Content uploaded by Nicholas P Jones
Author content
All content in this area was uploaded by Nicholas P Jones on Jan 23, 2018
Content may be subject to copyright.
Contents
Summary
Injury
Clinic
Spons Medicine
7:
163·181 (1989)
0112.1642/89/0003·0163/$09.50/0
©
ADIS
Press
Limited
All
rights reserved.
Eye
Injury
in
Sport
Nicholas
P.
Jones
Manchester
Royal Eye Hospital, Manchester, England
Summary ........................................................................................................................
..
..........
163
I. The Incidence and Importance
of
Sports
Eye
Injuries ....
..
................................................
164
2.
The Spectrum
of
Ocular Trauma ........................................................................................
165
2.1
Contusional Injury ...
...
....................................................................................................
166
2.1.1
Globe Injury: Anterior Segment ...........................................................................
166
2.1.2 Globe Injury: Posterior Segment ..........................................................................
166
2.1.3 Orbital and Adnexal Injury .....
..
..................
..
.............. ............ ........... ...................
167
2.2 Penetrating Injury
...
................................................................................................... .....
167
3.
The Sports Involved ............................
..
........................... ....................................................
167
3.1
Racquet Sports ................................................................................................................
168
3.1.1
Squash Racquets ............. ....................................................................................
...
168
3.1.2 Racquetball .....
... ...
.....
..
.......
..
............................................................................. ...
..
169
3.1.3 Badminton ....... ....... .... .................................
..
......................................
..
.................
169
3.1.4 Tennis .........
..
............ ..................................
....
.....................................................
..
.
170
3.2 Bat and Stick Sports
..
............................................. ..... ...................................................
170
3.2.1 Baseball ............. ...................................................
..
...
............ .
....
.............................
170
3.2.2 Ice Hockey ..............................................................................................................
171
3.2.3 Field Hockey ....... .
..
...
...
......................
...
.......... ........
..
..................... ....................... . 17I
3.2.4 Cricket
...
..
..................................
..
..................... ..... ..................................................
171
3.2.5
Golf
.........................................................................................................................
172
3.3 Large
Ball
Sports .....
...
.............. ..........
.... ..
...............
..
......................................................
172
3.3.1
North American Football .... ..................................................................................
172
3.3.2 Soccer ......................................................................................................................
172
3.3.3 Rugby Football .............................................
..
.
..
.
..
................................................. .
173
3.3.4 Basketball .....
..
.
..
.........................
..
...........................................................................
173
3.4 Boxing ................................
...
..
.............. ...........................................................................
173
3.5 Aquatic Sports ....
..
..........................................
..
........................................
....
...................
174
3.6 Skiing ....................
..
........... ..
...
................... .... .....
....
..
....
..
.....................
..
....
..
.......
..
.......... .
175
3.7 Shooting ..............................................................................
..
...........................................
175
3.8 Others ........ ... ........... ................
...
.... ..
................................................................................
176
4.
Principles
of
Ocular Protection ............................... ..... ........... .............................................
177
Eye
injury sustained
during
sport
is
increasing
in
incidence
worldwide.
reflecting
the
rise
in
popularity
of
sport
as
recreation.
It
can
account
for
up
to
25%
of
severe
eye
injuries.
This
paper
considers
the historical context and
demography
of
sports
injuries.
and the
physical mechanisms and
results
of
various
types
of
ocular
trauma
in
relation
to
sport.
It
reviews
the
specific
problems
associated
with
the
sports
considered
to
be
most
important
in
the epidemiology
of
eye
injuries today.
Eye
Injury in Sport
164
Certain
sports.
such
as
boxing.
have
an
intrinsic
risk
of
injury
so
high
that
some
con-
sider
the
sport
should
be
banned.
The
risk
of
injury
in
many
sports
can
be
mitigated
by
changes
in
rules.
such
as
the
prevention
of
high
sticking
in
ice
hockey.
Other
sports
with
high
risk
of
trauma
could
be
made
far
safer
with
the
widespread
introduction
of
eye
pro-
tection.
and
this
applies
especially
to
squash
and
badminton.
The
various
types
of
eye
protection
are
discussed.
There
is
an
urgent
need
to
increase
awareness
of
the
risk
of
eye
injury.
to
teach
safe
techniques.
and
to
encourage
the
use
of
appropriate
ocular
protective
wear
in
those
at
high
risk
of
injury.
espeCially
the
one-eyed.
Eye
injuries represent an important part
of
the
work
of
an
ophthalmologist. While his primary
function is the management
of
injuries already sus-
tained, it is also crucial to identify risk factors in
the causation
of
injury and to move to reduce these
wherever possible. In no field is this more im-
portant than in sport.
Sport currently accounts for an increasing num-
ber
of
eye
injuries and,
of
more importance, is re-
sponsible for substantial proportion (up to
25%)
of
severe
eye
injuries. This paper places the problem
into perspective and discusses the main mechan-
isms
of
injury and the spectrum
of
ocular trauma
in general. The most important sports worldwide
in the aetiology
of
injury have been discussed in
some detail with reference to special risk factors
inherent to each, and the need for more wide-
spread and more effective ocular protection has
been discussed.
Of
particular concern recently are the racquet
sports, mainly squash, but also badminton, tennis
and racquetball. They have a high incidence
of
in-
jury, are capable
of
severe
eye
injury and provide
in some centres the bulk
of
sporting trauma. Ocu-
lar protection for these sports
is
simple, inexpen-
sive and increasingly necessary. The efficacy ofleg-
islative changes in substantially reducing the
frequency
of
severe
eye
injuries in Canadian ice
hockey is a striking example
of
a success story in
preventive medicine and one that could be
re-
flected in many sports with proper organisation.
To this end the improved collection and assimi-
lation
of
data on sporting injuries is mandatory.
The accumulated information should lead to
re-
alistic discussion by the regulatory bodies
of
each
sport on how best to reduce the upward spiral
of
unnecessary trauma.
1. The Incidence and Importance
of
Sports
Eye
Injuries
In
1923
in Glasgow, Garrow presented the first
comprehensive survey
of
eye
injuries in the twen-
tieth century.
1000
patients with
eye
injuries ad-
mitted to hospital over a 5-year period included
only 7
(0.7%)
involved in a sporting activity. More
recent studies in the United Kindgom show very
significant changes. Lambah (1968), in a similar
survey
of
adult admissions, found that figure had
risen to
4.2%.
Canavan and co-workers (1980)
re-
ported a figure
of
7.0%,
again for adults, and most
recently Jones (1988) reports a figure
of
25.1
%.
The above surveys apply only to
eye
injuries
severe enough to require admission to hospital. For
eye injuries as a whole, Vernon (1983) found that
of
those attending an
eye
hospital accident and
emergency department,
2.5%
of
a sample
of
3210
injuries were caused by sport. Jones et
al.
(1986)
found this figure to be
2.2%
of
3536 injuries. This
low proportion is no cause for complacency. Most
patients attending an ophthalmic casualty depart-
ment have injuries which are not severe and can
be
managed as outpatients. The proportion
re-
quiring admission to hospital is extremely small
(0.42%,
Jones, unpublished data,
1983).
However,
on reviewing injuries sustained at sport it
is
im-
mediately apparent that a disproportionate num-
ber
of
these are severe. Gregory (1986) found that
18.5%
required admission to hospital, MacEwen
(1987) put the figure at
18.7%,
and Jones (1987) at
27.4%.
Accurate estimations
of
the incidence
of
sports
eye
trauma are difficult to find. Marshall and
Sandes (1977) reported a 2-year survey
of
sports
Eye
Injury
in
Sport
Fig.
1.
Multiple corneal abrasions caused by a squash ball. Vis-
ibility enhanced with fluorescein staining.
injuries in Dunedin and found that
of
a total
of
3894 cases,
of
which
18%
involved the head and
neck, only 0.6% affected vision in any way. Glynn
and
others (1988) performed a true population-
based survey in Massachusetts
and
found that
of
a random sample
of
3253 adults,
27
eye injuries
requiring medical attention had been sustained in
the previous year,
of
which 2 were related to sport.
The incidence here is thus
61
sport-related eye in-
juries per 100,000 population per year. Karlson &
Klein (1986), in a hospital-based study in Wiscon-
sin, found the figure to be 44 per 100,000 per year.
The difference between these 2 figures may be ac-
counted for by the fact that some patients attend
their usual physician rather than a hospital cas-
ualty department.
Comparisons
of
the incidence
of
sports injuries
are made difficult because
of
differences in popu-
larity
of
certain sports at local, regional
or
national
levels,
or
because
of
varying levels
of
participation
in general. There are
few
baseball players in Aus-
tralasia, and there is little cricket played in the
United States. A sample
of
recent studies on eye
trauma requiring admission to hospital illustrate
these differences. IIsar and co-workers (1982) re-
porting a study
of
eye injuries in Malawi, found
that sport accounted for only 2
of
205
patients
(0.97%). In Reykjavik, Thordarson and others
(1979) reported that 5
of
105
(4.
8%)
were so af-
165
fected. In Israel in a 3-year period, Koval et al.
(1988) reported that
5.3%
ofa
total
of
2276 patients
injured were involved in sport. Chapman-Smith
(1979), in Auckland, found sport the
rAluse
of
13
.
8%
of218
injuries, and Yinger (198Ia), reporting data
from Massachusetts, found that
23%
of
severe eye
injuries were sport-related. Table I compares the
sports most commonly causing injury in Great
Britain
and
the United States.
Parver (1986) reflected the strong feelings
of
many ophthalmologists when he described eye
trauma as 'the neglected disorder'. In the United
States alone, over 2.4 million eye injuries occur each
year (National Society Fact Sheet 1980),
of
which
a significant proportion result in permanent
ef
-
fects. It is felt
by
many that
90%
of
all eye injuries
are preventable, and sport-related injuries must be
high on the agenda. They are responsible for a dis-
proportionate number
of
severe injuries,
and
this
proportion is rising (Bell 1981). There are therefore
deserving
of
special attention.
2.
The
Spectrum
0/
Ocular
Trauma
Ocular trauma can be conveniently considered
in 2 broad categories, contusional and penetrating
injury, the former being
of
most importance in re-
lation to sports injuries.
Table I. The sports most frequently causing eye injury
in
Great
Britain and the United States of America
in
recent years. Taken
from amalgamated figures
of
surveys by Gregory (1986)
MacEwen (1987) and Jones (1987) [Great Britainl and National
Electronic Injury Surveillance System (1982) [United States)
Great Britain United States
sport %
of
total sport %
of
total
Soccer 36.0 Baseball 30.0
Squash 13.5 Basketball 24.5
Badminton 10.5 Bicycling 10.0
Rugby 9.0 American Football 7.5
Tennis 6.5 Squash & 7.0
Cricket 3.5 racquetball
Hockey 2.5 Tennis & badminton 5.5
Soccer 5.5
Eye
Injury in Sport
2.1
Contusional Injury
Contusional injury is the result
of
a blow from
a blunt object such as a squash
or
tennis ball. The
damage sustained will depend upon the mass
of
the object, its velocity, and therefore the force im-
parted to the eye (Runyan 1986).
It
will
also de-
pend upon the direction
of
approach
of
the pro-
jectile, its surface characteristics and its size. A small
blunt object striking the eye at speed will cause
rapid anteroposterior compression and consequent
equatorial dilatation (Clayton & Miller
1986;
Run-
yan 1986), followed by successively smaller waves
of
distortion. The eye will also be moved poste-
riorly en masse which can affect the integrity
ofthe
bony orbit by a piston effect (see section 2.1.3).
2.1.1 Globe Injury: Anterior Segment
Any object striking the cornea with moderate
force will disturb its epithelium, and an abrasion
results which is acutely painful
(fig.
I). The cornea
is displaced posteriorly
and
the intraocular pres-
sure suddenly rises
(fig.
2).
The pupil is pressed
onto the anterior lens surface and hydrostatic pres-
sure is directed into the angle
of
the anterior cham-
Fig. 2. A typical severe contusional injury caused by a squash
ball. Severe globe compression and equatorial dilatation with
intraocular haemorrhage and blowout fracture
of
the orbit floor.
166
Fig.
3.
Severe macular damage and choroidal rupture (arrow)
caused by a tennis
ban
. Visual acuity 6/36.
ber (Runyan 1986). Blood vessel rupture often oc-
curs, causing hyphaema which may be microscopic
or
macroscopic. Acute glaucoma
or
secondary
haemorrhage may result (Eagling & Roper-Hall
1986). The iris root may be ripped (angle reces-
sion)
or
completely disinserted (dialysis)
and
the
iris sphincter may be temporarily
or
permanently
disturbed (Paulmann 1986), causing a distorted
or
dilated pupil. Angle recession has implications for
visual deterioration in the future as a significant
proportion
of
affected eyes
go
on to develop chronic
glaucoma (Kaufman & Tolpin
1974;
Mooney
1973).
Traumatic cataract may occur within hours
of
in-
jury,
or
the lens may
be
displaced. The conse-
quences
of
blunt injury to the anterior segment are
discussed by Canavan & Archer (1982) who found
that
16.5%
of
their adult cases were caused by sport.
2.1.2 Globe Injury: Posterior Segment
Rapid distortion
of
the equatorial proportions
ofthe
globe places the retinal periphery under stress.
Vitreous haemorrhage is frequent
(fig.
2)
and vit-
reous base traction causes retinal tears which may
lead to retinal detachment. Trauma causes
10%
of
all cases
of
retinal detachment (Kanski 1986). Par-
ticularly implicated in this context has been tennis
(Seelenfreund & Freilich
1976).
At the macula, ret-
inal and choroidal haemorrhage
or
disruption may
occur
(fig.
3)
giving severe
and
permanent visual
loss (Eagling & Roper-Hall 1986). Optic nerve con-
Eye
Injury in Sport
tusional injury may occur. With severe blunt in-
jury, as can be caused for example by cricket ball
(Jones & Tullo 1986), golf club (Millar 1967)
or
hockey stick (Elliott & Jones 1984; Pashby 1985),
traumatic rupture
of
the sclera can occur with loss
of
intraocular contents, a situation usually leading
to loss
of
the eye. Schein et
a!.
(1988) found that
9%
of
all ruptured globes were caused
by
sport.
2.
1.3
Orbital
and Adnexal Injury
Posterior displacement
of
the globe into the or-
bit
is
more likely to disrupt bone than sclera and
this
is
the mechanism
of
blowout fracture
of
the
orbit (Pfeiffer 1943), usually involving the poste-
rior part
of
the floor (figs 2 and
4),
less commonly
the medial
or
other walls. Surgical management
is
complex. A more severe blow can fracture the or-
bital margins which are also often involved in mid-
facial fractures. Such complicated blunt facial
trauma often leads to eye injuries, many undiag-
nosed at the time
of
injury (Holt et
a!.
1983). In-
sertion
of
fingers or sharp objects into the orbit can
avulse muscles or the optic nerve, as has happened
in basketball (Chow et
a!.
1984)
or
skiing (Rous-
seau
1987).
The principles
of
management
of
or-
bital trauma
is
discussed
by
Hyde and Della Rocca
(1988) and Kay and Lendrum (1988).
Fig. 4. Radiograph showing blowout fracture of the left orbit
floor with extrusion of orbital contents into maxillary antrum (ar-
row). A football injury.
167
Fig.
5.
A perforating injury involving the posterior segment.
showing the exit wound of the projectile below the optic disc.
2.2 Penetrating Injury
Sharp injury to the globe in sport
is
not com-
mon (causing
2%
of
all penetrating injuries in
Ea-
gling's series in 1976, and
5%
in Cole et
a!.
1987)
but
is
often caused
by
the breakage
of
glass spec-
tacles (Cole et
a!.
1987; Ingram & Lewkonia 1973).
In mild cases involving only cornea, prognosis after
urgent surgery
is
good, but where sclera, ciliary
body, lens or posterior structures are damaged
(fig.
5),
visual outcome
is
much less certain and dev-
astating complications can ensue (Shock & Adams
1985). In some instances defective protective
equipment itself, such as swimming goggles (Jon-
asson 1977), can cause penetrating injury. Where
a foreign body such as an airgun pellet remains in
the eye the prognosis
is
extremely poor (de Juan
et
a!.
1983; Shock & Adams 1985).
An
account
of
the acute management
of
sports
eye injuries for the doctor
of
physiotherapist on
site
is
given
by
Ellis (1987).
3.
The
Sports Involved
Eye
injuries have been recorded in most sports
at one time or another. The following are consid-
ered worthy
of
special mention, and the principles
involved hold good for sport
of
all types.
Eye Injury in Sport
Table
II. Potential speed of ball or shuttlecock
in
racquet sports
(after data from Prof.
C.
Morehouse for the American Society
for Testing and Materials)
Projectile
Squash ball
Badminton shuttlecock
Racquetball
Tennis ball
3.1 Racquet Sports
Velocity (m/sec)
(mph)
62 (140)
57 (130)
48 (110)
48 (110)
Yinger (1985) estimated that over 40 million
people in the United States play racquet sports. In
recent reports
of
eye injuries, the racquet sports in-
variably feature prominently and together cause
more injuries than any other sport in Great Britain
(Jones 1987). In
1976
racquet sports were esti-
mated to cause 3220 eye injuries in the United
States (National Electronic Injury Surveillance
System 1976). Although these sports have in com-
mon the rapid exchange
of
a high velocity projec-
tile within a confined space, each has its particular
problems. Table
II
shows measured projectile ve-
locities for each sport.
3.1.1 Squash Racquets
In terms
of
eye injury, squash is the paradigm
of
racquet sports. A small ball bounces around in
a confined space at speeds up to 62 m/sec hotly
pursued by 2 players, each brandishing a flailing
racquet. The potential for ocular trauma
is
ob-
vious. The popularity
of
the sport has risen pro-
gressively over the last 20 years. Attention was first
drawn to the problem
by
North (1973) and Ingram
and Lewkonia (1973), and other reports have
fol-
lowed (Barrell et al.
1981;
Blonstein
1975;
Easter-
brook 1978, 1980; Mondon et al.
1981;
Moore &
Worthley
1977;
Quere & Pietrini
1986;
Sabiston
1976).
The size
of
the problem
is
now becoming ap-
parent. Gregory (1986) found squash the common-
est sporting cause
of
eye injury in Sussex
(26%),
and Karlson and Klein (1986) found it the second
commonest in Wisconsin
(15%),
as did Jones (1987)
168
in Manchester
(16%).
In terms
of
severe eye injury,
Canavan (1980) found it the second commonest
sport causing injury
of
sufficient severity to require
admission to hospital
(17%),
and this
is
supported
by
Jones (1988)
[23%].
Littlewood (1982) in Perth
found that trauma on the squash court caused more
hyphaemas
(21%)
than any other mode
of
injury.
Injury
by
the ball itself
is
most common, and
characteristically occurs when a player turns to
watch his opponent playa stroke. Kennerley Bankes
(1985) found that
69%
of
339 injuries were caused
by
the ball, and this high proportion
is
supported
by
others [Barrell et
al.
(1981),
71
%;
Gregory (1986),
71%;
MacEwen (1987),
79%;
North (1973),
77%]
.
A squash ball
is
ideally sized to allow entry into
the orbit and cause a compression injury to the
globe (Editorial 1973)
[fig.
6].
The spectrum
of
in-
jury was detailed
by
Kennerley Bankes (1985) and
not surprisingly included a large proportion ofhyp-
haemas
(43%)
. Injury
by
the racquet
is
often a more
serious matter. A disproportionate number
(43%)
of
severe injuries
is
caused in this way (Ingram &
Lewkonia 1973) and globe rupture has been re-
ported (Jones 1987) with loss
of
the eye.
A blow from squash racquet
or
ball is a blunt
injury. Rarely
is
such an injury
of
sufficient force
to rupture the globe itself. When glass spectacles
are interposed, however, penetration
of
the eye
is
facilitated (Christianson et
al.
1977;
Keeney &
Fig.
6.
A severe orbital haematoma caused by a squash ball
masks a typical contusional injury including hyphaema
and
blowout fracture of the orbit.
Eye Injury in Sport
Fig.
7.
Lensless eye protectors are inadequate for use in squash
because the ball can still deform enough
to
penetrate the gap
and cause compressive injury.
Renaldo
1975;
Moore & Worthley 1977). Ingram
and Lewkonia reported that 4
of
their
21
patients
suffered penetrating injury.
All
were wearing spec-
tacles, and 3
of
the 4 were struck
by
a racquet. Cole
(1987), reporting a large series
of
penetrating eye
injuries, found squash the commonest sport in-
volved, injuring 5 players, all
of
whom were wear-
ing glasses. Wearing glass spectacles on a squash
court
is
extremely dangerous and must be pre-
vented.
How dangerous, then,
is
squash? Barrell et al.
(1981) estimated that squash was the most dan-
gerous sport in the United Kingdom, generating an
eye injury rate
of
5.2 per 100,000 playing sessions.
Clemmett and Fairhurst (1980) reported a popu-
lation-based survey
of
10,658 matches involving
1327
competitive squash players, during I season.
There were
64
head injuries, and although in only
2 cases was the eye directly involved, the prepon-
derance
of
injuries around the ocular area was
striking. According to Reif et
al.
(1981), the regular
squash player
(3
times per week) over
25
years
of
play has a
25%
risk
of
significant eye injury. Locke
(1985), in his review
of
injuries
at
squash, includ-
ing sudden death, poses the salient question: squash
racquets
...
deadly
or
safe?
Despite some public awareness
of
the potential
for eye injury in squash, protective spectacles are
169
rarely worn, despite many writers on the subject
exhorting that they are necessary (Easterbrook
1978,
1980;
Editorial
1973;
Elman
1986;
Gregory 1986;
Ingram & Lewkonia
1973;
Jones
1987,
1988;
MacEwen
1987;
North
1973;
Yinger
1981
b, 1985).
These should contain polycarbonate lenses; lens-
less protectors are inadequate for squash (Easter-
brook
1980;
Yinger 1985)
[fig.
7].
There is little
doubt that the enforcement
of
such protection
would virtually eliminate eye injuries from the
game.
3.1.2 Racquetball
Although the sport has some similarities to
squash, fewer injuries have been reported
at
rac-
quetball. The sport
is
certainly increasing in pop-
ularity, and Doxanas and Soderstrom (1980) re-
ported a series
of
37
injured players, including a
large proportion
of
brow lacerations caused in the
follow-through
by
the racquet. Easterbrook (1980)
reported
18
cases,
of
whom
13
required admission
to hospital.
Eye
protection
is
certainly necessary
for this sport (Vinger
1985).
3.1.3 Badminton
The badminton shuttlecock can achieve veloc-
ity
of
57
m/sec (Vinger 1985) and thus impart con-
siderable energy to the globe
(fig.
8)
. Chandran
(1974) and Blonstein (1975) have reported eye in-
juries in badminton, yet on the whole these have
Fig. 8. Hyphaema (blood in the anterior chamber) caused by a
badminton shuttlecOCk.
Eye
Injury in Sport
been considered less severe than squash ball inju-
ries (Barrell
et
al. 1981). Badminton is becoming
more popular, however, and
was
found to be the
third commonest sport causing eye injury in the
United Kingdom by both Gregory (1986) and Jones
(1987), being responsible for
17%
and
14%
of
in-
juries, respectively. In these studies Kelly (1987)
has shown that badminton can and does cause sev-
ere injuries (including perforating injury), and Jones
(1988) found badminton to be responsible for
19%
of
severe eye injuries in sport.
Certain risk factors for eye injury in badminton
have been found. Doubles is more dangerous than
singles (Jones
1987;
Kelly 1987).
As
with tennis,
players
at
the net are more at risk than those in
the back court, and should protect their faces with
the racquet. Badminton is dangerous enough to
recommend that protective polycarbonate specta-
cles should be worn by all players (Vinger 1985).
3.1.4 Tennis
Recent interest in squash as a danger to the eye
has distracted attention away from tennis, yet Vin-
ger and Tolpin (1978), recording a survey
of
rac-
quet sport injuries, found tennis to cause as many
as
73
of
82
cases
(89%).
Seelenfreund and Freilich
(1976) described a series
of
patients with contu-
sional eye injuries caused by tennis balls, typically
including vitreous haemorrhage and retinal breaks,
some with established retinal detachment requiring
surgery. In
1976
there were an estimated
12
mil-
lion tennis players in the United States and in that
year 3220 eye injuries were sustained during play
(National Electronic Injury Surveillance System
1976).
The tennis ball,
at
6.25cm in diameter, cannot
enter the orbit as readily as the squash ball
or
shut-
tlecock, yet can obviously cause severe injury.
Al-
though it is capable
of
a similar velocity to a squash
ball,
it
is generally only volleys and the service that
achieve this.
It
is notable that Seelenfreund and
Freilich (1976) identified the player rushing into
the net as particularly at risk owing to the greater
speed
of
the ball in this situation. Ramanan (1976)
also rightly highlights the danger
of
turning round
to watch one's partner serve, for the same reason.
170
In tennis as in other sports, experience is often
thought to protect the player. Yinger and Tolpin
(1978) dispute this, and Duke (1976) records the
instance
of
a world class player losing an eye at
tennis. Experience is no protection, yet an identi-
fication
of
special risk areas, such as net play, turn-
ing back, and doubles play (Stein 1987) must lead
to better safety.
Stein (1987) considers that the routine use
of
safety spectacles
is
not necessary for tennis. It is
interesting to note that Yinger and Tolpin (1978)
found that ordinary spectacles were a considerable
protection against
eye
injury at tennis, yet
of
course
a shattered lens can have a devastating effect.
See-
lenfreund and Freilich (1976) recommend routine
protection for those at high risk from eye injury
(including
of
course the one-eyed) and illustrate a
lensless protector. Certainly all who wear specta-
cles should wear plastic lenses.
3.2
Bat and Stick Sports
The following sports have in common a hard,
fast-moving ball
or
puck struck by a hard stick, bat
or club. There the similarities end, as the individ-
ual features
of
each sport affect the likelihood
of
injury, though not necessarily its clinical features.
3.2.1 Baseball
In the United States baseball is estimated to
cause 900,000 injuries per year.
Of
these, 170,000
are to the face, and over 9000 directly involve the
eye, making it the most common cause
of
sport
injuries to the eye (Vinger 1985). When consider-
ing severe eye injuries alone, Schein
et
al. (1988)
also report that baseball is the leading sport, being
responsible for nearly
30%.
Hoefle (1987) finds that
within the comparatively small professional com-
munity, severe eye injuries are rare, but Yinger
(1985) estimates that eye trauma
is
most common
in the
5-
to 14-year
age
group, accounting for
45%
of
all baseball injuries.
Injuries are usually caused
by
the ball
(62%),
the
bat causing
16%
(Hoefle
1987).
The entire spec-
trum
of
blunt injury
is
possible, including ruptured
globe and orbital fracture. Professional players have
Eye
Injury in Sport
been forced to retire because
of
eye injury. In the
United States moves are beginning to introduce
fa-
cial protectors, initially for younger players, and
the American Society for Testing and Materials has
laid down standards for such protectors. With
widespread use
of
these, the Consumer Products
Safety Commission estimates that head and
face
injuries could be reduced by up to 54,000 cases per
year (Yinger
1985).
3.2.2 lee Hockey
Ice hockey is a popular winter sport in many
countries, but predominantly in North America.
Injuries are extremely common; Yinger (
1981
b) says
that
7%
of
unprotected hockey players were injured
during their first year, and at high school
60%
had
had ocular
or
facial injury.
Eye
and
face
injuries
accounted for one-third
of
all injuries in ice hockey
(Yinger
1985),
and most
of
these injuries
(80%)
were
caused by the stick (Yinger 1976). In
1974,
concern
about this problem led to the formation
of
a com-
mittee
of
the Canadian Ophthalmological Society,
to investigate the matter. Pashby and co-workers
(1975) recorded the initial surveys
of
hockey sea-
sons
1972
to
1975,
giving a catalogue
of
severe
ophthalmic injury including ruptured globes and
orbital fractures.
Of
all eyes injured,
15%
were ren-
dered legally blind. A resume
of
the types
of
eye
injury sustained in hockey
is
given by Rousseau
(1987).
Over the succeeding
few
years, a dramatic
fall
in the number
of
injuries ensued (Pashby 1977,
1979,
1985). There were 4 reasons for the
fall.
Firstly, a campaign to generate greater awareness
of
the risks
of
eye injury led to more widespread
use
of
head and eye protectors. Secondly, such pro-
tectors became more trustworthy following strin-
gent trials by the Canadian Standards Association.
Thirdly, a rule was introduced forbidding high
sticking (the practice
of
raising the hockey stick
above the shoulder) and, fourthly, head protection
was made mandatory for young players. The re-
sulting fall in injury rate has been hailed as one
of
the great successes in preventive ophthalmology,
and similar events have occurred in the United
States. However, although there has been a
sig-
171
nificant improvement in safety standards, Pashby
(1987) stresses that there
is
yet work to be done;
in Canada, 238 eyes have been blinded in
18
sea-
sons, and hockey still accounts for
37%
of
sporting
eye injuries and
56%
of
blinded eyes. Attention is
now focussing on the older
age
groups, and man-
datory facial protection for all seems the likely out-
come.
3.2.3 Field Hockey
Field hockey has attracted considerably less at-
tention than ice hockey, yet severe injuries do oc-
cur (Elliott & Jones
1984).
Three globe ruptures
were reported, all caused by an opponent's stick in
the follow-through. Clearly the problem
of
illegal
high sticking in field hockey must be addressed,
and the advisability
of
facial protection must be
discussed.
3.2.4 Cricket
Little attention has been paid to eye trauma in
cricket, yet it can be responsible for severe injuries.
In England, recent studies have found it to account
for
5.4%
(Gregory 1986) and
4.8%
(Jones
1987)
of
sporting
eye
injuries. In Australia, Littlewood (1982)
found it responsible for
7%
of
all traumatic hy-
phaemas. Coroneo (1985) described a series
of
in-
juries sustained in indoor cricket, a game played
with a softer ball. Jones & Tullo (1986) described
several cases
of
severe eye injury sustained
at
out-
door cricket, including retinal detachment
(fig.
9),
orbital fractures, and rupture
of
the globe. Some
common risk factors were identified. Most injured
players were struck by a ricochet off the bat edge,
and the hook shot placed the batsman at particular
risk, owing to body position at impact; the ball
tends to strike the eye from below and laterally,
and it
is
blows from this direction that are most
likely to cause globe rupture (Warwick 1976).
Al-
though the wearing
of
safety helmets in cricket has
quite rightly become commonplace, the provision
of
a polycarbonate visor
or
face
cage is not com-
mon to all helmets. Severe eye injuries would be
prevented
if
full facial protection were to be worn.
Eye
Injury in Sport
Fig.
9.
Retinal detachment caused by multiple retinal tears (ar-
rows). A cricket ball injury.
3.2.5
Golf
Golf
is an uncommon cause
of
eye injury. It
will, however, be appreciated that both ball and
c1ubhead are hard, small, and rapidly moving, thus
capable
of
deep penetration into an orbit. Injuries
sustained are therefore frequently severe. Millar
(1967) described a series
of
7 cases, including 2
globe ruptures, both requiring enucleation. Over a
20-year period in Massachusetts, golf caused
14%
of
all sports injuries leading to enucleation
of
the
globe (Portis et al. 1981).
It is appropriate to mention here that the prac-
tice
of
golf ball dissection
is
dangerous. The liquid
core is under high pressure and subconjunctival in-
jection by a spurt
of
fluid has been extensively re-
ported, causing characteristic granulomatous in-
flammation (Lucas et al. 1976). Liquid-core golf
balls should carry a clear warning to this effect.
Most golfing eye injuries are avoidable by the
practice
of
good etiquette on the tee and fairway.
Certainly all clubhead injuries should be prevented
by keeping clear
of
the player's swing. Although
protective eye wear should not be necessary, spec-
tacle-wearers should convert to polycarbonate len-
ses (Vinger 1985).
3.3 Large Ball Sports
Objects as large as footballs are less likely to
cause ocular damage than squash balls
or
hockey
sticks. Despite this, injuries are often seen. The
fol-
172
lowing sports also involve a variable degree
of
body
contact, and injuries can be caused by heads, el-
bows, fists and fingers.
3.3.1 North American Football
To
the unfamiliar, the football player appears
protected almost to excess. This misconception
is
soon dispelled by observing a typical game. Foot-
ball is estimated to cause 432,000 injuries per year
in the United States,
12%
of
all sporting injuries.
Despite protective wear, eye injuries are estimated
at 2350 per year, mostly in the
5-
to l4-year age
group (National Electronic Injury Surveillance Sys-
tem 1982). Helmets incorporating facial cages have
been proven effective in reducing facial injuries
(Wilson & Rontal 1973), but such cages easily per-
mit the entry
of
fingers, and ocular injuries pro-
duced in this way have been recorded (Helveston
1987), and are probably the commonest cause
of
eye injury, whether accidental
or
deliberate. The
replacement
of
facial cages with polycarbonate vi-
sors would remove this problem
and
would also
improve the visual field, which tends to be reduced
with currently available protectors (Vinger 1985).
3.3.2 Soccer
The 3 most recent surveys
of
sports-related eye
injury in Great Britain have found soccer to be re-
sponsible for a large number
of
injuries. Gregory
(1986) found it the second most common sport
causing eye injury, being responsible for
21
%
of
the
total. Both MacEwen (1987) and Jones (1987) found
it the commonest cause
of
injury, reporting 45%
and
27%,
respectively. Jones (1988), in a survey
of
severe eye injuries in sport, found it the commo-
nest cause
of
an admission to hospital (33%
of
total). Soccer is rising in popularity in the United
States
and
Burke et al. (1983) report a series
of
37
injuries, mostly caused
by
the ball itself. Although
the severity
of
these injuries compared favourably
with injuries sustained at hockey
or
racquet sports,
they included 8 cases
of
retinal damage and 2 or-
bital fractures
(fig.
10).
In view
of
the fact that a soccer ball is 21cm in
diameter, it is somewhat surprising that it is ca-
pable
of
blunt eye injury (Vinger 1985).
It
must be
Eye
Injury
in
Sport
capable
of
adequate deformation on impact to en-
ter the orbit. Burke and others (1983) recommend
the use
of
eye protection in soccer, though resist-
ance to any such initiative
is
likely to be strong.
Suggestions that young players should be discour-
aged from heading the ball (Vinger 1985) are un-
realistic as this action
is
intrinsic to the sport.
3.3.3 Rugby Football
Rugby compares with American football in
terms
of
physical contact between players, yet tra-
ditionally no protective wear
is
used. Injuries are
common, and in Dunedin, New Zealand, between
1974 and
1976
it accounted for
49%
of
all sports
injuries (Marshall & Sandes
1977).
Of
special con-
cern has been the tendency for cervical spine in-
juries in scrummages (Burry & Calcinai
1988;
Tay-
lor & Coolican
1987).
Ocular injury has not been
specifically documented, though in recent surveys
in the United Kingdom rugby accounted for
6.5%
(Gregory 1986),
8.3%
(Jones 1987) and
9.8%
(MacEwen 1987)
of
eye injuries in sport. Present
knowledge
of
causes
of
eye injury in rugby does
not allow informed comment on the need for ocu-
lar protection.
3.3.4 Basketball
Basketball
is
second only to baseball in the
league
of
eye injuries in sport in the USA (National
Electronic Injury Surveillance System 1982), caus-
Fig. 10. Computer-assisted tomograph showing blowout frac-
ture of the left orbit floor with extrusion of orbital contents into
the maxillary antrum. A football injury.
173
ing an estimated 7500 eye injuries, mainly in the
15-
to 24-year
age
group. In Wisconsin the sport
was the commonest cause
of
eye injury, being re-
sponsible for
19%
of
the total (Karlson & Klein
1986).
As
would be expected from the nature
of
the game, most injuries are caused by opponent's
fingers or elbows rather than the ball itself (Yinger
1985).
Karlson and Klein (1986) found that
74%
of
injuries were caused in this
way.
Extremely sev-
ere injuries can result from forceful insertion
of
a
finger into the orbit, and avulsion
of
the optic nerve
has been reported in basketball (Chow et
a1.
1984;
Park et
al.
1971).
Ocular trauma
is
common enough
to recommend universal eye protection for bas-
ketball players.
3.4 Boxing
Of
all sports with an intrinsic risk
of
injury,
pugilism has attracted more medical criticism than
any other. This
is
not surprising. Boxing shares with
few
other activities the essential prerequisite
of
damaging one's opponent. Indeed, in a position
statement from the International Federation
of
Sports Medicine (Yinger et al. 1988), boxing alone
with full-contact karate shares the distinction
of
being 'extremely high risk for eye injury'.
The debate has raged for many years and will
continue to do
so.
Its very inclusion as a sport
would be questioned by many, who would regard
it
at
best as distasteful entertainment,
at
worst as
legalised assault. Conversely, devotees
ofthe
sport
are
well
able, as Doggart (1955) says, to 'evolve a
set
of
reasons to justify their favorite pleasure'. De-
spite the emotive arguments, it
is
important to place
into perspective the very real capacity for injury,
and, in this context, eye injury.
Doggart (1955) and Pizzarello (1987) summar-
ise the various types
of
ocular or adnexal injury
typical
of
boxing. They enclose the whole spectrum
of
blunt trauma, though
of
special importance are
anterior chamber angle recession, and retinal dam-
age.
Many case reports exist on these subjects.
Though Whiteson (1981) felt that according to his
anecdotal experience, retinal detachment was not
a common problem among boxers, this
is
in direct
Eye
Injury
in
Sport
contradiction
to
the evidence presented
by
Ma-
guire & Benson (1986), who recorded 8 retinal de-
tachments
in
boxers
in
2 years
at
one
hospital.
Hospital-based
data
on
eye injuries
in
boxing
are relatively difficult
to
collect
or
assess
and
re-
ports remain largely anecdotal, although in this way
Elkington (1985) revealed 210 cases. There are,
however,
important
population-based reports
on
the
frequency
and
severity
of
such injuries. Mc-
Cowan (1959) found eye injuries
in
less
than
0.2%
of
a large sample
of
boxers. Palmer (1976) found
old anterior segment
trauma
in
16%
of
a sample
of
55 retired boxers. More recently, Giovinazzo
et
al. (1986),
in
New
York State, examined
in
detail
the
eyes
of
74 boxers who were applying for,
or
applying for the renewal of, a licence
to
box. They
found eye injuries
in
66%
of
boxers. More signifi-
cantly, injuries felt to
be
'vision-threatening' were
discovered
in
as
many
as
58%.
19%
had
anterior
chamber
angle deformities,
19%
had
traumatic cat-
aracts, 24%
had
retinal breaks
and
2 boxers
had
established retinal detachment.
Both
the
British Medical Association
and
the
American Medical Association have resolved to
campaign for
the
abolition
of
boxing as
an
organ-
ised sport. In the
United
Kingdom, the Board
of
Science
and
Education Working Party was set
up
to
investigate the problem. Its report (1984) in-
cludes
comments
on
the dangers
of
eye injury as
well as chronic
brain
damage, a subject also re-
ported elsewhere (Kaste
et
al. 1982; Ross et al. 1983;
Sironi
et
al. 1983).
Occasionally the public eye is directed towards
a serious injury
in
a famous boxer. Such attention
is usually short-lived
even
though blindness may
result.
This
media attention represents
the
tip
of
an
iceberg. Boxers, compared with controls, are
more
at
risk
of
eye injury,
and
more
at
risk
of
sight-
threatening eye injury, particularly retinal detach-
ment
(Giovinazzo
et
al. 1986).
What
measures
can
be taken
to
lessen the prob-
lem?
The
abolition
of
boxing as a sport is
the
aim
in
several countries.
On
the
assumption
that
this
is unlikely
to
occur
in
the near future, certain re-
strictions would undoubtedly reduce the risk
of
blindness
among
boxers,
and
these are admirably
174
dealt with by Giovinazzo
et
al. (1986), in particular
the
following:
1.
The
use
of
thumbless gloves should become
mandatory.
The
thumb
of
a boxing glove is much
more likely
to
penetrate the orbit
than
the fist.
2.
Boxers should undergo mandatory ocular
examination
at
stated intervals,
and
those
at
spe-
cial risk should be either suspended from boxing
for
an
appropriate time,
or
where necessary stopped
altogether.
3.
Ringside physicians should be better trained
in the examination
and
treatment
of
eye injuries.
4. Proper records
of
eye injuries should be kept.
3.5 Aquatic Sports
Indoor
swimming pools contain a variety
of
ir-
ritants
of
which the
most
common
is chlorine.
Abramson & McDonough (1987) describe
the
prin-
ciples
of
pool disinfection.
The
presence
of
a dis-
infectant
in
pool water serves
to
limit transmissible
infection, yet epidemics
of
adenoviral conjunctiv-
itis related
to
swimming pool water have been re-
ported (d'Angelo
et
al. 1979). Such irritants have
well-recognised effects
on
the cornea, as described
by Haag
and
Gieser (1983). In a group
of
50 swim-
mers using
the
pool for
an
average
of
34 minutes,
94%
had
corneal epithelial damage
and
68%
had
transient corneal oedema affecting visual acuity.
Ocular injury is by
no
means limited
to
the water
itself.
The
use
of
goggles
to
prevent the above ef-
fects is widespread, yet
on
occasion the goggles
themselves can cause injury, slipping
out
of
wet
hands
and
being pulled into the eyes by
their
elas-
tic straps, as described by Jonasson
in
1971. High
diving can rarely cause eye injury, including optic
nerve damage (Jonasson & Cullen 1982). Water
polo occasionally leads
to
ocular trauma, as finger
to eye contact is inevitable
at
times.
The
comparatively relaxed sport
of
angling
might be thought free
of
potential for eye injury,
yet
the
impalement
of
an
eye
on
a barbed fish hook
has been reported (Bartholomew & MacDonald
1980,
Grand
& Lobes 1980). Such injuries are,
however, rare.
Eye Injury in Sport
3.6 Skiing
Eye
injury in skiing
is
uncommon, but
fre-
quently severe. In Canada between
1973
and 1984,
only
10
cases
of
eye injury were reported to the
Canadian Ophthalmological Society but,
of
these,
6 were blinded in the involved eye (Rousseau
1987).
Snow blindness
is
caused
by
absorption
of
ultra-
violet light
by
the cornea, and can be prevented
by
adequate filter
goggles,
as specified
by
the Ameri-
can Society
of
Testing and Materials. Mechanical
injury
is
most commonly sustained during cross-
country skiing or off-piste downhill skiing through
trees (Rousseau 1987), when scratches from twigs
can occur. Occasionally blows from tree branches
are more severe, and a retained orbital wooden for-
eign body has been reported (Brock et al. 1980).
The skier's own equipment, particularly ski poles
or the ski itself, can cause optic nerve avulsion,
muscle transsection
or
perforating injury (Rous-
seau 1987) and the T-bar lift
is
capable
of
similar
injury (Amyot
1984).
Ultraviolet filter
goggles
are mandatory for skiing
in conditions which are likely to lead to snow
blindness, but many
of
these offer little protection
from mechanical injury. They should incorporate
polycarbonate lenses (Vinger 1985) and be able to
deflect blows
of
at least moderate force. Where the
risk
of
injury is high, as for downhill racing, hel-
mets incorporating polycarbonate visors should be
used.
3.7 Shooting
Shooting as an organised sport
is
time-hon-
oured, and many
of
its various forms are Olympic
sports. Under the most stringent safety controls,
injury from the use
of
firearms
is
unlikely. How-
ever, when injuries do occur they are frequently
severe. The ocular disruption caused
by
a small
projectile with a very high velocity
is
considerable.
An
airgun or shotgun pellet requires a velocity
of
greater than 40 metres per second to penetrate the
eye. The muzzle velocity
of
airguns
is
well
in ex-
cess
of
this figure, and for a shotgun it
is
multiplied
6-fold (Salisbury 1987).
175
Fig. 11. Lateral skull radiograph showing multiple shotgun pel-
lets including ocular damage.
There are several reports
of
ocular injuries due
to shotgun pellets in the literature (Drummond &
Kielar
1976;
Morris et al.
1987;
Roden et al. 1987).
They have in common the findings
of
frequent poor
visual outcome. In addition, owing to the spread-
ing nature
of
the blast, bilateral injuries are not
uncommon. Indeed, Morris et
al.
(1987) found both
eyes to be involved in
59%
of
cases. In Drum-
mond's series
of
20 perforating injuries, only
15%
attained a visual acuity
of
better than Hand Move-
ments. Heimann et al. (1983) found that in a large
series
of
308 eyes with intraocular foreign bodies,
those with the worst prognosis were those caused
by
gunshot
or
airgun pellets. In Morris' series in
1987,
29%
of
eyes required enucleation
(fig.
II).
The ophthalmic and general medical literature
has a plethora
of
reports
of
injuries caused by air-
gun projectiles, including fatal wounds (Chandu
Lal
& Subrahmanyam 1972), and it
is
distressing that
children are so frequently involved (Reid
1974;
Spitz
1968).
A
few
large series
of
ocular airgun in-
juries have been presented, notably
by
Bowen and
Magauran (1973) [105 cases], Sevel and Atkins
(1978)
[87
cases] and Moore et
aI
. (1987)
[60
cases].
The appalling prognosis
of
penetrating injuries
caused
by
airgun pellets has been highlighted
by
Sternberg and others (1984), when
of
22
injured
eyes,
19
required enucleation and the remaining 3
retained a visual acuity worse than 2/60
(fig.
12).
Airgun injuries are common, and it was estimated
Eye
Injury in Sport
Fig.
12.
Anteroposterior skull radiograph showing
an
airgun
pellet within the left orbit.
in
1981
that 22,800 injuries were caused in the
United States,
of
which
1255
were ocular (National
Electronic Injury Surveillance System 1981). The
average
age
of
the injured
is
in the teens [Bowen
& Magauran (1973),
14
years; Moore et at. (1987),
17
years].
Airguns are dangerous weapons. This
is
a truism,
but needs stating, as the fact
is
clearly not appre-
ciated by a substantial proportion
of
users. Better
education in the proper and supervised use
of
air-
guns
is
required.
In the prevention
of
injuries
of
all types from
firearms,
of
paramount importance is the educa-
tion
of
the user in gun safety techniques. In ad-
dition to this, the use
of
safety eye wear
is
to be
recommended. Apart from the risk
of
perforating
injury from projectiles, the eye
is
also exposed to
powder discharge, and small metallic particles from
cartridge cases ejected from the breach (Salisbury
1987). Robertson (1976) conducted experiments on
the efficacy
of
various materials for safety lenses
and found none to be completely satisfactory. Sim-
mons and co-workers (1983) found polycarbonate
to be extremely efficient in the prevention
of
pen-
etration
by
shotgun pellets, and recommended that
these be mounted in polyamide frames with 4mm
posterior rims to prevent posterior dislocation
of
the lenses. Standard frames were not found to be
adequate.
It
is
important to note that polycarbon-
ate becomes brittle
at
low temperatures (Keeney
176
1981)
and at freezing point, a 2.2mm lens
was
more
resistant to penetration than a 3.0mm lens. Poly-
carbonate
is
20
times more resistant than tempered
glass to high velocity low mass impact (Novak
1981). Gun
Users
should be exhorted to wear such
spectacles. Yinger (1985) gives comprehensive
guidelines for eye wear in shooting.
3.8 Others
Eye
damage has been reported in most sports
at
some time or another and new sports constantly
join the list. Cases
of
injury occur in such diverse
activities as baton twirling (Fern et
at.
1987)
and
war games (Easterbrook & Pashby
1985).
Men's lacrosse
is
known to cause frequent in-
jury, and head injuries account for
10%
of
these
(Mueller & Blyth
1982),
despite the use
of
helmets.
The eyes are usually
well
protected
by
a
face
cage,
but this will still admit fingers and sometimes the
stick, and Yinger (1985) recommends upgrading
protector standards to those
of
ice hockey. The
controllers
of
women's lacrosse have strongly crit-
icised suggestions that facial protection should be
used, on the basis
of
a difference in rules whereby
there
is
less bodily contact than in the men's game.
However, the United States Women's Lacrosse
As-
sociation (USWLA) reports an injury rate to the
face
(including eyes)
of
up to
9.9%
per player per
year. Despite this rate, the USWLA has prohibited
the
use
of
facial protection and helmets (Vinger
1985).
The game
of
darts
is
of
some concern, mainly
as eye injuries tend to occur in children. Cole and
Smerdon (1988) reviewed
19
such injuries during
an 8-year period, all perforating, and found that
the flight end
of
the dart was responsible for 6
of
the cases. In this survey, the dart injuries ac-
counted for
18%
of
all perforating injuries occur-
ring in the under
14
years
age
group, and this dis-
turbing tendency
is
also reported
by
Wykes (1988)
[25%
of
all
perforating injuries in the under
16
years
age
group caused
by
darts). The answer to the
problem probably lies in greater supervision rather
than protective wear.
Eye
Injury in Sport
4.
Principles
of
Ocular
Protection
Each sport has different requirements for pro-
tection, but all have in common the need to take
reasonable steps to prevent eye injury. In so doing
a structured approach is important (Yinger 1985).
I. Data collection identifies the incidence and
prevalence
of
injury for each sport.
It
provides in-
formation on the type
of
injuries caused and their
severity, and identifies risk factors within sports.
Over time changes in incidence are shown.
As
a
result action to reduce injury may be required, and
this essentially takes 2 forms: changing the pattern
of
the sport and/or using protective wear.
2.
Changes in the pattern
of
the sport may be
voluntary, through education,
or
mandatory owing
to changes in the rules
of
the sport. For instance,
in badminton it has been shown that most injuries
occur in doubles (Kelly 1987),
by
a shuttlecock
smashed into the eye
of
the person at the net.
Coaching novices to hold the racquet in front
of
the
face
in this position would protect from such
injury and would not interfere with play. In ice
hockey, the use
of
the stick above shoulder level
was identified as a high risk factor for severe eye
injury and in Canada the rules were changed to
prevent this. A reduction in injuries ensued (Pashby
1977).
3.
The ideal eye protector should prevent eye
injury by dissipating force onto a wide area, but in
no way should increase the risk
of
injury
by
re-
ducing visual field or giving misplaced overconfid-
ence and should not convert an oculofacial injury
into an intracranial one. The development and
constant updating
of
performance standards for
protectors is crucial and various factors must be
taken into consideration for each sport, for in-
stance the size and speed
of
the projectile, the like-
lihood
of
eye contact with the hitting instrument
if
any, the likelihood
of
body contact with an op-
ponent and the possible sequelae
of
all
of
these.
On the basis
of
these considerations a protector
is
devised, which should be safe, convenient, cos-
metically acceptable and as inexpensive as possi-
ble. Where the benefits
of
such protection are un-
177
arguable, widespread use,
by
legislation ifnecessary,
should be the aim.
Most sports eye protectors
(fig.
13)
dissipate en-
ergy onto the glabella and supraorbital ridges, and
via the lateral orbital margins to the facial bones.
For a blow from a squash ball, this
is
adequate and
does not lead to increased likelihood
of
intracran-
ial injury. A blow from an ice hockey stick, how-
ever, may carry sufficient force to cause brain dam-
age
if
the blow is deflected away from the orbit
(normally the eye, though severely damaged, will
absorb energy as will the orbit when its walls frac-
ture). Where such injury
is
possible, helmet pro-
tection
is
necessary and eye protection
is
mounted
within this. Other factors may need to be taken
into consideration such as the need to protect from
ultraviolet light (in skiing
goggles)
or from chem-
ical action (swimming
goggles).
Table III shows
suggested protectors for several sports.
There is unfortunately often a conflict between
optimum safety and acceptability
of
a protector. It
must be considered sensible in some circumstances
to sacrifice the former to obtain more widespread
usage and in general this means making it more
lightweight.
Lenses for modern spectacles are made
of
3 types
of
material: glass, which may be heat-treated to aid
strength, allyl resin or polycarbonate. Christianson
et al. (1977) compared glass, heat-tempered glass
and allyl resin lenses
by
the standard method
of
Fig.
13.
Typical sports eye protectors with polycarbonate frames
and broad, strong nasal bridge and sides, allowing absorption
and deflection
of
force. Plano
or
prescription polycarbonate len-
ses are used.
Eye
Injury in Sport
Table III. Risk levels for
eye
injury
in
certain sports.
and
recommendations for protective wear
Risk Sport Protective wear
Unacceptable Boxing Not applicable
Very high Ice hockey Helmet with full visor
Squash Polycarbonate sports
protector
Badminton Polycarbonate sports
protector
Basketball Polycarbonate sports
protector
Men's lacrosse Helmet with full visor
High Racquetball Polycarbonate sports
protector
Baseball Polycarbonate sports
protector
Cricket Helmet with full visor
Feild
hockey Helmet with full visor
Rugby football Debatable
Soccer Debatable
Water polo Polycarbonate goggles
Shooting Polycarbonate sports
protector
Women's lacrosse Helmet with full visor
Moderate Tennis Plastic lens spectacles
American football Helmet with
polycarbonate visor
Low Golf Sports protector if one-
eyed
Volleyball Sports protector if one-
eyed
Skiing
UV
filter goggles ±
helmet
Cycling Sports protector ±
helmet
Fishing Polycarbonate protector
if one-eyed
Swimming Goggles if in water for
long periods
High diving Not feasible
Track & field
None
required
dropping metal balls onto them from graded heights
and found that impact resistance increased in the
order; glass, heat-tempered glass and allyl resin.
Keeney and Renaldo (1975) found plastic lens
frames aid lens strength more than wire frames,
and noted that glass lenses most
at
risk
of
fracture
on impact were those with a minus cylindrical pre-
178
scription. Robertson (1976) compared heat-tem-
pered glass, chemical-tempered glass and allyl dig-
lycol carbonate lenses and found all to
be
unsatisfactory when hit
by
shotgun pellets, whereas
Simmons and co-workers (1984) found the per-
formance
of
polycarbonate resin in similar circum-
stances to be·dramatically better. In terms
of
im-
pact resistance, polycarbonate
is
incomparable
(Davis 1987) and is therefore the material
of
choice
for all sports protectors where impact
is
a risk,
whether in spectacle
or
visor form.
Polycarbonate
is
not a panacea; at
low
temper-
ature its fragility increases markedly (Simmons et
at. 1984) and it is prone to scratch, requiring sur-
face
coating. At present, however,
it
represents by
far the best material for lenses and visors for sport
protectors.
The prevention
of
future eye injuries can only
come from an awareness among sportsmen and
women
of
the possibility
of
such injury, and a sen-
sible appraisal
of
the risks. For some, such as the
one-eyed, these risks may be unacceptable for some
sports. For others, the use
of
protection
is
advis-
able. Unfortunately most sportsmen consider it
unnecessary. The belief that 'it will never happen
to me' is common and can only be changed by an
appreciation
of
the facts which must come through
education by ophthalmologists and sports physi-
cians.
References
Abramson DH. McDonough
RA.
Aquatic sports. In Pizzarello &
Haik (Eds) Sports ophthalmology, Charles
C.
Thomas, Illinois,
1987
American Society
of
Testing and Materials. Standard specifica-
tion for eye protective devices (alpine skiing) F659-80, Amer-
ican Society
of
Testing and Materials, Philadelphia, 1980
Amyot
M.
L'oeil
et
Ie
ski, condition d'exposition et protection.
L'Actualite Medicinale 5 (20): 37-39, 1984
Barrell OV, Cooper PJ, Elkington AR, MacFayden JM, Powell
RO, et al. Squash ball to eye ball. British Medical Journal 283:
893-895,
1981
Bartholomew
RS,
MacDonald
M.
Fish hook injuries
of
the eye.
British Journal
of
Ophthalmology
64:
531-533, 1980
Bell
JA.
Eye
trauma in sports: a preventable epidemic. Journal
of
the American Medical Association 246:
156,
1981
Blonstein JL.
Eye
injuries in sport with particular reference to
SQuash
rackets and badminton. Practitioner
215:
208-209,
1975
Board
of
Science and Education Working Party Report on
Box-
ing. British Medical Association, London, 1984
Bowen 01, Magauran DM. Ocular injuries caused
by
airgun pel-
Eye
Injury in Sport
lets: an analysis
of
105
cases. British Medical Journal
I:
333-
337, 1973
Brock
L,
Tanenbaum HL. Retention
of
wooden foreign in the
orbit. Canadian Journal
of
Ophthalmology
15:
70-73, 1980
Burke MJ, Sanitato JJ, Yinger PF, Raymond
LA,
Kulwin DR.
Soccerball-induced eye injuries. Journal
of
the American
Medical Association 249: 2682-2685, 1983
Burry HC, Calcinai CJ. The need to make rugby safer. British
Medical Journal 296: 149-150, 1988
Canavan YM, Archer
DB.
Anterior segment consequences
of
blunt
ocular injury. British Journal
of
Ophthalmology 66: 549-555,
1982
Canavan YM, O'F1aherty MJ, Archer DB. Elwood JH. A IO-year
survey
of
eye injuries in Northern Ireland 1967-76. British
Journal
of
Ophthalmology 64: 618-625. 1980
Chandran
S.
Ocular hazards
of
playing badminton. British Jour-
nal
of
Ophthalmology
58:
757-760. 1974
Chandu Lal
R.
Subrahmanyam
BV.
Accidental death by
air
rifle.
Forensic Science
I:
441-443. 1972
Chapman-Smith JS.
Eye
injuries: a twelve-month survey. New
Zealand Medical Journal 90: 47-49. 1979
Chow AY. Goldberg MF, Frenkel
M.
Evulsion
of
the optic nerve
in association with basketball injuries. Annals
of
Ophthal-
mology
16:
35-37, 1984
Christianson MD. Parker JA. Arndt J. Material
and
thickness:
the important factors in the impact resistance ofspectacle len-
ses. Canadian Journal
of
Ophthalmology
12:
300-303. 1977
Clayton T. Miller
D.
The response
of
the eye
and
adjacent struc-
tures to injury. In Miller & Stegmann (Eds) Treatment
of
an-
terior segment ocular trauma. Medicopoea. Montreal. 1986
Clemett RS. Fairhurst SM. Head injuries from squash: a pro-
spective study. New Zealand Medical Journal
92:
1-3.
1980
Cole MD, C1earkin
L.
Dabbs T, Smerdon D. The seat belt law
and
after. British Journal
of
Ophthalmology
71:
436-440. 1987
Cole MD. Smerdon
D.
Perforating eye injuries caused by darts.
British Journal
of
Ophthalmology
72:
511-514. 1988
Coroneo MT. An eye for cricket: ocular injuries
of
indoor crick-
eters. Medical Journal
of
Australia
142:
469-471. 1985
d'Angelo
U.
Hierholzer JC, Keenlyside RA, Anderson
U.
Mar-
tone WJ. Pharyngoconjunctival fever caused by adenovirus type
4:
report
of
a swimming pool related outbreak with recovery
of
virus from pool water. Journal
of
Infectious Disease
140:
42-47. 1979
Davis JK. Lenses for sports vision. In Pizzarello & Haik (Eds)
Sports ophthalmology. Charles C, Thomas. Illinois. 1987
de
Juan
E,
Sternberg P. Michels RG. Penetrating ocular injuries:
types
of
injury
and
visual results. Ophthalmology
90:
1318-
1322, 1983
Doggart JH. The impact
of
boxing upon the visual apparatus.
Archives
of
Ophthalmology
54:
161-169. 1955
Doxanas MT. Soderstrom C. Racquetball as
an
ocular hazard.
Archives
of
Ophthalmology 98: 1965-1966. 1980
Drummond J. Kielar RA. Perforating ocular shotgun injuries: re-
lationship
of
ocular findings to pellet ballistics. Southern
Medical Journal 69: 1066. 1976
Duke
M.
Tennis players and eye injuries. Journal
of
the Amer-
ican Medical Association 236: 2287. 1976
Eagling EM. Perforating injuries
of
the eye. British Journal
of
Ophthalmology
60:
732-736. 1976
Eagling EM. Roper-Hall MJ. Eye injuries:
an
illustrated guide,
Gower, London, 1986
Easterbrook
M.
Eye
injuries in squash: preventable disease. Ca-
nadian Medical Association Journal
118:
298-305, 1978
Easterbrook
M.
Eye
injuries in racquet sports: a continuing prob-
lem. Canadian Medical Association Journal
123:
268-269, 1980
Easterbrook
M,
Pashby TJ.
Eye
injuries associated with war games.
Canadian Medical Association Journal
133:
415-417, 1985
Editorial. A ball in the eye. British Medical Journal
2:
195-196,
1973
179
Elkington AR. Boxing and the
eye:
results
of
a questionnaire.
Transactions
of
the Ophthalmological Societies
of
the United
Kingdom
104:
898-902. 1985
Elliott AJ, Jones D. Major ocular trauma: a disturbing trend in
field hockey injuries. British Medical Journal 289: 21-22, 1984
Ellis GS. Sports eye injuries: first aid and prevention. In Pizza-
rello & Haik (Eds) Sports ophthalmology, Charles C. Thomas.
Illinois, 1987
Elman MJ. Racket-sports ocular injuries. Archives
of
Ophthal-
mology
104:
1453-1454. 1986
Fern AI. Kyle P. Allan D. Baton twirling: another cause
of
eye
injury. British Journal
of
Ophthalmology
71:
931-932, 1987
Garrow
A,
A statistical enquiry into 1000 cases
of
eye injuries.
British Journal
of
Ophthalmology
7:
65-80, 1923
Giovinazzo VJ, Yannuzzi
LA,
Sorenson JA. Delrowe OJ. Cam-
bell
EA.
The ocular complications
of
boxing. Ophthalmology
94: 587-596, 1987
Glynn RJ. Seddon JM, Berlin
BM.
The incidence
of
eye injuries
in New England adults. Archives
of
Ophthalmology
106:
785-
789, 1988
Grand MG. Lobes
LA.
Technique for removing a fishhook from
the posterior segment
of
the eye. Archives
of
Ophthalmology
98: 152-153. 1980
Gregory PTS. Sussex Eye Hospital sports injuries. British Journal
of
Ophthalmology
70:
748-750. 1986
Haag JR, Gieser RG. Effects
of
swimming pool water on the cor-
nea. Journal
of
the American Medical Association 249: 2507-
2508, 1983
Heimann
K.
Paulmann H, Tavakolian U. The intraocular foreign
body. International Ophthalmology
6:
235-242, 1983
Helveston EM. Football. In Pizzarello & Haik (Eds) Sports oph-
thalmology. Charles C. Thomas, Illinois, 1987
Hoefle
FB.
Baseball ophthalmology. In Pizzarello & Haik (Eds)
Sports ophthalmology. Charles C. Thomas. Illinois, 1987
Holt JE. Holt
R,
Blodgett JM. Ocular injuries sustained during
blunt facial trauma. Ophthalmology 90: 14-18. 1983
Hyde KJ. Della Roca
RC.
The management
of
acute trauma to
the orbit
and
adnexa. Seminars in Ophthalmology
3:
20-33,
1988
I1sar
M.
Chirambo
M,
Belkin
M.
Ocular injuries in Malawi. Brit-
ish Journal
of
Ophthalmology 66: 145-148, 1982
Ingram DV, Lewkonia I. Ocular hazards
of
playing squash rac-
quets. British Journal
of
Ophthalmology
57:
434-438. 1973
Jonasson
F.
Swimming goggles causing severe eye injuries. British
Medical Journal
2:
881, 1977
Jonasson
F.
Cullen JF. Axonal transport injury caused by diving.
American Journal
of
Ophthalmology
94:
813-815. 1982
Jones NP.
Eye
injuries in sport: an increasing problem. British
Journal
of
Sports Medicine
21:
168-
170.
1987
Jones NP. One year
of
severe eye injuries in sport. Eye, in press,
1988
Jones NP, Hayward JM, Khaw PT. C1aoue CMP, Elkington AR.
Function
of
an
ophthalmic 'accident
and
emergency' depart-
ment: results
of
a six month survey. British Medical Journal
292: 188-190, 1986
Jones NP, Tullo
AB.
Severe eye injuries in cricket. British Journal
of
Sports Medicine
20:
178-179. 1986
Kanski JJ. Pathogenesis: significance
of
trauma. In Retinal de-
tachment, Butterworths. London, 1986
Karlson T
A,
Klein
BE.
The incidence
of
acute hospital treated
eye injuries. Archives
of
Ophthalmology
104:
1473-1476, 1986
Kaste EM, Vilkki J. Sainio
K.
Is
chronic brain damage in boxing
a hazard
of
the past? Lancet
2:
1186-1188, 1982
Kaufmann JH, Tolpin OW. Glaucoma after traumatic angle
recession: a ten-year prospective study. American Journal
of
Ophthalmology
78:
648-654, 1974
Kay
S,
Lendrum J. Progress in cranio-orbital surgery. Seminars
in Ophthalmology
3:
1-19,
1988
Keeney AH. Ocular sports injuries: standards
of
protection
and
Eye Injury in Sport
prevention.
I.
Applications
of
protective principles from in-
dustry. International Ophthalmology Clinics
21:
168-169,
1981
Keeney AH, Renaldo DP. Impact resistance
of
ophthalmic lenses
of
various strengths and the influence
of
frame design. Ca-
nadian Journal
of
Ophthalmology
10:
367-376,
1975
Kelly SP. Serious eye injury in badminton players. British Journal
of
Ophthalmology
71:
746-747,
1987
Kennerley Bankes JL. Squash rackets: a survey
of
eye injuries in
England. British Medical Journal 291: 1539, 1985
Koval R, Teller J, Belkin M, Romem M, Yanko
L,
et al. The
Israeli Ocular Injuries Study. Archives
of
Ophthalmology
106:
776-780, 1988
Lambah
P.
Adult eye injuries at Wolverhampton. Transactions
of
the Ophthalmological Societies
of
the United Kingdom
88:
661-673, 1968
Littlewood KR. Blunt ocular trauma and hyphaema. Australian
Journal
of
Ophthalmology
10:
263-266, 1982
Locke
AS.
Squash rackets: a review -deadly
or
safe? Medical
Journal
of
Australia
143:
565-567,
1985
Lucas DR, Dunham
AC,
Lee WR, Weir
W,
Wilkinson FCF. Ocu-
lar injuries from liquid golf ball cores. British Journal
of
Oph-
thalmology 60: 740-747, 1976
MacEwen CJ. Sport associated eye injury: a casualty department
survey. British Journal
of
Ophthalmology
71:
701-705,
1987
Maguire JI, Benson
WE.
Retinal injury and detachment in box-
ers. Journal
of
the American Medical Association 255: 2451-
2453, 1986
Marshall RN, Sandes
H.
Dunedin sports injuries 1974-1976. New
Zealand Medical Journal
86:
423-427, 1977
McCowan
IA.
Protecting the boxer. Journal
of
the American
Medical Association
169:
1409-1413, 1959
Millar GT. Golfing eye injuries. American Journal
of
Ophthal-
mology 64,741-742, 1967
Mondon H, Lefrancois
A,
Lai C, Hamard H. Traumatisme ocu-
larie au squash. Bulletin
of
the Ophthalmological Society
of
France
81:
303-306,
1981
Mooney
D.
Angle recession and secondary glaucoma. British
Journal
of
Ophthalmology
57:
608-612,
1973
Moore AT, McCartney
A,
Cooling RT. Ocular injuries associated
with the use
of
airguns.
Eye
I:
422-429, 1987
Moore MC, Worthley DA. Ocular injuries in squash players. Aus-
tralian Journal
of
Ophthalmology
5:
46-47, 1977
Morris RE, Witherspoon CD, Feist RM, Byrne JB, Ottemiller
DE. Bilateral ocular shotgun injury. American Journal
of
Oph-
thalmology
103:
695-700, 1987
Mueller FO, Blyth
CS.
A survey
of
1981
college lacrosse injuries.
Physician and Sports Medicine
10:
87, 1982
National Electronic Injury Surveillance System. US Consumer
Product Safety Commission, 1976
National Electronic Injury Surveillance System. US Consumer
Product Safety Commission,
1981
National Electronic Injury Surveillance System.
US
Consumer
Product Safety Commission, 1982
National Society to Prevent Blindness. Fact sheet. New York,
1980
North
1M.
Ocular hazards
of
squash. Medical Journal
of
Aus-
tralia
I:
165-166, 1973
Novak JF. Discussion on gunshot injuries. Ophthalmology
91:
983, 1984
Palmer
E,
Lieberman TW, Burns
S.
Contusion angle deformity
in prize fighters. Archives
of
Ophthalmology
94:
225-228, 1976
Park
JH,
Frenkel
M,
Dobbie JG. Evulsion
of
the optic nerve.
American Journal
of
Ophthalmology
72:
969-971,
1971
Parver LM.
Eye
trauma: the neglected disorder. Archives
ofOph-
thalmology
104:
1452-1453, 1986
Pashby
n.
Eye injuries
in
Canadian hockey: phase II. Canadian
Medical Association Journal
117:
671-678, 1977
Pashby TJ. Eye injuries in Canadian hockey: phase III. Older
180
players now at risk. Canadian Medical Association Journal
121:
643-644, 1979
Pashby TJ.
Eye
injuries in Canadian amateur hockey. Canadian
Journal
of
Ophthalmology 20: 2-4, 1985
Pashby TJ.
Eye
Injuries in Canadian amateur hockey still a con-
cern. Canadian Journal
of
Ophthalmology
22:
293-295, 1987
Pashby
n,
Pashby RC, Chisholm LDJ, Crawford JS.
Eye
injuries
in
Canadian hockey. Canadian Medical Association Journal
113:
663-674,
1975
Paul mann
H.
Blunt trauma injuries to the anterior segment.
In
Miller & Stegmann (Eds) Treatment
of
anterior segment ocular
trauma, Medicopoea, Montreal, 1986
PfeitTer RL. Traumatic enophthalmos. Archives
of
Ophthalmol-
ogy
30:
718-726,
1943
Pizzarello LD, Jordan
B.
Pugilism.
In
Pizzarello & Haik (Eds)
Sports ophthalmology, Charles
C.
Thomas, Illinois,
1987
Portis JM, Vassallo SA, Albert DM. Ocular sports injuries: a re-
view
of
cases on file in the Massachusetts
Eye
and Ear Infir-
mary Pathology Laboratory. International Ophthalmology
Clinics
21:
4,
1981
Quere MA, Pietrini
P.
Eye
injuries and squash. Bulletin
of
the
Ophthalmological Society
of
France
86:
1499-1500,
1986
Ramanan SV.
Eye
injuries from tennis balls. Journal
of
the Amer-
ican Medical Association 236: 1355, 1976
Reid
IS.
Airgun injuries in children. Medical Journal
of
Australia
I:
64-66, 1974
Reif
AE,
Vinger PF, Easterbrook
M.
New developments in pro-
tection against eye injuries. Squash News
4:
10,
1981
Robertson DM. Safety glasses as protection against shotgun pel-
lets. American Journal
of
Ophthalmology
81:
671, 1976
Roden
D,
Cleary
P,
Eustace
P.
A five-year survey
of
ocular shot-
gun injuries in Ireland. British Journal
of
Ophthalmology
71:
449-453, 1987
Ross RJ, Cole
M,
Thompson JS, Kim KH. Boxers -computed
tomography, electroencephalography, and neurological evalu-
ation. Journal
of
the American Medical Association 249: 211-
213, 1983
Rousseau AP, Amyot
M,
Labelle PF. Winter sports: hockey and
skiing. In Pizzarello & Haik (Eds) Sports ophthalmology,
Charles C, Thomas, Illinois,
1987
Runyan TE. Physical forces involved in ocular trauma.
In
Miller
& Stegmann (Eds) Treatment
of
anterior segment ocular trauma,
Medicopoea, Montreal,
1986
Sabiston
D.
Squash and eye injuries. New Zealand Journal
of
Sports Medicine
4:
3-5,
1976
Salisbury JA. The eye and shooting. In Pizzarello & Haik (Eds)
Sports ophthalmology, Charles
C.
Thomas, Illinois, 1987
Schein OD, Hibberd
PL,
Shingleton
BJ,
Kunzweiler T, Frambach
DA, et al. The spectrum and burden
of
ocular injury. Oph-
thalmology
95:
300-305,
1988
Seelenfreund MH, Freilich
DB.
Rushing the net and retinal de-
tachment. Journal
of
the American Medical Association 235:
2723-2726, 1976
Sevel D, Atkins AD. Pellet gun injuries
of
the eye. South African
Medical Journal
54:
566-568,
1978
Shock JP, Adams
D.
Long term visual acuity after penetrating
and perforating ocular injuries. American Journal
of
Oph-
thalmology
100:
714-718,
1985
Simmons ST, Kroehl GB, Hay
PB.
Prevention
of
ocular gunshot
injuries using polycarbonate lenses. Ophthalmology
91:
977-
982, 1984
Sironi V
A,
Ravagnati
L.
Brain damage in boxers. Lancet
I:
244,
1983
Spitz
L.
Air rifle injuries
in
children. South African Medical Jour-
nal 43: 557-560, 1969
Stein H, Slatt
B,
Stein
R.
Visual approach to winning tennis. In
Pizzarello & Haik (Eds) Sports ophthalmology, Charles
C.
Thomas, Illinois,
1987
Eye Injury in Sport
Sternberg p. de Juan
E.
Green WR. Hirst
LW.
Sommer
A.
Ocular
BB
injuries. Ophthalmology
91:
1269-1277. 1984
Taylor TKF. Coolican MRJ. Spinal cord injuries in Australian
footballers 1960-1985. Medical Journal
of
Australia
147:
112-
118.1987
Thordarson
V.
Ragnarsson AT. Gudbrandsson
B.
Ocular trauma.
Acta Ophthalmologica
57:
922-928.
1979
Vernon
SA.
Analysis
of
all
new cases seen in a busy regional
centre ophthalmic casualty department during 24-week period.
Journal
of
the Royal Society
of
Medicine
76:
279-282. 1983
Yinger PF. Ocular injuries in hockey. Archives
of
Ophthalmology
94:
74-76. 1976
Yinger PF. The incidence
of
eye injuries in sports. International
Ophthalmology Clinics 21(4):
37.
1981a
Yinger PF. Sports eye injuries. A preventable disease. Ophthal-
mology
88:
108-112. 1981b
Yinger PF. The eye and sports medicine. In Duane
TO
(Ed.)
Clinical ophthalmology. vol
5.
Harper & Row. Philadelphia.
1985
181
Yinger PF. Knuttgen HG. Easterbrook
M.
Pashby TJ. Schnell
D.
Eye
injuries and eye protection in sports: a position statement.
International Federation
of
Sports Medicine.
1988
Yinger PF. Tolpin OW. Racket sports: an ocular hazard. Journal
of
the American Medical Association 239: 2575-2577.
1978
Warwick R (Ed). Wolffs anatomy
of
the eye and orbit. 7th ed
.•
ch.
2.
HK
Lewis. London.
1976
Whiteson
AL.
Injuries in professional boxing. Practitioner 225:
1053-1057.
1981
Wilson
K.
Rontal
M.
Facial injuries in football. Transactions
of
the American Academy
of
Ophthalmology and Otolaryngology
77:
434.
1973
Wykes WN. A
IO-year
survey
of
penetrating
eye
injuries in Gwent
1976-85. British Journal
of
Ophthalmology
72:
607-611.
1988
Author's address: Mr
N.P.
Jones.
Manchester Royal
Eye
Hospital.
Oxford Road. Manchester M
13
9WH (England).
4th
World Conference on
Clinical
Pharmacology
and
Therapeutics
Date: 23-28 July 1989
Venues: Mannheim-Heidelberg, West Germany
For further information, please contact:
CPT89
c/o GKV
Congress and Conventions
P.O. Box 100619
D-6050 Offenbach 1
Federal Republic of Germany
