When It Comes To Sports Safety, Optometrists Need to Get in the Game

If National Sports Eye Safety Month taught us anything, it’s that athletes of any age can do with advice from an optometrist on how to mitigate potentially vision-threatening ocular injuries. If it’s an optometrist’s duty to protect patients’ vision, finding out what sports they may play and advising them on eye safety options is a key function. 

While most ODs see at least some patients who spend time on a field, a diamond, a rink, or a court, few have the depth of experience of those who serve as official team clinicians. But with the advice of some of those expert optometrists, any optometrist can integrate a major league-worthy sports eye safety protocol into their practice.

Ocular Sport Injury Risks and Statistics

Combat sports, such as boxing and mixed martial arts, may appear to present a clear danger to patients’ vision, but studies suggest that basketball actually poses the greatest risk — followed by baseball, air rifle use, racquetball, and hockey.^1,2 By some estimates, more than 600,000 sports-related eye injuries occur every year with approximately 13,500 resulting in permanent loss of sight.³ Despite these numbers, however, the American Academy of Ophthalmology (AAO) reports that 90% of these injuries could be avoided if athletes utilized proper eyewear.¹ At first glance, their guidance is quite straightforward and simple: “Protective sports glasses with shatterproof plastic, called polycarbonate lenses, should be worn for sports such as basketball, racquet sports, soccer and field hockey. Choose eye protectors that have been tested to meet the American Society of Testing and Materials (ASTM) standards or that pass the CSA racquet sports standard.”¹

This advice could result in fewer sports-related eye injuries, but implementing them may present practical challenges or affect athletic performance. Will athletes, professional or otherwise, allow anything to stand in the way of sinking a 3-pointer or hitting a home run? 

Protective Eyewear 

Paul Harris, OD, professor at Southern College of Optometry has seen his share of sports-related eye injuries both during his days of private practice, and in his current role as team optometrist with the Baltimore Orioles. While he staunchly advocates having school-aged athletes protect their eyes at all times on the field, he acknowledges that this may not always be possible for athletes at the professional level. 

“The younger the player, the more at risk they are,” he says. While it may be true that professionals throw harder fastballs, deliver more powerful slapshots, or hit harder than their amateur or high-school level counterparts, Dr Harris attributes experience and sports IQ with an ability to avoid injury. “The higher the level of athlete, the better the ability to avoid various levels of injuries or concussions.”

Research supports Dr Harris’s assertions. Dynamic visual acuity in college baseball players was found to be superior to that of their less athletic peers “due to an improved ability to track moving targets with their eyes.”⁴ The development of superior eye tracking is not exclusive to baseball players. And another study suggests that age, in addition to athletic proficiency, affects the decision-making abilities of athletes of all skill levels: “age-related improvements in visual cognition and accumulation of sport-specific experience explain a considerable amount of the development in decision making in volleyball.”⁵ 

In his days of private practice, Dr Harris made an effort to ensure that his patients were informed on the dangers of participating in sports without eye protection, and that they understood that dress glasses do not serve an adequate protective function. He explains that every dispensary should display sports safety glasses alongside dress wear frames, and that it is not enough for eye care professionals to simply recommend these devices. They must also ensure the glasses are appropriately sized and fit to adequately protect upon impact. 

However, Dr Harris acknowledges that fitting athletes with such glasses is not always feasible. “Contact lenses are preferred over glasses” as a method of vision correction for those playing at the elite level, he explains. Although protective eyewear could potentially shield these athletes from the impact of a speeding fastball, he says that they present the problem of “induced prism caused by spatial distortions.” Fast and tricky pitches require optimal eye-tracking, and the peripheral distortions that sometimes accompany spectacle lenses may complicate getting a hit or making the split-second decision to jump out of the way of an errant fastball. 

Hockey players face similar challenges according to David Meltzer, OD, an assistant professor at Salus University. In addition to serving as an optometrist and an educator, Dr Meltzer is also a member of the Philadelphia Warriors, an NHL-affiliated hockey team for US military veterans. Like Dr Harris, he acknowledges that it is not always practical for these athletes to wear safety appropriate glasses. “It affects their side vision and below at their feet,” he says. Hockey players need to be concerned with appropriately tracking the puck and keeping an eye out for opponents who may be trying to hit them. 

Despite their ability to protect from impact, safety glasses, visors, and face cages can serve as potential obstructions to field of view and these athletes “don’t want anything in their field of vision and want to control the puck with no issues,” according to Dr Meltzer.

However, the mitigation of risk is essential — particularly in the often lucrative, but short-lived world of professional athletes. Although contact lenses may be the preferred method of vision correction in professional sports, Dr Harris acknowledges that player safety is of utmost importance. “If you have a player with damage to one eye, you want to make sure you have protection in front of that eye,” he emphasizes. 

For Dr Meltzer also, eye safety is paramount, both in clinical practice and on the ice. In fact, he wears a face cage while playing himself. Not all of his teammates follow suit, however. While he admits that he may occasionally discuss eye safety with his team, playing good hockey is the main objective once he suits up for a game. Whether he is among his Warriors teammates or serving patients in his clinical role, he knows that it is not easy to change old habits, particularly when it comes to individuals playing a game they love. “Sometimes it’s hard to change the way people play sports,” he says.     

Backyard Eye Injuries

However, one does not need to play at a competitive level to be at risk for ocular injury. A majority of eye injuries do not occur on the baseball diamond or basketball court, but right within the confines of one’s own home — 50% in fact, according to the American Academy of Ophthalmology.⁶ Although cleaning, home improvement projects, and yard work are considered some of the biggest culprits, lawn sports such as badminton and volleyball claim their fair share of eye-related injuries. Estimates show that 25 to 40% of patients admitted to the hospital with ocular trauma are victims of sports-related causes, and among those, 14.3% are the result of badminton.⁷ 

Whether playing a friendly backyard game of badminton or competing in an intense game 7 eliminator during the Stanley Cup playoffs, sports-related eye injuries are always a possibility. While one may easily argue that professional athletes are well compensated for the sight-threatening hazards accompanying their occupation, it would be difficult to apply similar logic to children participating in recreational sports. Those with the ability to compete at higher levels in the future may not have the opportunity to actualize their potential in the event of an eye injury. Other sports and recreational activities that come with the potential for ocular injury include wrestling, the use of non powdered guns, cheerleading, and gymnastics.⁸ Nonetheless, a majority of such injuries are preventable. Miller et al argue that “Increased prevention efforts are needed, including child, parent, and coach education, along with adoption of rules that mandate the use of eye protective equipment to decrease sports- and recreation-related eye injuries among children.”⁸

Get An Eye Exam Before Joining the Team

As parents, leagues, and coaches ramp up their prevention efforts, clinicians must use their expertise to navigate young athletes away from potential injury. While appropriate equipment is essential, simply reminding patients of the importance of coming in for yearly eye exams may help them become more aware of specific reasons to protect their vision. “Comprehensive eye care may be a key component to eye safety,” according to Katherine Weise, OD, a professor at the University of Alabama at Birmingham (UAB) School of Optometry. As eye care physician for UAB’s athletic teams, Dr. Weise states that specific clinical findings may help athletes understand the importance of protecting their vision and compel them to take appropriate precautions. During her tenure with the Blazers, Dr Weise and her colleagues researched how athletes approach comprehensive eye care vs preseason physicals. “[We] found that nearly two-thirds of the athletes tested had never had a formal eye exam before,” according to Dr Weise. “When we followed up with dilated eye exams, we found that 5% had a reason to recommend extra eye protection including fragile corneas and retinas. We found another 5% that required extra eye protection (having 1 good eye and 1 bad eye).” If athletes are more aware of the unique circumstances pertaining to their eyes, they may be more inclined to heed clinical advice on protecting their vision.    

Nonetheless, even with appropriate preventative measures, an athlete can still experience a potentially sight-threatening injury. Eye care professionals must act promptly and appropriately in such situations. Dr Weise advises, “Eye injuries may be rare, but an approach on how to become rapidly available in acute situations is critical. Team eye doctors need to assess how well a player sees (or doesn’t), whether or not they are seeing double, the integrity of the facial bones, the structural integrity of the eyelids, and whether or not there is inflammation inside the eye, a scratch to the eye, or a detached or bruised retina.” 

The research echoes Dr Weise’s recommendations — particularly with respect to performing preparticipation eye exams. “A complete eye examination should be part of any sports physical,” according to an investigation. “With each athlete, physicians should obtain an ocular history, paying special attention to prior conditions such as a high degree of myopia, surgical aphakia, retinal detachment, eye surgery, and injury or infection.”⁹ However, in the event an eye injury does occur, the same study advises that eye care providers determine the mechanism of injury, perform confrontation visual fields, examine pupils for reflex and anisocoria, assess full motility in all gaze positions, and perform an external examination.⁹

Although Dr Weise’s advice can serve as a general guide to treating ocular injury, such injuries vary in their nature and severity. They can be minor, such as subconjunctival hemorrhages or corneal abrasions, or more serious or vision-threatening injuries such as a hyphema or puncture.⁸ Minor, nonsight-threatening injuries such as corneal abrasions may simply warrant close monitoring and extra caution. Topical anesthetic treatments may even harm the corneal epithelium, and protection with an eye patch is not recommended.¹⁰ Athletes can even return to play, in most cases, if visual acuity is unaffected, provided they abstain from contact lens use.¹⁰ 

More serious injuries such as hyphema, vitreous hemorrhage, retinal detachment, and globe-penetrating injuries will require referral to an ophthalmologist.¹⁰ Nonetheless, optometrists can take care to shield and protect the injured eye, and discontinue the use of anti-inflammatory and anticoagulant drugs in cases of hyphema and vitreous hemorrhage in states where there scope of practice allows them to do so.¹⁰

Responses From Professional Sports Leagues    

The AAO adds that athletes are not the only individuals at risk for ocular injury during sporting events. Spectators may unwillingly find themselves involved in the action, and “balls, bats, and players can end up in the stands at any time. Keep your eyes on the game and watch out for foul balls and flying objects,” they advise.¹ Line drives and deflected pucks have left spectators with severe injuries, with 1 such injury resulting in death.¹¹ The 2018 Ryder Cup witnessed a spectator becoming blind in one eye as the result of an errant golf stroke.¹¹ These events have caused professional sports leagues to take notice and some have implemented ways of protecting fans. When a stray puck killed a 13-year old girl during a Columbus Bluejacket’s game in 2002, the NHL mandated the installation of 18-foot nets in the corners and ends of the ice in all of its stadiums.¹¹ A 2018 Major League Baseball mandate requires teams to extend netting to the end of the dugout, with some teams opting to provide even greater protection.¹¹   

Although there is no way to guarantee the alleviation of sports-related ocular injuries with 100% certainty, adhering to AAO guidelines on sports safety glasses can help make eye injuries more of an exception than a rule.  

References

1. Sports eye safety. American Academy of Ophthalmology. https://www.aao.org/eye-health/tips-prevention/injuries-sports. Updated March 8, 2021. Accessed May 2, 2022. 
2. Haring RS, Sheffield ID, Canner JK, Schneider EB. Epidemiology of sports-related eye injuries in the United States. JAMA Ophthalmol. 2016;134(12). doi:10.1001/jamaophthalmol.2016.4253
3. Mishra A, Verma AK. Sports related ocular injuries. Med J Armed Forces India. 2012;68(3):260-266. doi:10.1016/j.mjafi.2011.12.004
4. Uchida Y, Kudoh D, Murakami A, Honda M, Kitazawa S. Origins of superior dynamic visual acuity in baseball players: superior eye movements or superior image processing. PloS One. 2012;7(2):e31530. doi:10.1371/journal.pone.0031530
5. De Waelle S, Van Bostraeten S, Lenoir M, Deconinck FJ, Bennett S. Visual cognition and experience mediate the relation between age and decision making on youth volleyball players. Optom Vis Sci. 2021;98(7):802-808. doi:10.1097/OPX.0000000000001724
6. Eye safety at home: preventing eye injury. American Academy of Ophthalmology. https://www.aao.org/eye-health/tips-prevention/injuries-in-home. Updated March 1, 2016. Accessed May 2, 2022.
7. Khandelwal R, Majumdar MR, Gupta A. An unusual mechanism of ocular trauma in badminton players: two incidental cases. BMJ Case Rep. Published online August 8, 2012. doi:10.1136/bcr-2012-006363
8. Miller KN, Collins CL, Chounthirath T, Smith GA. Pediatric sports- and recreation-related eye injuries treated in US emergency departments. Pediatrics. 2018;14(2):e20173083. doi:10.1542/peds.2017-3083
9. Rodriguez JO, Lavina AM, Agarwal A. Prevention and treatment of common eye injuries in sports. Am Fam Physician. 2003;67(7):1481-1488. https://www.aafp.org/afp/2003/0401/p1481.html
10. McCracken W, Smith D. Sports-related eye injuries. Curr Sports Med Rep. 2017;16(2):64-65. doi:10.1249/JSR.0000000000000336
11. Farrell S. Sports leagues taking steps to further protect fans from balls, bats and pucks. Cronkite News. Posted August 26, 2019. https://cronkitenews.azpbs.org/2019/08/26/sports-fan-safety-protective-nets/. Accessed May 2, 2022.