|
|
In fact sports vision consists of two levels. The first level involves working with recreational and competitive athletes in everyday practice. This requires the practitioner to take an accurate case history (including asking patients if they play sport and, if so, which sports and at what level), have strong optometric skills and the knowledge to recommend the best products and advice for patients. You will be surprised how many people coming into your practice are involved in some sporting activity (Table 1).
The second level of sports vision involves working with elite athletes and requires high-tech, expensive equipment and an extensive knowledge of binocular vision, visual perception and the neurological processing of visual information, as well as an approach which is entirely scientific and analytical.
At elite level, you need to have an understanding of the infrastructure of the coaching set-up and be able to integrate your work with that of the sports scientists, strength and conditioning coaches, as well as the physiotherapists and management team. To get the best results you also need to have a clear understanding of and ability to work with the psyche of the elite athlete.
Working with this group of clients requires additional training and experience which is beyond the scope of this article. To do so without the complete skills set puts at risk not only whether the athlete reaches peak performance but also your reputation.
We recommend you refer elite athletes to specialist sports vision practitioners, who will then hand back the athlete for you to manage their contact lenses and product sales.
Choosing the best option
Are contact lenses the best correction for sport?2 In most cases, the simple answer is yes, although there may be some debate with respect to water-based sports and special consideration needed for some activities which we will discuss later in this article.
With such an array of contact lens choices, patients should be given the opportunity to try contact lenses for their sport so that they can experience the many advantages this form of correction offers (Table 2).
Contact lenses used for sport need to deliver the following:
? Comfort - so they are not a distraction
? Clear, stable vision which meets the demands of the sport
? Adequate oxygen and tear exchange to protect the health of the eye.4
Additionally, your patients must be confident in their choice of correction, trusting that it will provide the vision they require without becoming dislodged or knocked out of place, and that the lenses are the best they could be wearing for their sports environment.
Previous articles have debated whether soft lenses or gas-permeable lenses should be fitted, but with the advent of new soft contact lens technology this has become less of a discussion.4 Since the vast majority of prescriptions are now available in daily lens form, we suggest the use of daily disposable lenses as the first-choice option for vision correction for all sports, followed by monthly or two-weekly disposable soft lenses, and finally gas-permeable lenses (not an option for contact sports).
Some sports environments provide greater challenges to contact lens wear than others, and these include water sports, winter sports, shooting and contact sports such as rugby. The specific demands of each sport need to be taken into consideration.
Practitioners also need to consider hygiene, since many sports are played outdoors and changing room environments may not be ideal, increasing the risk of contact lens contamination and ocular infection.
Water-based sports
This is always a dilemma for practitioners because on the one hand we want to offer the most practical solution (which is not spectacles), yet we also have to manage the risk of lens loss, the risk to eye health through infection, and the possibility of lens adherence.5
The risk of lens loss is less than might be expected. Galkin and Semes6 studied contact lens-wearing waterskiers, and showed that in over 100 trials, of which 76 per cent resulted in the waterskier's head being fully submerged under the water, not one lens was lost.
With fast impact sports such as waterskiing, and other water sports, it may be that the blink reflex is protective and works to keep the lens in place. Sea water also has the effect of causing contact lenses to tighten slightly under exposure.
As a practitioner, you need to ensure that the lens remains in place even with a strong blink, but there is no need to be preoccupied with whether the lens will float off.
With regard to infection risk, Vesaluoma et al7 found high concentrations of Staphylococcus, Pseudomonas and amoeba in 41 per cent of Finnish swimming pools (and an even higher incidence in hot tubs). Chlorine in pools was not enough to protect the eye from these microbes.
Recent research has investigated the effect of wearing goggles over contact lenses during swimming. Wu et al8 showed that swimming goggles reduced the amount of bacterial colonies found on the lenses, although contamination was not reduced to zero.
Other correction options are available such as prescription goggles, orthokeratology, refractive surgery, and potentially semi-scleral or scleral contact lenses. Prescription goggles are associated with the least amount of risk,3 but they are not always practical (think waterskiing, surfing, white-water kayaking) and your patient may not want to wear them. In water polo, goggles are forbidden entirely.
Orthokeratology is a good alternative to soft contact lens wear for water sport athletes, especially those who play water polo, but it does not work for all refractive errors. Refractive surgery is another option,9 but there are numerous other factors that must be considered when recommending this option to any patient, and especially to a sports patient, which are beyond the scope of this article.
Semi scleral and scleral contact lenses may prove to be another option, but with only a small percentage of the population wearing them, more research is needed before they can be actively recommended for sports vision patients.
Managing swimmers and other water sport athletes
Traditional advice has been to avoid wearing contact lenses for swimming, but it is important to recognise that patients still need clear vision in this situation. They need to be able to walk safely from the changing room to the pool (on a wet surface). They need to see where other people are, again for safety reasons. And they may be supervising their children.
The vision may not need to be corrected to 6/6, but the correction does need to allow functional vision for patients, and they need to feel they can see everything they want to see.
The safest, and your best defensive practice, is to advise prescription swimming goggles. For the majority of swimmers this provides a practical and cost-effective way of ensuring clear vision and low risk to the eyes. Ortho-K or daily disposable contact lenses with tight-fitting goggles are alternatives.
Current BCLA advice is to avoid wearing contact lenses for swimming unless using goggles (or wear single-use lenses and discard them after swimming).10
For goggle-unfriendly sports such as waterskiing and surfing, it is my belief that if you offer patients clear, coherent, reasoned advice, then they are more likely to follow your instructions than if you give advice that they deem impractical or unrealistic given their perceived risks. There are countless web forums where athletes are advising other athletes that they have no problems with wearing contacts when playing water-based sports.
If ortho-K is not an option, we suggest a strict routine as detailed in the panel (right) as a suggested compromise, but note it is a compromise and you must flag up the increased risk of microbial keratitis when wearing contact lenses in water. Many practitioners will feel uncomfortable with taking responsibility for this regime and, where this is the case, should not practise in this way.
That is the big challenge of sports vision where we manage the athlete's sports performance and eye safety, not just the eye. We urge the research departments to look at the infection risk to the contact lens-wearing eye in sports such as surfing etc where goggles are not worn. Research is also needed into risks with different modes of contact lens correction and care strategies in swimming and other water sports.
There will be times (clinical or financial) when a patient cannot wear the same daily disposable lenses for everyday life that he/she wears for sport. For example, some patients may prefer monthly lenses every day for financial reasons and use their daily disposable lenses only for their water-based sport. This arrangement is often reached after your patient has asked why they can't use their monthly lenses in the water.
As a practitioner, you need to spend time discussing the risks of water-based sports and the reasons behind your recommendation with your patient. It often helps to remind them that they have special equipment for their sports (who wears a wet suit to the office?), and the daily disposable contact lenses you are recommending are just another specific piece of equipment for their sport.
Winter sports
In winter and other high-altitude sports, UV exposure and atmospheric dryness are significant concerns. Snow reflects almost 80 per cent of UV light, and UV exposure increases approximately 4 per cent for every 300m increase in altitude.
Under these conditions, UV-blocking contact lenses do not provide sufficient protection for the eye and the adnexa. Patients need to wear UV-blocking wraparound sunglasses or goggles, and a suncream may be also advisable.
It is imperative you also advise your winter sport athletes that UV-blocking contact lenses are not a panacea. They will not protect the eyelids (a site for aggressive basal-cell carcinoma), conjunctiva or other tissues in the orbit from UV. Additional UV protection must be used.
The relative humidity in winter tends to be lower than in the summer months. This is further exacerbated by the use of heating systems in vehicles and buildings, and by the high speed which some winter sport athletes move at (downhill skiers can reach speeds upwards of 60-80mph).
Non-preserved artificial tear drops are an ideal way to combat contact lens dryness in winter sports. They are widely available and should be recommended to all winter sport athletes. Additionally, wearing protective sunglasses, goggles or a helmet face shield will help minimise the effects of wind and speed on the drying of the contact lens.
Summer sports
UV exposure is an important consideration in summer sports as well, and should be managed as discussed previously. Spring and summer sport athletes, like many contact lens wearers, suffer from hayfever. In the past, many practitioners have shied away from prescribing contact lenses for hayfever sufferers. However, in many cases daily disposable lenses provide a helpful barrier, as shown by Stiegemeier et al.11
Special considerations
Other sports such as shooting may require special considerations. The disadvantages of contact lenses for target shooters and clay can be:
? Reduced stability of vision (may notice lens movement)
? Reduced blink rate with concentration - causing tear-related vision and comfort issues.
While many athletes shoot successfully wearing contact lenses, you should be prepared to change tack and offer an appropriate shooting lens if contact lenses are not delivering the quality of vision demanded by this exacting group of athletes.
Our practice has a wide range experience working with elite athletes, yet we refer our elite shooting athletes to Ed Lyons of Flint and Partners, Wolverhampton, who we believe has the best record of successful management of shooters' vision in Europe.
Children and sport
Sport is essential for the well-being of a child. It teaches them many things including working within a team, dealing with success and failure, and the reality of a competitive world. Sport is also an essential ingredient for the long-term physical fitness of the child.
In our sports vision clinic, we have seen numerous cases where children have almost given up competing at a high level of sport (county or national) simply because their myopia did not allow them to see the ball well enough, and their practitioner had not discussed contact lenses as an option.
Evans13 suggests high oxygen, daily disposable lenses are the first-choice lens type for children to wear. They learn quickly and are more likely to follow your instructions than many adults.
We specifically fit contact lenses to children on a part-time (sport) schedule so that they remain comfortable wearing spectacles. Make sure you schedule regular follow-ups and your practice management systems can keep track of those who fail to attend.
Correcting small errors
In sport, small cylinder corrections (and small amounts of anisometropia) make a difference, especially if there is more impact to the dominant eye. Uncorrected astigmatism can cause problems with sports hall lights, floodlights and problems tracking small fast balls such as in lacrosse, cricket and hockey. Long gone are the days of thick soft lenses that could mask small amounts of astigmatism.
Eye protection
The greatest disadvantage of contact lenses for sports use is that they offer limited eye protection from fingers, stray squash balls, etc. It is imperative that you remember to advise your sports patients about the appropriate protective eyewear for their sport. You have a responsibility to your patients to do this, and your advice needs to be noted on the patient's records.14,15,16
In summary, contact lenses are an ideal way to start building your sports vision practice. Your patients will thank you, your business will thank you, and interacting with the patient about their passions means that you will enjoy your job more too. ?
References
1 Consumer participation in sport in the UK. Mintel 2011.
2 IACLE. Contact lenses for sporting activities. International Association of Contact lens Educators.1st Edition, IACLE, 1998; 89-108.
3 Bomholt N and Schnell D. Corneal physiology and stress on the cornea in contact lens wearers during sporting activities. Contactologia, 2000; 22:114-117.
4 Cardall M. Contact lenses in sport. Optician, 2006;231:6034 22-26.
5 Choo, J, Vuu K, Bergenske K, et al. Bacterial populations on silicone hydrogel and hydrogel contact lenses after swimming in a chlorinated pool. Optom Vis Sci, 2005;82:2 134-7.
6 Galkin KA and Semes L. Risk of loss of SofLens during water skiing. J Am Optom Assoc, 1983;54:3 267-9.
7 Vesaluoma M, Kalso S, Jokipii L, et al. Microbiological quality in Finnish public swimming pools and whirlpools with special reference to free living amoebae: a risk factor for contact lens wearers? Br J Ophthalmol, 1995;79:178-181.
8 Wu YT, Tran J, Truong M, et al. Do swimming goggles limit microbial contamination of contact lenses? Optom Vis Sci, 2011; 88: 4 456-460.
9 Naroo SA, Shah S and Kapoor R. Factors that influence patient choice of contact lens or photorefractive keratectomy. Journal of Refractive Surgery, 1999; 15:132-136.
10 Your checklist for healthy contact lens wear. BCLA 2012.
11 Stiegemeier MJ, Fahmy M and Thomas S. Beating back SAC. Optometric Management, 2008;43:9 84-85.
12 Quevedo L, Cardona G, Solé J, et al. Sportsvision: comparative study of the characteristics of the tear film. ICLC, 2000; 27:6-10.
13 Evans B. Fitting children with contact lenses. OT supp May 2012.
14 Barr A, Baines PS, Desai P, et al. Ocular sports injuries: the current picture. Br J Sports Med, 2000;34:456-458.
15 Capão F, Rocha-Sousa A, Falcão-Reis F, et al. Modern sports eye injuries. Br J Ophthalmol, 2003;87:1336-1339.
15 Classé JG. Legal aspects of sports vision. Optometry Clinic, 1993;3:1 27-32.
? Gavin Rebello is a sports vision optometrist and partner at Patrick and Menzies in Essex, and vice chair of Sight Care, the business support group for independent opticians. He currently works with GB ladies volleyball, England lacrosse, GB hockey, Harlequins Rugby and several professional footballers among others