Eye care professionals encounter sports-related eye injuries frequently. Squash, shuttle cock and tennis ball injuries are fairly common injuries regularly seen in my practice. Others that spring to mind include the Liverpool footballer who had to visit Moorfields Eye Hospital following a scratch to his cornea and, worse still, a contact lens infection resulting from dirt flying into the eye of a Watford footballer during a match. This latter case eventually required a full corneal graft. In this article, I will describe three sporting injuries in some detail.
Case 1
A 39-year-old male goalkeeper suffered injury during a match when the ball ricocheted off a defender straight onto his left side of the face. On returning home, he complained to his wife that his left eye hurt on lateral movement. He also reported a slight blurring of vision inferiorly, but no defined loss of vision. He had undergone bilateral LASIK surgery some 10 years earlier which had corrected his -6.50DS myopia.
Ophthalmic examination
1 Visual acuity; R and L 6/6 and N5.
2 Ocular motility; no restriction of movement or discomfort in either eye on examination
3 External eye
- No signs of orbital floor fracture or adnexal tissue compromise
- No corneal abrasion
- No eyelid abnormalities
4 Ophthalmoscopy
- No crystalline lens abnormalities
- No abnormalities of the right eye
- The left retina showed a superior whitish patch in the posterior pole suggestive of commotio retinae (figure1). There were no signs of retinal tear and no signs of retinal haemorrhages.
Action
Initially it was explained to the patient that the retina had suffered trauma following the football impact, and a period of rest would allow time for this to resolve. Reassessment was pencilled in for two weeks’ time. Soon afterwards, his wife rang to say that she was concerned about his welfare as he had slept heavily the following night and complained of ‘feeling drunk’. I explained this sounded like concussion and he should bounce back in a few days.
Figure 1: (a) Ultrawide field SLO view showing white, glistening opacification of the superior peripheral retina subsequent to blunt trauma. (b) Autofluorescence image of the same eye showing no signs of hyperfluorescence. This indicates that the retinal change in (a) is not a result of changes to the retinal pigment epithelium, but rather in the neuroretina
Two weeks later; the patient acknowledged he had initially suffered concussion which explained his brief period of feeling light-headed and tipsy without having drunk any alcohol. He felt he had slept solidly for two days after which he had felt a lot better. He also found that the slight inferior blur had disappeared after this time. A second ophthalmic examination revealed no abnormality of the left retina and the white patch had completely disappeared (figure 2).
Figure 2: (a) red free image of left retina at first presentation showing lesion in superior periphery and (b) full colour image after two weeks showing resolution of lesion
Discussion
The term ‘commotio retina’ is derived from the Latin description of ‘commotion’ or ‘agitation’ of the retina. When affecting the posterior pole, the condition is often described as Berlin’s oedema in memory of the ophthalmologist who first described it in 1873. It results from a blunt trauma or violent shaking and agitation causing a shockwave within the eye resulting in stress on soft tissues, in this case those of the retina. The feeling of light headedness reported in this case was further evidence of a concussive cause.
Commotio retinae is thought to primarily represent damage to the neuroretina, particularly the photoreceptors caused by the shock waves following a blunt trauma. Ophthalmoscopically, a sheen-like retinal whitening appears some hours following the initial injury. Retinal opacification is thought to be due to extracellular oedema, glial swelling and photoreceptor outer segment disruption. Some authorities suggest this is retinal pigment epithelium (RPE) disruption, but autofluorescence imaging usually reveals no hyperfluorescence, as would the case be with RPE active changes. The prognosis for commotio retinae is good, with full recovery usually reached after two to four weeks.
Case 2
A 14-year-old female participated in a martial arts competition. She suffered a knuckle blow to the left cheek. Over the subsequent weekend, the eyelids became swollen to the point where she could no longer open her eyes. By the following Monday, by which time the swelling had largely subsided, she noticed her vision in the left eye was poor and, after telling her parents, was brought to our clinic to ascertain what had happened.
Ophthalmic examination
- Visual acuity;
- Right – 6/6 and N5
- Left – hand movements only
- Right eye – no abnormalities of the fundus or anterior segment.
- Left eye;
- A laceration below the lower eyelid and slight eyelid swelling (figure 3).
- No corneal injury, low grade conjunctival hyperaemia.
- Normal vitreous with no signs of inflammation, posterior vitreous or perifoveal vitreous detachment.
- Distinct tear of the central macula.
- Commotio retina surrounding the tear
- A V-shaped flap of macula had been dislodged by the impact, but there were no obvious signs of vitreomacular traction.
- Inferior to the optic disc, a large haemorrhage apparently on the surface of the retina (look at the RAM image on the right of figure 3 which shows the retinal vein is obscured by the blood).
- In the inferior temporal retina, a line of haemorrhages following the vascular arcade (again in figure 3, these haemorrhages appear to be on the surface close to the vitreous face)
OCT Assessment (figure 3)
- A macula tear with a flap extending into the vitreous seen at the posterior pole.
- The superior-temporal aspect shows photoreceptor disruption and possible serous retinopathy.
- Inferiorly, small, discrete haemorrhages within the vitreous are seen due to inner retinal capillary damage from the force of the injury and resulting in blood leakage.
- No sign of perifoveal vitreous detachment confirming that the vitreous is intact and not responsible for the macula tear.
- The macula tear can be recorded as a grade 3 macula hole (roughly 900µm in size).
Six weeks later there were significant pigmentary changes suggesting photoreceptor death and hyperplasia of the retina.
Figure 3: Blunt trauma to left cheek from a knuckle punch causing laceration of the cheek and, at the fundus, commotio retina (seen as a white circular area) with haemorrhages both centrally and inferior to the disc, both upon the retinal surface. OCT scan clearly shows the macula hole with V-shaped flap and adjacent serous changes
Discussion
Macular tears due to sport injury are not common. A Portuguese study from a decade ago showed that sport is the most likely cause of injury to the eye, and the commonest sporting injury is a squash ball injury (some 30%), with other notable causes including paint ball-related injury (20%) and football-related injury (15%).1
In the UK, there are 2,000 cases of eye injury related to squash, tennis, football, badminton and rugby each year, with ball trauma and eye gouging most likely during contact sports. Again, squash ball trauma is seen to be the most common of the injuries, followed by paintball injury. Some 90% of injuries involve males compared to 10% involving females. Around 70% of injuries happen during the weekend. Eye care professionals have a key role in advising patients about adequate eye protection.
Figure 4: Appearance of the retina after 6 weeks showing pigmentation due to hyperplasia and photoreceptor death subsequent to the macula tear. Loss of photoreceptors prevents normal metabolic activity and may cause RPE detachment and pigment migration to the area of damage
The commonest ocular damage caused by sports injuries are:
- Corneal laceration and erosions
- Hyphaema
- Macula oedema
- Retinal tears and breaks
- Orbital floor fracture
Direct injury to the globe is particularly traumatic with a squash ball injury due to being the exact diameter of the eye socket, so there is a near complete transfer of force to the orbital contents. Eye gouging is common in rugby, though there have been reports of retinal detachment as well as orbital floor fracture when direct trauma to the globe is experienced (for example, from elbowing).
The incidence of a macula tear is very low, with occurrence of just one in over 10 million. I have come across just one incidence of macula tear published in the literature, this happening to a patient after football injury. I have, however, seen macula tears in two patients after fireworks injury.
Macula tear formation develops over individual stages:
- Stage 1 – contracting phase: Impact leads to a contraction of the eyeball within the orbit. The eyeball contracts front to back while the middle of the eyeball expands. The pressure from the eyeball retraction is transferred to the posterior retina resulting in contusion of the retina and causing commotio retinae. Contusion of the retina can lead to retinal bleeding and the development of the whitish appearance seen at the retina.
- Stage 2 – inflating phase: The contracted eyeball then rebounds back to its inflated state. This exerts a force anteriorly as the eye retracts. The vitreous adhesion is very strong at the fovea, and this strong attachment is distributed temporally along the posterior vascular arcade and so distributes the impact force posteriorly and radially. There is a ‘push and pull’ effect due to these opposing forces that may result in a tear at the weakest spot, the fovea. The Muller cells within the inner and outer retina form only a weak infrastructure supporting the oblique Henle’s fibres and so macula hole formation may result. The simplest way to visualise the macula tear is by way of analogy with a tight-fitting shirt. As we lift the shirt upwards, there is antagonistic upward and downward forces resulting in a tear at the weakest spot, in this case in the arm pit area.
Case 3
An 11-year-old boy was shot in the left eye with a foam bullet from a toy gun while playing at a friend’s party. An hour or two, later he started to notice blurring of his vision, particularly around lights, and pain on movement of both eyes. He was brought to our clinic and we were able to see him later that day.
Ophthalmic examination
- Visual acuity; R and L 6/6 and N5.
- Pupil reactions were normal, recorded as PERRLA R and L
- Left eye;
- Hyphaema (Grade 1) – blood in the inferior anterior chamber (occupying <1/3rd space) and fibrous membrane development (figure 5)
- No retinal tear and no signs of commotio retinae.
- Intraocular pressures; R 16mmHg L 24mmHg.
Action
The patient was referred urgently to Moorfields Eye Hospital on the basis of the blood in the anterior chamber, raised intraocular pressures, light sensitivity and blurring of vision. He was seen immediately at the eye clinic and prescribed:
- Steroid eye drops (Maxidex) to use 6x a day
- Beta-blocker eye drops (Timolol) to use 2x a day
- Cyclopentolate to use 2x a day
He was also told to have complete bed rest for a week and to have pressures rechecked by the optometrist in five days.
After five days, his hyphaema had cleared to just some micro-bleeds in the anterior chamber and his pressure was now 28mmHg in the left eye, possibly related to the use of steroid. We decided to taper the steroid from 6x to 5x, 4x, 3x and 2x on a daily basis until his next appointment at the eye clinic. The clinic was satisfied with his hyphaema being clear and his pressures reduced to 20mmHg. He had to continue timolol for another month at which point he was discharged.
Figure 5: Impact to the left cornea from a toy gun (upper right) resulting in grade 1 hyphaema (< one third anterior chamber fill – lower left) due to iris blood vessel rupture. There is also conjunctival hyperaemia and a corneal response. There was recovery of the hyphaema after five days (lower right)
Discussion
Hyphaema is defined as the presence of blood within the aqueous fluid, usually as a result of ocular trauma. It appears due to iris vessel thrombosis and a subsequent accumulation of blood between the cornea and the iris.
Hyphaema is graded as follows:
- Grade 0 – micro bleeds within the chamber
- Grade 1 – <1/3rd anterior chamber volume occupied by blood
- Grade 2 – 1/3rd to half anterior chamber volume occupied by blood
- Grade 3 – >1/2 anterior chamber volume occupied by blood
- Grade 4 – complete anterior chamber occupied by blood
The size of the hyphaema id directly related to any subsequent rise in intraocular pressure. With less than half anterior chamber occupation, there is a 4% incidence of raised IOP. Where more than half of the anterior chamber is filled with blood, there is an 85% incidence of raised IOP.
Management of hyphaema usually involves the following:
- Total bed rest for the blood to clear.
- Head maintained in an upright position, even during sleep when possible.
- Steroids to limit inflammation.
- Topical hypotensive drugs to reduce the pressures.
- Mydriatic drugs to ease iris spasms and reduce pain.
- Avoidance of drugs containing aspirin or ibuprofen.
Eye care in the community
1 Optic disc drusen
2 Vein thrombosis
3 Sports injuries
4 Ehlers-Danlos syndrome
5 Myasthenia gravis
6 Total sight loss
7 Shingles, molluscum contagiosum and VKC
8 Field loss
9 Sjögren’s disease
10 Optic neuritis
11 Glaucoma monitoring
12 Iris melanoma
Kirit Patel is an optometrist in independent practice in Radlett, Hertfordshire.
Reference
1 J A Capao Filipe, A Rocha-Sousa, F Falcao-Reis, J Castro-Correia. Modern sports eye injuries. British Journal of Ophthalmology, 2003;87:1336–1339.
