ation is essential. Whether on the playing it is important to keep in mind that severe

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1 JENNIFER LAIO, MD, and BRUCE M. ZAGELBAUM, MD NYU School of Medicine, Manhasset, NY North Shore University Hospital, Eye injuries sustained in sports and recreational activities are common in the United States. Of the more than 2.4 million ocular injuries that occur each year, approximately 100,000 cases are sports related (Stock & Cornell, 1991). Once an eye injury is sustained, prompt evalu- With any eye injury, raold and treatment is ess~~ ntial for optimizing visual out( OM?. An emerqency first-ai d kit for oc~ examination should a lways be available, complete.,, atter hov injury see ation is essential. Whether on the playing field or in the office, it is important to keep in mind that severe underlying injuries may exist and vision-threatening complications may occur. A systematic approach including a careful history, complete examination of both eyes, and appropriate management is the key to reducing ocular morbidity from sports related injuries (Grewel et al., 1996; Zagelbaum, 1995a, 1995b. Sport-specific trends are well recognized in eye injuries. When evaluating sports related eye trauma, one should inquire about the environment in which the injury occurred and the mechanism of injury. It is important to note whether the patient wore contact lenses, glasses, or protective eyewear at the time of injury; these items should be inspected for damage. The examiner should also obtain the patient's ocular history including any past trauma or surgery to the eye concerned. Knowing the patient's baseline best-corrected vision helps in assessing the severity of the injury. Finally, questions regarding past medical history, medications (including eye drops), and allergies are obtained. A complete examination of both eyes enables an examiner to determine the nature and the extent of injury. In most instances, the initial examination of an athlete with an eye injury will take place at the sporting event. For this reason, an emergency first-aid kit for ocular examination should always be available. Examination should always include the following: Visual Acuity Ideally, visual acuity should be tested with a Snellen eye chart posted at 20 feet away or a pocket vision card held at a comfortable reading position. Each eye should be tested independently (the fellow eye is covered) for the best-corrected vision. Glasses or contact lenses, if worn, should be used. Start with the smallest line on the chart and move up, recording the smallest line where more than half of the letters are read accurately. When patients fail to see the largest line at 20 feet, they should be moved closer to the eye chart until they can see the larger print on the chart. The distance at which patients stand from the chart is noted in feet. The visual acuity will be I999 Human Kinetics. ATT L(5), pp. 36-L SEPTEMBER 1999 ATHLETIC THERAPY TODAY

2 that involves the margin should be evaluated by an ophthalmologist, as it may involve damage to the nasolacrimal system. Significantperiorbital edema and eccyhmosis should raise suspicion of an underlying orbital wall fracture. Palpate the area for subcutaneous emphysema, the orbital rim for bony displacement, and the cheek for hypesthesia (numbness). Pupils ipped ay~plicators(sterile Eye pad sleye shield (plastic or n Idpt: T.. - Sterile ocular irr igant (scxueeze b pica1 antibiotics (I.e., tomamy Contact lens case and sc Sterile gauze spcx-iges recorded by using the distance as the numerator. For instance, a patient seeing a line at 5 feet from the chart has visual acuity. If the patient cannot read the Snellen chart, he or she should be asked to count the examiner's fingers at different distances. If unable to count fingers, perception of hand movements or light should be recorded. A penlight or flashlight can be used as the light source. The results should be documented as finger counting or hand movements, light perception or no light perception. If a standard vision chart is not available, a newspaper or magazine can be used. In trauma cases, vision should be tested promptly for both medical and legal reasons. Any decrease in visual acuity is a red flag for the examiner to suspect a vision-threatening injury. Eyelids and Adnexa The lids and periorbital areas should be thoroughly inspected for abrasions, lacerations, foreign bodies, edema, erythema, and ecchymosis. A lid laceration ATHLETIC THERAPY TODAY Using a penlight, inspect both pupils for size, shape, and reaction to light. An irregularly peaked pupil warrants a careful examination for possible ruptured globe. Each pupil is tested individually for direct reaction to light and the consensual response is checked as well by swinging a penlight back and forth between the two pupils. Each pupil should normally constrict when the light is directed toward the fellow pupil. Detection of a paradoxical dilation of any pupil (relative afferent pupillary defect) is significant and requires evaluation by an ophthalmologist. Extraotular Movements Extraocular muscle function is tested by asking the patient to look up, down, right, and left without moving the head. It is important to look for limitations of movements in any gaze and see if there is any diplopia (double vision) in a particular gaze. The presence of any of the above may indicate an orbital fracture with muscle entrapment or hemorrhage. Anterior Segment The conjunctiva should be inspected for injection (redness), swelling, hemorrhage, lacerations, or foreign bodies. Applying fluorescein dye into the area helps visualization of transparent objects, such as glass and contact lens fragments. The cornea should also be checked for abrasions, lacerations, haziness, and foreign bodies. If a corneal laceration is present, this is a medical emergency and should be referred to an emergency room immediately. The anterior chamber-the space between the cornea and the iris plane-is examined for depth and hyphema (blood in the anterior chamber). One eye should be compared with the other for depth. The iris should be checked for any irregular shape. Although difficult, if the lens is viewed, its clarity should be noted. SEPTEMBER

3 Posterior S~grnent A good examination of the vitreous cavity, retina, choroid, and optic nerve requires both pupils to be dilated. When a patient is unconscious or confused, dilation should be deferred until a neurologic evaluation is done. A hand-held direct ophthalmoscope can be used to examine the posterior segment. Indirect ophthalmoscopy provides a broader view and is usually done by an ophthalmologist. Diagnsris and Managamsnt Corn~al Abrasion Corneal abrasions are among the most common sports related eye injuries. They result from a blunt or projectile object striking the eye. The corneal epithelium is disrupted and sloughs off, rendering the underlying layers susceptible to infection. Patients with corneal abrasions generally complain of foreign body sensation, pain, tearing, and sensitivity to light. Visual acuity is decreased to various degrees depending on the location of the abrasion. Other signs include conjunctival injection, eyelid swelling, and iritis (inflammation in anterior chamber). The cornea may be examined with a slit lamp or penlight with a cobalt blue filter. A drop of fluorescein dye with or without topical anesthetic is applied to the inferior cul-de-sac, the space between the lower lid and the globe. The dye is taken up by an epithelial defect and gives off a bright green fluorescent light when viewed with a penlight (Photo 1). A cobalt blue filter attached to a penlight allows a better view. The primary treatment for a corneal abrasion is a broad-spectrum topical antibiotic and a pressure Photo I The briaht stain lcentrallv located) appeared on thiipatientlicornea after fluorescein was applied. The staining area outlines the corneal abrasion present. patch. A cycloplegic agent (e.g., 1 % cyclopentolate hydrochloride) may be used for patient comfort. The patient should be evaluated the following day. Topical anesthetic agents should not be used to treat corneal abrasions. Their regular use may cause corneal epithelial defects, infiltrates, inflammation, severe pain, and decreased vision (Zagelbaum et al., 1994). A pressure patch should not be used for contact lens wearers, as this puts them at risk for developing further infection. Chato Z A subconjunctival hemorrhage is seen as blood loculated ~ Q ~ W the Q Q white ~ sclera and the overlying conjunctiva. Subtonjunctival Hemorrhag~ Breakage of small conjunctival vessels results in a blood loculus forming between the conjunctiva and the sclera (Photo 2). This is a common finding with blunt eye trauma and patients are usually asymptomatic. Upon initial examination, the hemorrhage should be traced to its posterior border in order to rule out a retrobulbar hemorrhage. The presence of other signs associated with retrobulbar hemorrhage, such as proptosis and limitation of extraocular movements, will further differentiate the two. Subconjunctival hemorrhage., usually resolves within 2 weeks and treatment is not necessary. When patients have marked subconjunctival hemorrhage in association with significant chemosis (swelling of bulbar conjunctiva) and/or decreased vision, a ruptured globe should be suspected. Prompt evaluation by an ophthalmologist is indicated.. Trau Traumatic iritis is an inflammation of the iris or ciliary body. Blunt trauma to the orbital region generally causes this condition. Patients typically complain of 38 1 SEPTEMBER 1999 ATHLETIC THERAPY TODAY

4 photophobia, pain, and decreased vision. The pupil may become miotic (constricted) and react poorly to light. The conjunctiva is injected, especially in the area directly surrounding the cornea (ciliary flush). Treatment of iritis consists of a topical steroid (e.g., prednisone acetate 1 %) to reduce inflammation and a cycloplegic agent (e.g., cyclopentolate hydrochloride 1 %) to reduce pain and photophobia. Topical steroids should be tapered off quickly when the inflammation is resolved. Eyelid Laceration Patients with eyelid lacerations should have a complete ocular examination before repair to ensure that there is no other ocular damage. If an eyelid laceration involves the lid margin or deep structures of upper eyelids, or if there is excessive loss of tissue, repair should be done by an ophthalmologist. Otherwise, the laceration may be closed by careful approximation of skin using 6-0 or 7-0 silk or nylon sutures. In preparation for the repair, the wound and surrounding tissues should be thoroughly irrigated with saline solution and cleaned with povidone iodine. Local anesthesia (e.g., 2 5% lidocaine with epinephrine) is used and sterile technique should be followed throughout the procedure. Tissues should be handled with care in an effort to preserve the structure of the lid. Sutures are generally removed within 7 days. Uyphema Hyphema is blood in the anterior chamber, usually as a result of blunt trauma or direct laceration to the globe. The blood comes from broken vessels in the iris or ciliary body. Patients often complain of decreased vision and pain. The blood exists in the anterior chamber as a clot, a pool of layered blood, or suspended red blood cells (microhyphema) (Photos 3 and 4). A complete eye examination should be performed to make sure the patient has not sustained a ruptured globe. Management of hyphema could be complicated and at least three issues should be addressed: (a) decrease the patient's discomfort, (b) minimize the chance of rebleeding, and (c) prevent complications. Long-standing hyphema can cause corneal staining and significant elevation of intraocular pressure. The Pketcl3 Bright red blood can be seen in the anterior chamber, between the cornea and the iris. This signifies a hyphema. Also note: (a) the subconjunctival hemorrhage present and (b) the irregular pupil. This patient actually had a ruptured globe. Photo 4 In this case the hyphema is layered. general recommendations for management include the following: a topical steroid or cycloplegic agent for patient comfort; an eye shield for protection; reduced activity level or bed rest; elevating the head of the bed 30" ; and avoiding aspirin or anticoagulants. Patients should be examined by an ophthalmologist daily. Patients who are unable to comply with the above regimen are admitted for hospitalization. Sometimes surgical intervention may be required for hyphema and its associated complications. Foreign Bodies Patients who complain of foreign body sensation, pain, photophobia, and tearing should be checked for the presence of foreign bodies. These tend to lodge on the corneal and conjunctival surfaces as well as in the conjunctival fornix. A penlight or slit-lamp allows direct visualization of the foreign body most of the time. Applying a drop of fluorescein dye onto the surface helps outline clear objects and detect associated ATHLETIC THERAPY TODAY SEPTEMBER

5 corneal and conjunctival damage. It is necessary to evert the upper eyelid to look for hidden foreign bodies. Treatment begins with administering a topical anesthetic drop to alleviate pain. Generous irrigation with saline is performed, directing the stream at the eye. A sterile cotton swab may be used to sweep away any loose foreign material. If a foreign body is embedded into the corneal surface, its removal requires the use of a 30-gauge needle or a foreign body spud. This is usually done by an ophthalmologist with the aid of a slit-lamp for magnification. A topical antibiotic drop or ointment is applied after removal. A pressure patch may necessary if a corneal abrasion has occurred. The patient can be managed with a topical antibiotic. Orbital Wall Fracture Orbital wall fractures, or "blowout fractures," often occur with blunt trauma to the orbit. Compact forces are transmitted to produce anteriorlposterior compression and equatorial expansion. Since the medial wall and the floor are the thinnest orbital bones, they tend to be fractured most frequently. Patients present with periorbital edema, ecchymosis, and pain. Other symptoms and signs include painful and limited eye movements (Photo 5), diplopia, subcutaneous emphysema, swelling of lids with nose blowing (due to fracture into the sinuses), hypesthesia in the upper cheek area, and enophthalmos (inward displaced eye). Radiological studies are indicated if patients have signs and symptoms of orbital wall fractures. Plain x- rays may be used, but CT scanning using thin 3-mm cuts (axial and coronal views) is preferred. Initial management of orbital wall fractures includes abroadspectrum oral antibiotic for prophylaxis and observation. Patients should avoid nose blowing if possible. Surgery is delayed for 10 to 14 days after the injury to allow the swelling to subside. Indications for surgical repair are persistent diplopia (secondary to entrapped extraocular muscle and tendon) or cosmetically significant enophthalmos (caused by prolapse of orbital content through a large bony defect). Ratptuhed Globe When evaluating a patient with an eye injury, one should always suspect a ruptured globe. The symptoms associated with a ruptured globe are typically pain and decreased vision. However, symptoms may be nonspecific and can vary in intensity. Alerting signs include excessive conjunctival hemorrhage and edema, irregular pupil shape, prolapsed iris through a wound (Photo 6), asymmetry of anterior chamber depth between both eyes, and very low intraocular pressure. PLapto 6 The iris is prolapsed through the eye, signifying a ruptured globe. When the diagnosis of a ruptured globe is made or strongly suspected, the affected eye should immediately be covered with a protective shield. Eyedrops should not be used and there should not be any manipulation of the eye or adnexa. The patient is not allowed to eat or drink, as prompt surgical intervention is generally required. If an intraocular foreign body is suspected, CT of the orbits should be performed. Photc E After sustaining blunt trauma, extraocular movements were checked. Note that upon upgaze, the left eye was unable to look up. A left orbital floor fracture was present with entrapment of the inferior rectus muscle. Posterior segment damage includes vitreous hemorrhage, commotio retinae, choroidal rupture, retinal 40 1 SEPTEMBER 1999 ATHLETIC THERAPY TODAY

6 tears or detachment, retinal hemorrhage, and traumatic optic neuropathy. Patients usually complain of decreased vision, although they may be asymptomatic. In retinal detachment, patients often report seeing flashes of light, a gray shadow, or a curtainlshade being pulled over the eye. The posterior Segment is best examined by an ophthalmologist using indirect ophthalmoscopy. For cases when it is not possible to view the posterior segment, an ultrasound exam is necessary. RQ~QCQWC~S Grewal, R.K., Dhaliwal, D.K., Hersh, P.S., & Zagelbaum, B.M. (1996). Anterior segment injuries. In B.M. Zagelbaum ( ~ d. )Sports, ophthalmology (pp ). Cambridge: Blackwell Scientific. Stock, J.G., & Cornell, F.M. ( 1 991). Prevention of sports-related eye injury. American Fami& Physician, 14, Zagelbaum, B.M.(1995a). A close look at a "red eye": Diagnosing visionthreatening causes. The Physician and Sportsmedicine, 23(11), Zagelbaum, B.M. (1 995b). Examining a "red eye": Diagnosing non-visionthreating causes. The Physician and Sportsmedicine, 23(12), Zagelbaum, B.M., Tostanoski, J.R., Hochman, M.A., & Hersh, P.S. (1994). Topical lidocaine and proparacaine abuse. AmericanJournal ofemergency Medicine, 12, Qonclurionr 'ports in a wide range of injuries can eye injuries. An orderly and systematic approach in evaluating these injuries is necessary in order to identify and manage these conditions properly. Our role is to rapidly formulate a diagnosis, treatment, and plan that in the best 'Itimate outcome for the athlete. II ATHLETIC THERAPY TODAY Jennifer Laio is the chief resident in ophthalmology at North Shore University Hospital. New York University School of Medicine, in Manhasset, NY. She graduated from the State University of New York at Stony B ~ O O ~, Of Medicine, in Bruce M.ZQgelbaum is in private practice in Manhasset, NY, and is an assistant professor at North Shore University Hospital, NYU School of Medicine. He is the team ophthalmologist for several pro sports teams and also an ophthalmology consultant to the NFL. He is author of the textbook sports ~ ~ h t h a l m ~ l o ~ ~ SEPTEMBER