis. London. 1976 Whiteson AL. Injuries in professional boxing. Practitioner 225: 1053-1057. 1981 Wilson K. Rontal M. Facial injuries in football. Transactions of the American Academy of Ophthalmology and Otolaryngology 77: 434. 1973 Wykes WN. A IO-year survey of penetrating eye injuries in Gwent 1976-85. British Journal of Ophthalmology 72: 607-611. 1988

Author's address: Mr N.P. Jones. Manchester Royal Eye Hospital. Oxford Road. Manchester M 13 9WH (England).

4th World Conference on

Clinical Pharmacology and Therapeutics Date: 23-28 July 1989 Venues: Mannheim-Heidelberg, West Germany For further information, please contact: CPT89 c/o GKV Congress and Conventions P.O. Box 100619 D-6050 Offenbach 1 Federal Republic of Germany