Eye Injuries

General Principles

  • A 2013 study estimated over 30,000 emergency department visits annually for sports- and recreation-related eye injuries. The majority of these injuries occurred in individuals younger than 25 years, with a peak during adolescence, and 80% occurred in males.

  • Approximately 1.5% of all sports-related injuries involve the eye or ocular adnexa. These injuries have a high morbidity rate, and long-term visual impairment can lead to additional medical and socioeconomic sequelae. The highest rate of visual impairment occurs with projectile-firing devices, such as paintball, air, or pellet guns.

  • In the United States, basketball is the leading sports-related cause of eye injuries, followed by baseball/softball and cycling. In Europe and South America, soccer is the leading cause.

  • Although eye protectors cannot completely eliminate the risk of injury, appropriate and well-fitted eye protection can reduce the risk of significant eye injury by as much as 90%.

  • The American Association of Pediatrics and the American Academy of Ophthalmology 2004 position statement on protective eyewear in young athletes categorizes sports by the risk of eye injury to the unprotected eye ( Table 47.1 ). Although there is no ideal collecting system for data, there are national reporting systems at the high school (High School Reporting Information Online [HS RIO]) and collegiate levels (National Collegiate Athletic Association Injury Surveillance Program [NCAA ISP]) ( Table 47.2 ).

    Table 47.1
    Risk Categories for Sports
    Modified from Vinger PF. A practical guide for sports eye protection. Phys Sports Med. 2000;28(6):49–69; Committee on Sports Medicine and Fitness. Protective eyewear for young athletes. Pediatrics. 2004;113(3):619–622.
    High risk Small, Fast Projectiles

    • Air rifle/BB gun

    • Paintball

    • Hard projectiles, fingers, “sticks,” close contact

    • Baseball/softball/cricket

    • Basketball

    • Fencing

    • Field hockey

    • Ice hockey

    • Lacrosse (in men and women)

    • Squash/racquetball

    • Street hockey

    Intentional Injury

    • Boxing

    • Full-contact martial arts

    Moderate Risk
    • Fishing

    • Football

    • Soccer/volleyball

    Low Risk
    • Bicycling

    • Noncontact martial arts

    • Skiing

    Eye Safe
    • Gymnastics

    • Track and field

    Table 47.2
    Rate of Eye Injuries as Reported in NCAA ISP
    Data from Boden BP, Pierpoint LA, Boden RG, Comstock RD, Kerr ZY. Eye injuries in high school and collegiate athletes. Sports Health . 2017;9(5):444–449.
    Rate of Eye Injury Per 100,000 Athlete-Exposures
    Men Women
    Wrestling 10.06
    Field hockey 5.61
    Basketball 5.13 7.24
    Softball 2.39
    Baseball 1.64
    Soccer 2.09 2.55
    Volleyball 1.32
    Football 0.83
    Lacrosse 0.70

Mechanisms of Eye Injuries in Sports

  • Eye injury severity is correlated with total impact force, rate of force onset, and kinetic energy of impacting object.

  • Ocular injuries fall into several broad categories ( Table 47.3 ).

    Table 47.3
    Relative Frequency of Eye Injuries
    Most Common Relatively Infrequent Eye Emergencies
    Corneal abrasion Chemical burns Globe disruption
    Corneal foreign body Vitreous hemorrhage Retinal detachment
    Conjunctival foreign body Retinal edema or hemorrhage Lens dislocation
    Subconjunctival hemorrhage Hyphema Blowout fracture of the orbit
    Eyelid laceration Injury to the lacrimal system Optic nerve injury

  • Open globe injuries are full-thickness wounds to the eye wall (cornea or sclera) and may result from a blunt or penetrating trauma. Activities that cause ruptured globes typically have a stick or projectile that fits into the orbit. An underlying history of eye surgery or eye disease may increase the risk of open globe injury.

  • Lacerations may be caused by objects that “slice” or penetrate the eye, which may lead to open globe injuries.

  • Closed globe injuries are those that do not completely penetrate the cornea or sclera. These include lamellar lacerations, corneal abrasions, contusions, hyphema, or injury to the choroid, macula, retina, or optic nerve.

  • Blunt injuries, typically causing contusions, globe rupture, or adnexal injury, account for most sports-related eye injuries. Contusions are usually caused by blunt objects smaller than the orbit (e.g., golf ball or finger). In addition, several objects will deform significantly on impact (e.g., soccer ball), producing a “knuckle” that will impact the eye ( Fig. 47.1 ). With objects smaller than the orbit, there is generally a greater force transmitted to the internal structures of the eye, whereas with larger objects, there is an increased risk of orbital wall fracture and occult internal ocular injuries.

    Figure 47.1, Large object causing injury to the globe.

  • Radiant energy or ultraviolet (UV) burn injuries are less common but may occur in activities that take place at a high altitude or on snow.

Principles of Protection From Eye Injuries in Sports

  • Protective devices work by deflecting the impact energy away from the eye and dissipating the energy over time and area. This is typically accomplished with either a lens or a mechanical grid (e.g., wire-framed face guard or mesh-fencing helmet).

  • Inappropriate fit of protective gear can decrease the protection offered, placing the eye at an increased risk.

  • Gear must be comfortable and not interfere with athletic performance.

  • Contact lenses offer no protection. Athletes who wear corrective lenses should wear one of these three options:

    • Contact lenses plus the appropriate protective eyewear

    • Polycarbonate lenses in sports frames that pass the appropriate American Society for Testing and Materials (ASTM) standard

    • Over-the-glasses protector that conforms to the appropriate ASTM standard

Certification and Selection of Eyewear

  • Organizations that certify sports protective eyewear include the Protective Eyewear Certification Council (PECC), Canadian Standards Association (CSA), Hockey Equipment Certification Council (HECC), and National Operating Committee on Standards in Athletic Equipment (NOCSAE). The equipment approved by these organizations commonly bears their seal and should be selected when available ( Table 47.4 ).

    Table 47.4
    Standards and Certifying Organizations for Selected Sports
    From the American Academy of Ophthalmology (AAO). www.aao.org .
    Sport Eye Protection Standards Certifying Organizations
    Baseball Polycarbonate or wire face guard attached to a helmet while batting; sports goggles with polycarbonate or TriVex lenses while on the field ASTM F910 PECC
    Basketball Sports goggles with polycarbonate or TriVex lenses ASTM F803 PECC
    Field hockey Full face mask for the goalie; sports goggles with polycarbonate lenses or wire mesh goggles while on the field ASTM F803 PECC
    Football Wire face mask and polycarbonate eye shield attached to the helmet NOCSAE
    Ice hockey Helmet with full face protection ASTM F1587
    ASTM F513
    Men’s lacrosse Helmet with full face protection NOCSAE
    Women’s lacrosse Full face protection or sports goggles with either polycarbonate lenses or wire mesh goggles ASTM F803 PECC
    Paintball Full face protection ASTM F1776 PECC
    Racket sports Sports goggles with polycarbonate or TriVex lenses ASTM F803 CSA/PECC
    Skiing High impact–resistant eye protector ASTM F659 PECC

  • ASTM International has written performance standards based on design and strength, upon which many of these organizations base their certification (see Table 47.4 ).

  • For sports with no appropriate ASTM standards or certified equipment, the American National Standards Institute (ANSI) should be considered.

Preparticipation Eye Examination

  • Preparticipation eye examinations should include the assessment of visual acuity, visual fields, pupillary size and responsiveness, eye movements, and ophthalmoscopy.

  • Documentation of anisocoria is imperative in order to determine if it is preexisting or caused by an acute injury. Up to 20% of the population may have physiologic anisocoria of >0.4 mm. In physiologic cases, there will be no associated visual field defects or diplopia. The afferent and efferent pupillary light reaction will also be normal.

  • Assess athlete’s history for high degree of myopia, surgical aphakia, retinal detachment, eye surgery, infection, or injury and family history for retinal detachment, retinal tears, or diabetic retinopathy. All these conditions increase risk of serious eye injury and thus require ophthalmologic consultation before participation in high-risk or very high-risk sports.

Visual Risk Factors

  • Best-corrected visual acuity worse than 20/40 in either eye or spectacle correction for myopia or hyperopia >6 diopters; disease, degeneration, or structural weakness of the eye itself; thin sclera; history of retinal degenerative disease; and history of eye surgery that weakens the outer wall of the eye, particularly cataract or refractive surgery. Athletes with such risk factors should be evaluated by an ophthalmologist before engaging in high-risk or very high-risk sports.

  • Disability from high corrective spectacle lenses can sometimes be mitigated by contact lenses; however, contact lenses themselves can be a risk factor.

  • Functionally one-eyed athletes face additional risk. A person is functionally one-eyed when loss of the better eye would result in significant changes in lifestyle because of poor vision in the remaining eye.

    • A child with vision worse than 20/40 should be considered functionally one-eyed. Assessment of adults is more difficult because their judgment and values determine the visual impairment they are willing to accept. Special considerations are necessary for such athletes.

    • The only sports absolutely contraindicated for functionally one-eyed athletes are boxing and full-contact martial arts because the risks of serious injury are high and there is no effective eye protection. Wrestling and noncontact martial arts have a lower incidence of eye injury, but also do not have effective eye protection. They should be discouraged for functionally one-eyed athletes and banned for monocular athletes.

Examination and Functional Testing After Injury


  • Mechanism of injury is important. Historical features such as type of trauma (blunt vs. penetrating), direction of force, object size, and whether eye protection was worn influence the type of injury.

  • Relevant signs and symptoms include pain, decreased visual acuity, diplopia, flashers, floaters, and halos around lights.

  • Intraocular injuries or foreign bodies may be painless because the lens, retina, and vitreous have no pain sensation.

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