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Eye Injuries In Sport (Ray) --__--__-- Message: 1 From: Ray To: eskrima@martialartsresource.net (Eskrima) Date: Sun, 29 May 2005 11:04:40 -0700 (PDT) Subject: [Eskrima] funny Reply-To: eskrima@martialartsresource.net Monday's lesson... http://daynews.ru/index.php?act=show_news&id=939751 Ray Terry rterry@idiom.com --__--__-- Message: 2 From: Ray To: eskrima@martialartsresource.net (Eskrima) Date: Sun, 29 May 2005 17:57:38 -0700 (PDT) Subject: [Eskrima] Eye Injuries In Sport Reply-To: eskrima@martialartsresource.net Eye Injuries In Sport NICHOLAS P JONES Consultant Ophthalmologist Manchester Royal Eye Hospital Manchester, England http://www.sportsci.org/encyc/drafts/Eye_injuries.doc Every sport carries some risk of injury. The eyes occupy less than one percent of the body surface, and eye injury in sport is fortunately very uncommon. However, because of the delicacy and functional importance of the eye, such injuries rightly attract attention and demand the need for safe play and protection. To understand the mechanisms and effects of eye injuries, a basic knowledge of normal structure and function is necessary. The Normal Eye and Orbit The eye is approximately spherical and lies mostly within a bony cavity, the orbit. Its normal anatomy is shown in Figure 1. The junction between the orbit and the face is constructed of strong bone, but internally the walls of the orbit, especially below, are thin and prone to fracture. Within the orbit are the extraocular muscles responsible for eye movement, and a network of nerves and blood vessels. These delicate tissues are supported by fat which fills the remaining orbital space. The eye itself is suspended within the orbit by a system of fibrous ligaments. It is connected to the brain by the optic nerve, which, together with blood vessels, enters the orbit from behind. The tough outer coat of the eye is the sclera, a white layer of collagenous connective tissue. In front, part of this coat is structured microscopically in a more regular way, which makes it transparent. This is the cornea, the window of the eye. The eye is maintained in its proper shape by internal clear fluids maintained at some pressure, the aqueous humor and the vitreous humor. Between these two fluid compartments is suspended the crystalline lens, a transparent lens which is capable of movement and focus. It is suspended in place by the suspensory ligament, which is a fine radial meshwork of collagen fibres, connected to a circular muscle, the ciliary body. This muscle contracts and relaxes to enable the eye to focus. The amount of light entering the eye is regulated by a muscular diaphragm, the iris, which lies in front of the lens. It has a central aperture, the pupil, which can be enlarged or constricted by iris muscles. At the back of the eye is the retina, a complex layer of nerve fibres and light-sensitive cells which registers an image and transmits it to the brain down the optic nerve. It lies upon a vascular and pigmented layer, the choroid. Perfect visual function is a complex process. The eye must be able to look in the right direction and all extraocular muscles must function correctly. The light must be able to pass through the eye to the retina without absorption or interference (therefore the cornea, crystalline lens, aqueous and vitreous humors must remain transparent) and it must be formed into images by refraction, mainly by the cornea, but fine adjustment is performed by the crystalline lens. The iris and ciliary body must be capable of movement and the pupil must not be occluded. The retina must be properly in position and must be connected to the optic nerve. The Dynamics Of Eye Injury: Cause and Effect Eye trauma can be broadly classified into sharp, lacerating injuries and blunt, contusional injuries. In sport generally there are few opportunities for sharp injuries and these are fortunately rare. The danger of playing any sport while wearing spectacles with glass lenses has now been accepted; any blow on these spectacles may create sharp glass fragments which may convert an otherwise mild injury into a complex and dangerous one. Only the foolhardy would now wear such spectacles. Less well known is the potential for damage from hard contact lenses. It is a common misconception that contact lenses offer some partial protection of the eye in the event of injury. This is not so. At best, the contact lenses do not complicate the injury. At worst, a fractured hard contact lens may lacerate the eye. The great majority of trauma in sport involves blunt objects of relatively high velocity. Many of these objects are the projectiles of the particular sport: baseball, squash ball, hockey puck or badminton shuttlecock. Sometimes, and typically imparting a more serious injury, the eye is hit by a hitting instrument: golf club, hockey stick or badminton racket for example. In the large-ball team sports, body contact is common. Any body extremity can injure the eye or orbit: the reaching fingers in basketball, the elbow in soccer, the heel in karate, the knee in rugby. Lastly, some sports involve the use of weapons which may deliberately or inadvertently impart injury: the boxing glove, the kendo shi-ai, the high- velocity paint pellet in war games. Though the means of injury can vary markedly, the general effects on the eye and orbit can be effectively grouped into the general category of "blunt injury". Any or all of the following may be seen: An object strikes the eye and its surrounds. If the object is large, much of its kinetic energy will be absorbed by the structures around the eye, the face, nose and orbital margins. If the blow is severe, then injuries to these surrounding structures may be seen, such as a nasal or zygomatic fracture. Even though they are large- diameter, hollow air-filled balls such as a soccer ball can distort markedly on impact, protruding into the orbit and pushing the eye backwards (Figure 2). The eye itself is a remarkably tough structure, at least externally. It can however transmit the forces of impact backwards into the orbit, compressing its contents progressively into a decreasing space. In this situation the thin bones of the orbital walls may fracture outwards a so-called "blowout" fracture. The floor of the orbit is most commonly broken in this way, forcing bone and usually some orbital contents downwards into the maxillary sinus of the face. This form of injury is shown in Figure 2. In this circumstance the eye can appear to have sunk backwards into the orbit and may be restricted in movement, causing double vision especially when looking up. Other features of this injury include numbness of the skin of the cheek, or teeth, on the same side as the injury. Such fractures are best repaired surgically within a few days, and such surgery usually involves the implantation of a permanent silastic orbital floor implant. Such a "blowout" fracture may be considered to be a form of protective mechanism. The orbital fat and bone, by acting as a "crush zone", may protect the eye from injury. Indeed, the lightweight bones of the face, with their internal air-filled spaces, are considered by some to be a "crumple zone" to protect the cranium itself from the effects of blunt injury. Smaller-diameter projectiles are far more likely to penetrate into the orbit and transmit greater energy onto the eye itself. In this way the eye may be injured. Most severe blows cause abrasions to the eyelids or cornea (depending on whether the eyelids were open or closed at the point of impact). Corneal abrasions are very painful but will heal uneventfully and rarely become infected. Of greater importance is the potential for internal damage. Figure 3 shows the distortion of the eye when struck, for example, by a badminton shuttlecock. The eye is compressed, causing its internal pressure to rise. The iris and lens are forced backwards. The former may become torn in this way. A pressure wave travels the ocular fluids and hits the back of the eye. During these few milliseconds of contact, the internal structure of the eye can be irreparably damaged. Directly after impact, the eye returns to its normal shape via a series of oscillations which in themselves may cause further internal disruption. These oscillations affect different components of the eye in different ways, depending on their location and tissue density. Following this blunt injury, the normally transparent cornea may become swollen and hazy. It is not uncommon for the eye to bleed internally, either into the aqueous or vitreous humor, or both. A small pool of blood may be visible behind the cornea within minutes of the injury. This hyphema is an indication of severe injury and the eye should always be examined by an ophthalmologist. The iris may be torn, either at the margins of the pupil, permanently affecting its ability to constrict, or more peripherally, giving rise to a false pupil. The iris nerves may be damaged, so that it can no longer regulate the light entering the eye. The crystalline lens may be torn from its suspensory ligament and dislocate, or it may become opaque (cataract). Bleeding into the vitreous humor behind the lens may indicate that retinal damage has taken place. The retina may tear after a blunt injury. If it does so, it may become detached from its normal location lining the inside of the back of the eye. It will eventually lose all function if allowed to remain detached, so surgery will be necessary to replace it. Behind the retina is the choroid, which may also rupture. It is a very vascular structure and extensive hemorrhage may occur between it and the retina. The sclera, the tough outside coat of the eye, is very resilient but even so can be ruptured by a very severe blow. Such an incident is fortunately rare - the eye rarely survives such an injury. Occasionally the optic nerve itself is damaged by objects (such as fingers) penetrating into the orbit. Likewise orbital blood vessels and muscles may be traumatized. The "black eye" is merely bleeding from the orbit which has come forward into the eyelids. Following blunt injury, the eye will attempt repair of the damage by healing. Internal blood will be absorbed, but may leave behind scar tissue which may exert tractional effects and cause future problems. The delicate internal balance between fluid secretion and absorption, responsible for maintaining a correct internal pressure, may fail, causing a rise in pressure with permanent damage to vision. This is a form of glaucoma. Failure of the iris to function properly may cause problems in bright light or poor visual acuity. Damage to the lens or its focusing structure may cause failure of close-up vision. Scarring of the retina or choroid may permanently damage visual acuity. Despite these potential permanent effects, spontaneous recovery of most or even all visual function, is the rule rather than the exception. During this healing period, the function of the ophthalmologist is one of damage limitation and protection from complications, while allowing healing to take its course. The Sports Causing Eye Injury Every sport carries some risk of eye injury. Trauma statistics show however that some have far greater risks than others. In the United States, basketball and baseball cause most eye injuries. In the UK and Europe, soccer and racket sports are the culprits (5). However, these figures probably reflect the popularity of these sports rather than their intrinsic danger. In terms of risk of injury per unit time, squash rackets is generally considered the most dangerous sport (1). Even so, a significant eye injury occurs only once in more than 10,000 playing sessions, and the average regular player has a greater than even chance of going through a lifetime without sustaining a serious eye injury. The risk of particular sports is a function of the style of play. In squash, the ball, a small hollow rubber sphere, is fast-moving (measured at up to 60 meters per second) and so is the racket head that strikes it. The player swings the racket in a wide arc. Both players occupy the same confined space and move rapidly within it. The potential for collision is obvious. From studies of squash eye injuries (about three quarters caused by the ball, one quarter by the racket head) one can identify particular risks; Most racket injuries are caused by attempting shots near the opponent's body where the let rule should have been called. Similarly, pursuing the opponent into the court corner places the player at risk from his follow- through. Players caught at the front of the court, and turning around, are at risk from the ball itself. Of the other racket sports, badminton registers most injuries. In this sport, injuries in singles are very uncommon - most occur in doubles, especially mixed doubles. Players at the net are at risk from the smashed shuttlecock, and are also at risk from their own partner's racket if they both pursue a high shot; the forward player steps backwards and her face is hit by the follow-through of her partner's smash. In racketball, played on a squash court with a larger ball and short rackets, injuries are less frequent than in squash, yet the sport is popular amongst youngsters and early tuition and supervision may be lacking. Players sometimes injure their own eyes by the follow-through of their racket. Otherwise, the causes of injury resemble those in squash. Tennis provides relatively few injuries, almost always in doubles, the player at the net being at risk. Though few would recommend the widespread use of eye protectors for tennis, ophthalmologists at least would regard them as important for the other racket sports. Typically, large-ball sport injuries are caused by parts of the opponents' bodies rather than by the ball itself, though a few occur in this way. Most are team games played on large fields or courts. Competition for the ball will involve fast-moving hands near faces. Probing fingers in basketball, rugby or water polo may injure the eye. Even face cages in American football do not prevent such injuries. Likewise, elbows, feet and even knees have the potential to cause orbital and eye damage. Some of these injuries are deliberate; it is difficult to protect or legislate against assault on the sports field. The bat and stick sports, ice hockey, field hockey, baseball, cricket and the rest, may have widely different styles and rules, but all involve a very hard projectile and a heavy, unyielding stick, bat or club with which to hit it. Only ice hockey routinely uses head protection with eye protection incorporated, cricket occasionally. The kinetic energy carried by a fast-moving projectile as used in these sports is massive. Though the bony margins of the orbit may prevent entry of most of the ball or puck, and though these projectiles do not deform and protrude like a squash ball, there is great potential for injury. In hockey, high sticking (raising the stick above shoulder level) though illegal, causes many injuries. In baseball and cricket, balls glancing off the bat into the eye can be devastating, and close fielders are also at risk. The risk to the baseball catcher is well appreciated - he wears extensive protection. Cricket wicketkeepers, however, do not and can be injured if standing close. In sports where sticks are allowed to rise above shoulder level, and where close contact is common, the potential for injury is clear. Men's lacrosse requires the use of helmets and eye protection. The ladies have yet to be convinced, on the grounds that a more aggressive style of play is encouraged by the use of protective wear. Meanwhile eyes and faces continue to be injured. The remaining eye injuries are caused by a plethora of sports, as various as skiing and swimming, fishing, hurling and pelota. No sport entirely escapes the risk of injury, yet many sports have such a small risk that commonsense application of the rules and courtesies of the game will suffice. It is in the high-risk sports that legislation and protection are so important, and the racket sports, particularly squash, are the center of attention. The combat sports are a special case. Since their main aim is actually to injure (or simulate injury to) the opponent, the protagonists must accept injury as part of the sport. The detached retina and various other ocular damage is an occupational hazard to the boxer (indeed, Giovinazzo in 1987 found that 58% of boxers examined in New York State had sight-threatening eye injuries), but such injuries may also occur in simulated combat where contact was not intended. Severe eye injuries have been recorded in semi-contact karate, especially from high kicks, and similarly in Thai boxing. The recent widespread popularity of war games has inevitably led to injuries (2). Though eye protection should be worn, it may be occasionally removed for cleaning or demisting. The high-velocity paint pellets used in these games characteristically cause devastating eye injury. First Aid A severe blunt eye injury causes severe pain. It may also cause a faint, and frequently nausea and vomiting. The injured party may be disabled for a period. Several questions should be asked immediately after such injury: 1. How severe is this injury; does it need hospital treatment? 2. Is there also a serious head injury? 3. What do I need to do right now? 4. Can the injured player carry on playing? In general, unless the player is participating in a match of great importance, the answer to the last question should always be "no". An eye injury may be exacerbated by continued activity and any temporary visual disability (such as blurred or double vision) will also render the person liable to further injury. In general terms, apart from the removal of trivial foreign bodies from an eye, a frequent event on the sports field, the physiotherapist or spectator can not be expected to treat an eye injury of any significance. His job is to recognize its severity (from witnessing the force of the blow) and to protect the eye from further damage. The player should be rested, though rarely needs to be immobilized. The eye should be covered. The application of a cool pack often reduces the amount of swelling and hematoma and will reduce the pain level. Nothing should be given by mouth, because sometimes surgery is needed on the same day. The attention of a physician is required, and he may wish an ophthalmologist to examine and treat the eye. Remember that an eye injury can combine with a head injury. Any change in consciousness, loss of vision, double vision, vomiting or severe eye pain will make the urgent opinion of a physician mandatory. Always play safe. If in doubt, do not continue playing. Injury Prevention and Eye Protection The complete avoidance of eye injuries in sport is unattainable. At present however, inadequate attention is paid to eye safety in many sports. A substantial reduction in the frequency of such injuries could be obtained in a number of ways; Proper coaching of a sport will instill into learners the safest and most courteous way to play. Proper usage of rules designed to avoid injury (the let rule in squash is an obvious example) go far to help. The strict penalization of players who play with unwarranted aggression, or who, openly or covertly, assault their opponents, is of fundamental importance and is the responsibility of the organizational bodies and their referees and umpires. Protection of the eyes is not possible for many sports; to do so would so alter the style of the sport that it would change irrevocably. Soccer is an obvious example. However, in some cases the development and enforcement of proper protection has led to a safety revolution. In no sport is this more obvious than Canadian hockey, where rule changes and the enforcement of head and eye protection have drastically reduced the incidence of blinding injuries (7,8). The use of eye protectors is becoming increasingly frequent in basketball, yet in the racket sports, particularly squash and badminton, there is far to go before the use of proper protectors becomes universal (6). This is probably the most important single objective in sports injury prevention today. References 1. Barrell, G.V., P.J. Cooper, A.R. Elkington, J.M. MacFayden, R.G. Powell et al. Squash ball to eye ball: the likelihood of squash players incurring an eye injury. Br Med J 291;1539, 1985. 2. Easterbrook, M. and T.J. Pashby. Eye injuries associated with war games. Can Med Assoc J 133;415-417, 1985 3. Giovinazzo, V.J., L.A. Yannuzzi, J.A. Sorenson, D.J. Delrowe, and E.A. Cambell. The ocular complications of boxing. Ophthalmology 94;587-96, 1987 4. Jones, N.P. Eye injury in sport. Sports Med. 7:163-181, 1989 5. Jones N.P. One year of severe eye injuries in sport. Eye 2;484-487, 1988 6. MacEwen, C.J. and N.P. Jones. Eye injuries in racquet sports. Br Med J 302;1415-1416, 1991 7. Pashby T.J., R.C. Pashby, L.D.J. Chisholm, J.S. Crawford. Eye injuries in Canadian hockey. Can Med. Assoc J. 113;663-674, 1975 8. Pashby, T.J. Eye injuries in Canadian amateur hockey still a concern. Can J Ophthalmol 22;293-295, 1987 9. Pizzarello, L.D. and B.G. Haik (Eds) Sports Ophthalmology. Charles C Thomas, Springfield 1987 10. Vinger, P.F. The eye and sports medicine. In Duane, T.D. (Ed) Clinical Ophthalmology Vol 5, Harper & Row, Philadelphia 1985 Legends To Figures Figure 1 A cross-dection of a normal eye and optic nerve. The structures referred to in the text are labeled. Figure 2 A soccer ball strikes the eye and face, distorting and protruding into the orbit. The eye is pushed backwards and an orbital blowout fracture is sustained. (Reproduced with permission of the Journal of the Royal College of Surgeons of Edinburgh [Jones NP, 38;127-133, 1993]) Figure 3 A badminton shuttlecock strikes the eye, causing anteroposterior compression and internal distortion. (Reproduced with permission of Optician Journal [Jones NP, 202;22-29, 1991]) --__--__-- _______________________________________________ Eskrima mailing list Eskrima@martialartsresource.net http://martialartsresource.net/mailman/listinfo/eskrima http://eskrima-fma.net Old digest issues @ ftp://ftp.martialartsresource.com/pub/eskrima Copyright 1994-2005: Ray Terry, MartialArtsResource.com, Sudlud.com Standard disclaimers apply. Remember September 11. End of Eskrima Digest