Soccer-Related Ocular Injuries

EPIDEMIOLOGY Soccer-Related Ocular Injuries

Joaõ A. Capaõ Filipe, MD, MSc; Vitor L. Fernandes, MD; Henrique Barros, MD, PhD; Fernando Falcaõ-Reis, MD, PhD; Jose´ Castro-Correia, MD, PhD

Objective: To outline the severity and long-term se- sulted from a kicked ball (79.1%) near the goalpost quelae of eye injuries in soccer. (60.1%). Angle recession and peripheral vitreoretinal lesions were more likely to occur in the superotemporal Design: Prospective observational study of 163 pa- quadrant (54.7%; 95% confidence interval, 44.2%- tients who sustained soccer-related ocular injuries be- 65.0%; and 57.6%; 95% confidence interval, 48.4%- tween April 1, 1992, and March 31, 2000 (8 years). 66.4%; respectively). Vitreoretinal lesions were present in 42.2% (95% confidence interval, 33.1%-51.8%) of pa- Methods: Patients were observed at a sports ophthal- tients with “normal” visual acuity (Ն20/40) and in 50.0% mology unit located in the largest university hospital of (95% confidence interval, 38.1%-61.8%) of patients with- the northern region of the country and central to all ma- out hyphema. No significant association was found be- jor soccer fields in town. The data were recorded using tween severity of injury and age, sex, type of soccer, level the United States Eye Injury Registry report forms for ini- of athletic expertise, or player position. tial and follow-up observation. Conclusions: Severe ocular lesions can occur in soccer Main Outcome Measures: (1) Self-reported history players without symptoms and at all skill levels. The de- surrounding the ocular trauma, initial visual acuity, di- velopment of laboratory models will be essential to ex- agnosis, and operations and (2) final visual acuity, late plain the tendency for lesions to be in the superotempo- diagnosis, and additional operations. ral quadrant. The data support the need for protective eyewear designed specifically for soccer. Results: Injuries occurred predominantly in young men (mean±SD age, 23.2±8.8 years) practicing indoor soccer (50.9%) or outdoor soccer (47.2%), and most re- Arch Ophthalmol. 2003;121:687-694

HE EFFECT of ocular trauma other sports.23 The incidence of soccer- on the health care system related eye injuries increased by more than and the community is po- 260% from 1973 to 1978 in the United tentially enormous.1-5 States.24,25 This corresponds to soccer’s Sports are recognized as a rapid rise in popularity among school- leadingT cause of serious eye injuries.6-11 The aged children. It is possible that soccer may first wave of effort by ophthalmologists to become worldwide the most common alter the incidence of eye injuries in sports cause of sports eye injury. was directed toward hockey, baseball, and Regular patient observation and fol- racquet sports.12-14 The successful work low-up were performed in a sports oph- done with these sports has involved the thalmology unit, using the United States From the Sports efforts of ophthalmologists to identify the Eye Injury Registry report forms.18 The ob- Ophthalmology Unit, sports that are inherently more danger- jective of this study was to outline the se- Departments of Ophthalmology ous, analyze injury mechanisms, and de- verity and long-term sequelae of eye in- (Drs Capaõ Filipe, Fernandes, velop standards for protective eyewear spe- juries in soccer. Falcaõ-Reis, and cific to the sport. Castro-Correia) and Soccer is the most common cause of Epidemiology (Dr Barros), sports-related eye injuries in Europe and METHODS University of Porto School of 15-22 Medicine, S Joaõ Hospital, Israel. Although little is written in the One hundred sixty-three soccer players (163 in- Porto, Portugal. The authors American literature concerning soccer injured eyes) who sustained sports-related ocu- have no relevant financial juries, the injury potential appears to be lar injuries and were seen at the Eye Emer- interest in this article. disproportionately severe compared with gency Department of S Joaõ Hospital between

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 BACKGROUND DATA AND DEMOGRAPHICS Table 1. Mechanism of Injury by Sport (N = 163)* One hundred fifty-two patients (93.3%) were male and Type of Soccer 11 (6.7%) were female, with a 14:1 male-female ratio. The Mechanism Total Indoor Outdoor Other mean±SD age was 23.2±8.8 years (range, 9-48 years). Ball† 129 (79.1) 72 55 2‡ For male and female patients, the mean±SD ages were Fist§ 10 (6.1) 3 7 . . . 23.6±8.8 years and 16.9±5.8 years, respectively. This dif- Foot§ 10 (6.1) 1 8 1࿣ ference was statistically significant (P=.007). One hun- Head§ 3 (1.8) 2 1 . . . dred fifteen patients (70.6%) were adults, and 48 (29.4%) Elbow§ 2 (1.2) 2 ...... were classified as pediatric (aged Ͻ8 years). Patients Knee§ 2 (1.2) 1 1¶ . . . younger than 35 years (145 subjects) accounted for 89.0% Goalpost 2 (1.2) 1 1 . . . Glasses frame 1 (0.6) . . . 1 . . . of all injuries. Other/ 4 (2.4) 1 3 . . . The seasonal distribution showed a peak incidence unknown in March and May, with a decrease in April, July, August, and December (corresponding to holiday months). The *Values are expressed as number of injuries (percentage of total). injuries occurred during the weekend in 77 cases (47.2%). †Kicked directly from an opposing player or rebounds of the ball kicked by the player himself or herself. Thirty-five patients (21.5%) played with some vi- ‡Beach (n = 1) and intramural (n = 1). sual acuity handicap. Thirty subjects (18.4%) wore glasses §From an opposing player. with corrective lenses on a regular basis but did not use ࿣Volleyball. them during sports practice. Two patients (1.2%) wore ¶By the player himself or herself. contact lenses during the game. Four patients (2.5%) were functionally 1-eyed (visual acuity, Ͻ20/300), one of whom April 1, 1992, and March 31, 2000, (8 years) were studied. Pa- tients were observed at a sports ophthalmology unit located in sustained 2 injuries during the study. the largest university hospital of the northern region of Portu- gal and central to all major soccer fields in town. Patients un- MECHANISM OF INJURY derwent periodic ophthalmologic examinations by one of us (J.A.C.F.), including best-corrected visual acuity, intraocular pres- Most injuries resulted from impact by the ball kicked from sures, and dilation. A slitlamp was used to examine the anterior an opposing player or by rebounds of the ball (n=129, segment; Goldmann 3-mirror lens and direct and indirect oph- 79.1%), followed by fist (n=10, 6.1%) and foot traumas thalmoscopy were used to examine the posterior segment. Angle (n=10, 6.1%) (Table 1). The most serious eye injury recession was diagnosed by gonioscopy during follow-up. Ex- was caused by a fingernail scratch from an opponent soc- amination findings were recorded using the initial and fol- cer player. Injury was considered unintentional in 155 low-up United States Eye Injury Registry report forms adapted to sports-related injuries.1,18,26,27 The initial standardized regis- patients (95.1%). Of the 8 athletes (4.9%) who consid- tration included details related to the circumstances of the eye ered the injury an assault, 6 were professional. injuries (the source, place, whether the subject was wearing eye No patient had any experience of ocular protection protection at the time of injury, and level of athletic expertise), or knowledge about where to obtain it. The only patient initial tissues involved, best-corrected visual acuity, diagnosis, wearing glasses was an outdoor soccer spectator, who was and operations. The follow-up form included final best- wearing street wear spectacles for high myopia. When corrected visual acuity, late diagnosis, and additional opera- hit with a ball, he had a retinal dialysis after the eyeglass tions. A severe injury was defined as one requiring hospitaliza- frame collapsed. tion or outpatient follow-up for hyphema or vitreoretinal (VR) lesion. Patients were followed up for at least 1 year. PLACE OF INJURY AND PLAYER POSITION Results are presented as mean±SD or proportions and re- spective 95% confidence intervals (CIs). Proportions were compared using ␹2, Fisher exact, or McNemar test when paired Inside the arenas, injuries occurred more frequently near samples were evaluated, as was the case for impaired vision at the goalpost (60.1%) than in the midfield (34.4%). The first and final observations. A statistical power of 80% and a ball hit 7 subjects who were not on the playing field: significance level of PϽ.05 were considered for the analysis. 5 soccer spectators on the bench, 1 reserve player, and 1 soccer linesman. The injuries were spread across all of RESULTS the player positions, with forwards (38.7%) and defenders (30.7%) being most prone to injury. INJURIES BY TYPE OF SOCCER VISUAL ACUITY An analysis of all soccer injuries (N=163) showed indoor soccer (50.9%) injuries to be the most common, fol- At initial examination, visual acuity was 20/40 or better lowed by outdoor soccer (47.2%), with 1 case each of in 116 patients (71.2%), and ranged between 20/20 in 79 beach soccer, volleyball soccer, and intramural soccer. patients (48.5%) and light perception in 7 patients (4.3%) The latter is indoor soccer played inside a closed field. (Figure 1). The visual acuity of 8 patients (4.9%) re- Most players were practicing recreational sports mained less than 20/300 at the final follow-up examina- (n=83, 50.9%), followed by professional (n=45, 27.6%) tion; 3 (1.8%) of these patients were functionally 1-eyed and school (n=35, 21.5%) sports. Six patients were not with poor visual acuity previous to the sports injury. The athletes (5 soccer spectators and 1 soccer linesman), and causes of permanent visual loss of the remaining 5 pa- all were hit by a ball. tients (3.1%) were 3 cases of contusion maculopathy

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Table 2. Clinical Diagnosis at Initial Examination and During Follow-up* 80 Diagnosis No. (%) 70 Initial 60 Eyelids or orbit 92 (56.4) Eyelid or orbital contusion 90 (55.2) 50 Eyelid laceration 6 (3.7) 40 Orbital fracture 4 (2.5) No. of Eyes Conjunctiva 23 (14.1) 30 Subconjunctival hemorrhage 23 (14.1) Cornea 35 (21.5) 20 Corneal abrasion 34 (20.9) 10 Corneoscleral laceration 1 (0.6) Anterior chamber 114 (69.9) 0 Uveitis 50 (30.7) Hyphema 89 (54.6) 20/20

20/20 Glaucoma, secondary 43 (26.4) ∗ 20/25-40 20/25-40

20/50-80 Iris laceration or dialysis 3 (1.8) 20/50-80 HM HM LP LP

0 Vitreoretinal 83 (50.9) 20/100-200 ∗ 0 Initial VA20/100-200

20/300-400 Vitreous hemorrhage 52 (31.9) 20/300-400 Final VA Retinal hemorrhage 63 (38.7) Retinal edema 24 (14.7) Figure 1. Initial and final best-corrected visual acuity (VA). LP indicates light Macular edema 10 (6.1) perception; HM, hand motions; and asterisk, functionally 1-eyed with poor Macular hemorrhage 4 (2.5) VA previous to the sports injury (3 patients). Retinal dialysis 4 (2.5) Retinal detachment (rhegmatogenous) 7 (4.3) (caused by a ball), 1 case of corneoscleral laceration with Choroidal hemorrhage 1 (0.6) Follow-up retinal detachment and proliferative vitreoretinopathy (due Corneal scar in visual axis 1 (0.6) to a fingernail scratch), and 1 case of retinal detachment Angle recession 57 (35.0) with glaucoma (caused by an eyeglass frame). Patients with Glaucoma, secondary (not controlled) 2 (1.2) good initial visual acuity also had the best visual acuity at Iris deformity 3 (1.8) the end of follow-up, and a significant correlation was found Traumatic mydriasis 7 (4.3) between the 2 observations (PϽ.001). Contusion maculopathy 7 (4.3) Macular hole 2 (1.2) Retinal break 11 (6.7) CLINICAL DIAGNOSIS Proliferative vitreoretinopathy 1 (0.6) Choroidal rupture 1 (0.6) The left eye was significantly more frequently injured (n=91, 55.8%; vs n=72, 44.2%) (P=.04). All injuries were *Data are presented as the proportion of each lesion among the 163 unilateral. The most common ocular tissue involve- injured eyes. ment was the anterior chamber, followed by the eyelids or orbit, and VR lesion (Table 2). The most common initial diagnosis was eyelid or orbital contusion and hy- VR LESIONS phema, followed by retinal hemorrhage, vitreous hemorrhage, and uveitis. The most frequent diagnosis dur- Peripheral VR lesions were more frequently in the supe- ing follow-up was angle recession and retinal tears. Four rotemporal quadrant (57.6%; 95% CI, 48.4%-66.4%), fol- patients (2.5%) had orbital fractures caused by the im- lowed by the superonasal quadrant (24.0%; 95% CI, pact of a foot (2 cases), elbow (1 case), or hand (1 case). 16.8%-32.4%) (Table 3). Fifteen patients had blunt injuries causing peripheral retinal breaks, which pro- GLAUCOMA AND ANGLE RECESSION ceeded to retinal detachment in 7 instances. Most breaks were holes, occurring in 10 patients, with 6 cases of mul- Forty-three patients (26.4%) had intraocular pressures tiple holes (3 cases of 2 holes, 2 cases of 3 holes, and 1 greater than 21 mm Hg, and 2 patients (1.2%) required case of 4 holes). The holes showed particular predilec- medication for persistently elevated pressures. Acute glau- tion for the superotemporal quadrant, followed by the coma was present in 41 (46.1%; 95% CI, 35.4%-56.9%) superonasal quadrant. Retinal dialysis, the second most of 89 patients with hyphema and in 2 (2.7%; 95% CI, common type of break (4 patients), showed also a pre- 0.3%-9.4%) of 74 patients without hyphema (PϽ.001). dilection for the superotemporal quadrant. The only Angle recession was present in 46 patients (51.7%; 95% horseshoe tear was located superotemporally and su- CI, 40.8%-62.4%) with hyphema and in 11 patients peronasally. Retinal detachment was also present more (14.9%; 95% CI, 7.7%-25.0%) without hyphema frequently in the superotemporal quadrant, followed by (PϽ.001). Angle recession was more frequent in the su- the superonasal quadrant. The circumferential exten- perotemporal quadrant (54.7%; 95% CI, 44.2%-65.0%), sion of retinal detachment was more than 90° in 3 cases. followed by the superonasal quadrant (25.3%; 95% CI, No severe myopia was present in any of these patients 16.9%-35.2%) (Table 3). with retinal breaks or retinal detachment.

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Retinal Breaks Peripheral VR Retinal Characteristic Angle Recession Lesion Holes† Dialysis Tears Detachment No. of quadrants involved (n = 57) (n = 80) 1 27 (47.4) [34.0-61.0] 45 (56.3) [44.7-67.3] 6 4 . . . 3 2 25 (43.9) [30.7-57.6] 28 (35.0) [24.7-46.5] 4 . . . 1 3 3 2 (3.5) [0.4-12.1] 4 (5.0) [1.4-12.3] ...... 1 4 3 (5.3) [1.1-14.6] 3 (3.8) [0.8-10.6] ...... Quadrant (n = 95) (n = 125) Superotemporal 52 (54.7) [44.2-65.0] 72 (57.6) [48.4-66.4] 8 3 1 7 Superonasal 24 (25.3) [16.9-35.2] 30 (24.0) [16.8-32.4] 4 1 1 4 Inferotemporal 12 (12.6) [16.7-21.0] 16 (12.8) [7.5-20.0] 2 ...... 1 Inferonasal 7 (7.4) [3.0-14.6] 7 (5.6) [2.3-11.2] ...... Extent, ° (n = 57) (n = 80) Յ90 41 (71.9) [58.4-83.0] 59 (73.8) [62.7-83.0] 10 4 1 4 Ͼ90 16 (28.1) [17.0-41.5] 21 (26.3) [17.0-37.3] ...... 3

*Values are expressed as number of injuries (percentage of total) [95% confidence interval]. Some percentages do not sum to 100 because of rounding. †Six cases of multiple holes.

angle recession (64.9%; 95% CI, 51.1%-77.1%; vs 43.4%; Table 4. Anterior Segment Lesions and Vitreoretinal (VR) Lesions (N = 163) 95% CI, 33.8%-53.4%) (P=.01).

Anterior Segment No. VR Lesion % (95% P HYPHEMA AND VR LESIONS Lesion (% of Total) Confidence Interval) Value There was no association between the extension of hy- Eyelid or orbital contusion phema and the presence of VR lesions (Table 5). A simi- Yes 90 (55.2) 52.2 (41.4-62.9) lar number of peripheral retinal breaks was present in .83 No 73 (44.8) 49.3 (37.4-61.3) patients with or without hyphema (9.0%; 95% CI, 3.7%- Subconjuntival 16.9%; vs 9.6%; 95% CI, 3.9%-18.5%). Among patients hemorrhage without hyphema, there were 5 cases of multiple holes Yes 23 (14.1) 34.8 (16.4-57.3) .15 No 140 (85.9) 53.6 (45.0-62.0) and 1 case of macular hole. Corneal abrasions Yes 34 (20.9) 47.1 (29.8-64.9) VISUAL ACUITY AND VR LESIONS .75 No 129 (79.1) 51.9 (43.0-60.8) Uveitis As expected, a higher level of visual acuity at initial exami- Yes 50 (30.7) 58.0 (43.2-71.8) .30 nation was associated with a lower proportion of VR le- No 113 (69.3) 47.8 (38.3-57.4) Hyphema sions (P=.002). Also, visual acuity recovery was more com- Yes 89 (54.6) 51.7 (40.8-62.4) mon in patients without VR lesions. However, 49 (42.2%; .95 No 74 (45.4) 50.0 (38.1-61.8) 95% CI, 33.1%-51.8%) of 116 patients with “normal” vi- Glaucoma sual acuity (defined as Ն20/40) had VR lesions (Figure 2). Yes 43 (26.4) 55.8 (39.9-70.9) .57 If we exclude 3 patients who were functionally 1-eyed with No 120 (73.6) 49.2 (39.9-58.4) poor visual acuity previous to the sports injury, all of the Angle recession Yes 57 (35.0) 64.9 (51.1-77.1) patients with final visual acuity worse than 20/40 had an .01* No 106 (65.0) 43.4 (33.8-53.4) initial visual acuity worse than 20/40 and a VR lesion.

*PϽ.05. SEVERE INJURIES

Among all severe injuries (n=123, 75.5%), 65 lesions ANTERIOR SEGMENT (52.8%) occurred during indoor soccer games, and 56 le- AND VR LESIONS sions (45.5%) occurred during outdoor soccer games (Table 6). The remaining injuries were associated with Patients with anterior segment lesions were not more likely other types of soccer games. No significant association was to experience a VR lesion (Table 4). No significant trend found between severe injuries and patients’ age, sex, type to VR lesions was observed in patients with or without eye- of soccer, level of athletic expertise, or player position. lid or orbital contusion (52.2% vs 49.3%), subconjunctival hemorrhage (34.8% vs 53.6%), corneal abrasions (47.1% TREATMENT AND ECONOMIC EFFECT vs 51.9%), uveitis (58.0% vs 47.8%), hyphema (51.7% vs 50.0%), or glaucoma (55.8% vs 49.2%) (PϾ.05 for all). Twenty-two patients (13.5%) required 42 surgical pro- The only exception was patients with angle recession, who cedures (Table 7). The retina was successfully re- had significantly more VR lesions than patients without attached in all cases. After retinal surgery, 5 patients had

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Peripheral Retinal Breaks Retinal Size of Hyphema Hyphema VR Lesion Holes Dialysis Tears Macular Hole Detachment No hyphema 74 (45.4) 37 (50.0) 5 (6.8)† 1 (1.4) 1 (1.4) 1 (1.4) 4 (5.4) Hyphema 89 (54.6) 46 (51.7) 5 (5.6) 3 (3.4) ...... 3 (3.4) Microhyphema 18 (20.2) 9 (50.0) 1 (5.6) ...... Ͻ25% 41 (46.1) 19 (46.3) 1 (2.4) 1 (2.4) ...... Ն25% to Ͻ50% 19 (21.3) 13 (68.4) 2 (10.5) 2 (10.5) . . . 1 (5.3) 2 (10.5) Ն50% to Ͻ75% 2 (2.2) ...... Ն75% to Ͻ100% 3 (3.4) 2 (66.7) ...... 100% 6 (6.7) 3 (50.0) 1 (16.7)‡ ...... 1 (16.7)

*Values are expressed as number of injuries (percentage of total). Some percentages do not sum to 100 because of rounding. †Three cases of 2 holes, 1 case of 3 holes, and 1 case of 4 holes. ‡One case of 3 holes.

163 Patients

VA Initial VA Initial Worse Than 20/40 20/40 or Better 28.8% (47) 71.2% (116)

No With No With VR Lesion VR Lesion VR Lesion VR Lesion 27.7% (13) 72.3% (34) 57.8% (67) 42.2% (49)

VA Final VA Final VA Final VA Final VA Final VA Final Worse Than 20/40 20/40 or Better Worse Than 20/40 20/40 or Better 20/40 or Better 20/40 or Better ∗ 15.4% (2) 84.6% (11) 23.5% (8)† 76.5% (26) 100.0% (67) 100.0% (49)

Figure 2. Initial and final best-corrected visual acuity (VA) in patients with vitreoretinal (VR) lesions. Asterisk (2 patients) and dagger (1 patient) indicate functionally 1-eyed with poor VA previous to the sports injury.

visual acuities of 20/40 or better. Visual acuity re- proximately 12300 men and 2000 women participate in mained worse than 20/200 in 3 cases; these patients had organized indoor soccer, and 95800 men and 900 women severe traumatic maculopathy. Most patients required participate in outdoor soccer. Although our results partly topical medication (mydriatics, corticosteroids, antibi- reflect the fact that soccer is by far the most popular sport otics, ␤-adrenergic blocking agents, or patching) and sys- in Portugal, they also highlight the serious nature of in- temic medication (antibiotics, nonsteroidal anti- door and outdoor soccer injuries. Despite the small num- inflammatory agents, corticosteroids, anticoagulants, or ber of players in new soccer modalities, we already have acetazolamide). This sample of patients required 31 di- seen injuries in beach soccer, volleyball soccer, and in- agnostic x-ray films and 7 computed tomographic scans tramural soccer. Analysis of ocular lesions allows us to for suspected orbital fracture. Twelve retinal fluores- answer some questions about these sports.11 cein angiographies, 24 ocular echographies, and 20 Hum- phrey automated perimetries were performed. SOCCER BALL INJURY

ABSENCE TIME Most patients were young men, amateurs, playing recreational sports, and hit by a soccer ball during week- Twenty patients (12.3%) required hospitalization. The ends or at school, as found in previously published stud- in-hospital stay averaged 5 days. The mean absence time ies.16,18,20,28 The finding that 75.5% of eye injuries in the for all 45 injured professional players was 15 days, which soccer players we treated were severe corroborates the increased to 80 days for operatively treated patients. Forty- findings of previous studies23,29,30 showing that soccer in- five injuries (100.0%) resulted in at least 2 missed games, juries were disproportionately severe compared with those and 29 players (64.4%) were absent from soccer train- of other sports. One of the most surprising results of our ing or games for more than 1 month. One professional data was that the age, sex, type of soccer, level of ath- player, a female outdoor soccer player, was unable to prac- letic expertise, and player position did not relate to the tice sports indefinitely. severity of ocular injury, despite the inherent differences. Beyond an unknown ball velocity limit, which COMMENT needs to be determined, injury can occur independent of all these differences. Soccer enjoys a large and active participation in Europe. It is a common misconception that experience in it- Each season in the Portugal Football Association, ap- self protects from injury. In our series, 27.6% of the sample

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 We are unable to provide an explanation why the Table 6. Severe Injuries Distribution* left eye was more frequently injured, because no such hy- pothesis was specifically tested. However, we speculate Severe Injury† No. of P that this could result from the fact that most players are Distribution Players No Yes Value right-footed kickers. Total 163 40 (24.5) 123 (75.5) Age, y PATHOGENESIS OF EYE CONTUSION Ͻ18 48 13 (32.5) 35 (28.5) .77 Ն18 115 27 (67.5) 88 (71.5) Despite the differences between the opening of the bony Sex orbit and the diameter of a standard indoor or outdoor Male 152 35 (87.5) 117 (95.1) .19 soccer ball, direct trauma to the globe is possible. The Female 11 5 (12.5) 6 (4.9) Type of soccer reason is that the soccer ball frequently comes toward Indoor 83 18 (45.0) 65 (52.8) the eye from below. The flatter inferior orbital rim af- .52 Outdoor 77 21 (52.5) 56 (45.5) fords less protection to the globe from a projectile com- Other 3 1 (2.5) 2 (1.6) ing at this angle. Therefore, whether the ball is or is not Athletic expertise underinflated, the force of the impact is strong enough Professional 45 16 (40.0) 29 (23.6) to deform the intraocular structures without exceeding School 35 9 (22.5) 26 (21.1) .09 Recreational 83 15 (37.5) 68 (55.3) the tensile strength of the eyewall. As a result, hyphe- Player position mas and peripheral VR lesions were the most frequently Goalkeeper 14 6 (15.0) 8 (6.5) encountered injuries. As expected, the ball caused none Defender 50 12 (30.0) 38 (30.9) .30 of our cases of blowout fracture. Midfielder 27 6 (15.0) 21 (17.1) The flat orbital rims in children and young teenag- Forward 63 12 (30.0) 51 (41.5) ers give the globe more prominence, theoretically mak- Spectator 7 3 (7.5) 4 (3.3) ing these persons more susceptible to soccer ball in- No position 2 1 (2.5) 1 (0.8) jury.30 Our data did not support this; adults were just as *Values are expressed as number of injuries (percentage of severe susceptible to soccer eye injuries. Among patients who injuries). Some percentages do not sum to 100 because of rounding. were younger than 30 years, a previous study31 found that †Defined as one requiring hospitalization or outpatient follow-up for the most common cause of traumatic retinal detach- hyphema or vitreous and/or retina lesion. ment was a soccer ball striking the eye. The data from these series showed that the patients had myopic globes. This sharply contrasts with the findings of the present Table 7. Surgical Procedures (n = 42) by Type study, in which none of the retinal detachment cases were of Soccer Among 22 Patients associated with severe myopia. Therefore, the impact of the soccer ball is strong enough to cause a lesion in per- Procedure Indoor Outdoor Intramural sons without previous ocular fragility. Repair wound, eyelid 2 6 3 Repair corneoscleral rupture . . . 1 . . . SUPEROTEMPORAL Hyphema removal . . . 1 . . . RD prophylaxis, laser 7 6 1 QUADRANT LESIONS RD prophylaxis, buckle . . . 2 . . . RD repair, buckle 2 4 1 Our study confirms that in soccer VR lesions tend to oc- RD repair, vitrectomy 1 3 . . . cur in the superotemporal quadrant.31 The literature de- RD repair, silicone oil . . . 1 . . . scribes that traumatic breaks are commonly found in the MH repair, vitrectomy, ... 1 ... inferotemporal and superonasal quadrants.32 Blunt trauma perfluoropropane can cause retinal damage by direct contusive injury to Abbreviations: MH, macular hole; RD, retinal detachment. the globe through 2 mechanisms: coup (adjacent to the point of trauma) and countercoup (opposite to the point of trauma). The classic experiments of Schepens33 have were professional sports players of proven competence. elucidated the pathogenesis of retinal detachments caused The illusion that injuries occur only among beginners by ocular contusion. How can we explain in soccer why must be quashed. The injuries occurred predominantly peripheral angle recession and VR lesions tend to occur among forwards and defenders near the goalpost. This in the superotemporal quadrant? The answer may be that area of the field may be where the ball is kicked more the soccer ball frequently comes toward the eye from be- often, because the forwards kick the ball to the goal, while low. On the other hand, we found that retinal holes rather the defenders kick off the goal. Furthermore, the goal area than tears are likely to develop from soccer-associated has the greatest number of players nearby during the blunt trauma. This confirms that small holes at the pos- match. In fact, most of the injuries resulted from the ball terior border of the vitreous base and equatorial holes, kicked directly from an opposing player who was nearby without apparent VR attachment and secondary to reti- or from rebounds of the ball kicked by the player him- nal necrosis, constitute the major types of retinal breaks self or herself. These rebounds of the ball are a mecha- seen following contusion.34,35 The development of more nism similar to injuries experienced in squash, in which sophisticated laboratory experiments will doubtless re- players may not know from which side the ball is com- veal additional alterations as a consequence of soccer ball ing and cannot protect their eyes. blunt injury.

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 CLINICAL MANAGEMENT ers who require prescription lenses, functionally 1-eyed athletes, and those who have had refractive surgical pro- It may be appropriate in soccer to encourage visits to the cedures that weaken the eye.41 Dresswear glasses are never emergency department or physician’s office regardless of recommended for use during soccer. the immediate assessment of injury severity. Although an athlete may not report symptoms suggestive of pe- CONCLUSIONS ripheral VR lesions, a thorough examination should be performed immediately after the game injury. The con- Indoor and outdoor soccer trauma is an important eye siderable number of patients with superficial injuries in health problem in Europe, and likely in the United States, whom we found unsuspected VR damage emphasizes this. affecting young athletes independent of age, sex, type of We postulate that 38.1% to 61.8% of patients without hy- soccer, level of athletic expertise, or player position. An phema (no blurred vision) and 33.1% to 51.8% of pa- explanation for the predilection of eye injury lesions in tients with normal visual acuity (defined as Ն 20/40) may soccer to the superotemporal quadrant needs to be sought have VR lesions. Among patients with hyphema, 40.8% by development of laboratory models. Soccer player edu- to 62.4% may have angle recession. Any athlete with hy- cation is warranted to raise awareness about the risk of phema is at a lifelong heightened risk of glaucoma and ocular trauma and about the appropriate ocular protec- should have pressures checked regularly. tion conforming to the moderate impact standard requirements to prevent eye injuries. EYE INJURY PREVENTION Submitted for publication March 5, 2002; final revision re- Our study alerts us to the need to protect soccer specta- ceived July 24, 2002; accepted January 22, 2003. tors, including the assistant referees. How can we pro- Corresponding author and reprints: Joaõ A. Capaõ Fil- tect them, especially when stadiums are removing lat- ipe, MD, MSc, Sports Ophthalmology Unit, Department of eral protections because of the danger of unruly spectators Ophthalmology, University of Porto School of Medicine, S Joaõ smashing them against people and things? It will prob- Hospital, 4200-319 Porto, Portugal (e-mail: jacapaofilipe ably be necessary to maintain a set distance between the @netcabo.pt). stadium arena and the spectators. Inside the arenas, the area in and around the goal- REFERENCES post is the area most often associated with injury. The proportion of goalkeepers with injuries in our sample (ap- proximately 10%) indicates that, although they are the 1. May DR, Kuhn FP, Morris RE, et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol. 2000; only players using their hands and thus are more able to 238:153-157. protect their eyes, they also are at risk. The use of pad- 2. McCarty CA, Fu CLH, Taylor HR. Epidemiology of ocular trauma in Australia. Oph- ded goalposts in soccer has been documented to reduce thalmology. 1999;106:1847-1852. injuries in the laboratory phase and in pilot testing.36 3. Karlson TA, Klein BEK. 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Call for Papers

he ARCHIVES and the National Eye Institute will T be publishing a special theme issue on epidemiology of blinding diseases and blindness prevention. Bar- bara Blodi, MD, and Frederick Ferris III, MD, will be guest editors for this special issue. We invite all investigators to submit important research addressing issues concerning blindness such as diabetic retinopathy, age-related macular degeneration, cataract, glaucoma, refractive er- ror, low vision, and blindness. Early receipt ensures the best chance for acceptance for this special issue. Ac- cepted manuscripts not included in this issue will be published in other issues of the ARCHIVES. All manuscripts are subject to peer review. Please note in the cover let- ter that the submission is for the “epidemiology of blinding diseases and blindness prevention” theme issue.

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