Traumatic Hyphema in a 13-Year-Old Girl: Eye Protection Regulation in Badminton Is Needed

PRACTICE | CASES CPD

Traumatic hyphema in a 13-year-old girl: eye protection regulation in badminton is needed

Dan Ni Wang BS, Micah Luong MD, Christopher Hanson MD n Cite as: CMAJ 2020 July 6;192:E778-80. doi: 10.1503/cmaj.191273

13-year-old girl was assessed at our eye care clinic after being struck in the left eye by a badminton shuttlecock. KEY POINTS She was not wearing protective eyewear at the time of • Badminton is the leading cause of racquet sports–related eye injury.A Visual acuity in the patient’s left eye was hand motion and injuries in Canada, and traumatic hyphema is a common her intraocular pressure (IOP) was 19 (normal 11–21) mm Hg. complication. Slit-lamp examination showed a thick clot of hemorrhage in the • More than half of patients with ocular injuries from badminton anterior chamber (Figure 1). We diagnosed a traumatic hyphema never regain full visual acuity. and managed the patient with topical prednisolone acetate and • Ocular injury from badminton can be prevented with the use of atropine 1% drops, an eye shield and bed rest. We also advised eye protectors that meet standard F803 of the American Society that she sleep with the head of the bed elevated and return to for Testing and Materials. the clinic if her vision decreased. At the 1-week follow-up visit, the patient showed substantial improvement in visual acuity to 20/70 in the left eye. sports and baseball.3 Most eye injuries from badminton occur from shuttlecock impact, because of its small base diameter; Discussion high velocity, which can reach more than 482 km/h (137 m/s); and the relatively close distance between players during games.4 An estimated 3.7% of Canadians older than 15 years, and 2.7% The majority of ocular injuries in badminton occur during dou- between age 5 and 14 years, play badminton.1 It is a popular bles games, where injury can be caused by an opponent’s shut- sport among youth and adults and is generally considered to tlecock, the racquet of a partner or a player looking back toward have a low risk of injury. However, badminton is the leading a partner during a “smash” hit.5 cause of racquet sports–related eye injuries in Canada.2 The Blunt trauma to the eye from sports can result in a wide vari- overall incidence of sports-related eye injuries in Canada in 2012 ety of presentations. Traumatic hyphema is the most common was 8.6%, with the most common causes being hockey, racquet ocular presentation from eye injury in badminton, with the majority of cases occurring in children.5 Traumatic hyphema occurs when blood pools in the anterior chamber after blunt force to the orbit causes rupture of the vessels that supply the iris and ciliary body.3 Patients typically present with blurred vision and pain after blunt eye trauma; severity can range from a micro- hyphema to a total or complete hyphema. Examination of the eye will show fresh or clotted blood that pools in the anterior chamber. Initial evaluation includes a thorough history and phys- ical examination of the eye, including testing for visual acuity, IOP, extraocular movements, slit-lamp examination and a dilated fundus examination. Patients should be referred immediately to an ophthalmologist for a comprehensive assessment to rule out other associated eye injuries, and receive close follow-up to monitor for complications if a hyphema is suspected. Initial management of a hyphema includes conservative Figure 1: Slit-lamp photography of the left eye of a 13-year-old girl, showing measures to promote resorption of blood, including bed rest, 6 a 1-mm inferior hyphema (black arrow) and clot in the anterior chamber elevation of the head of the bed at night and an eye shield. A partially obstructing the iris (blue arrow). topical cycloplegic such as atropine and a corticosteroid eye

10 E779 Ocular Ocular 9 Kelly and 5 Similar declines would Similar declines would 10 All studies noted that many of those many of those All studies noted that 8 Badminton remains one of the only high- Badminton remains 9 ISSUE 27 ISSUE | Mandatory eye protection is currently required across many is currently required across many Mandatory eye protection Canadian regulations and recommendations for protective for protective Canadian regulations and recommendations colleagues looked at 6 casescolleagues com- eye injuries in of badminton in Leicester Royal Infirmary treated at petitive players suffered 1985, of which 2 players between 1979 and Manchester permanent vision loss. affect all age groups and levels of players, injuries from sports are preventable with protective eyewear. and more than 90% risk sports without formal eye protection regulations. risk sports without injured were not wearing protective eyewear. injured were not wearing including baseball, hockey, football, sports internationally, lacrosse and squash. Previously, squash and racquetball accounted for 73% of sports- Previously, squash and - The implementation of mandatory eye pro related eye injuries. racquetball in 1982 caused this proportion tection in squash and to decrease from 73% to 23% by 1993. be expected if implemented in badminton. Ontario Badminton eyewear are shown in Box 1. In 2005, the players in competi- Association mandated that all junior double meet the international tive games wear protective eyewear that (ASTM) F803 stan- American Society for Testing and Materials province that has man- dard. British Columbia is the only other than 19 years. dated F803 eyewear for junior players younger protective eyewear for Newfoundland and Labrador mandates Prince Edward junior girls in mixed-doubles competitions, for doubles and Island requires junior players to wear eyewear Scotia requires players mixed-doubles competitions, and Nova mixed and doubles for goggles wear to years 19 than younger informally recom- doubles. Alberta, Quebec and Saskatchewan eyewear. The mend the use of polycarbonate protective of unilateral ocular injury from badminton between 1968 and and 1968 between from badminton injury ocular of unilateral and presented with hyphema, most patients 1972 in Malaysia; of chronic vision loss. half had some degree more than VOLUME 192 VOLUME | A 6 Formal regulation and recommendation for protective eyewear protective for and recommendation regulation Formal JULY 6, 2020 JULY | CMAJ It most often presents It most often presents 6 No formal regulations; informally recommends the use of polycarbonate protective eyewear. protective the use of polycarbonate recommends informally regulations; No formal than 19 years. younger junior players for F803 eyewear ASTM Mandated or recommendations. regulations No formal or recommendations. regulations No formal competitions. mixed-doubles junior girls in for eyewear protective Mandates or recommendations. regulations No formal games. doubles and mixed-doubles for goggles wear to than 19 years younger players Requires or recommendations. regulations No formal in competitive all junior double players that Association mandated Badminton In 2005, the Ontario F803 standard. ASTM technical the international meets that eyewear protective wear games competitions. doubles and mixed-doubles for eyewear wear to junior players Requires eyewear. protective the use of polycarbonate recommends informally regulations; No formal eyewear. protective the use of polycarbonate recommends informally regulations; No formal or recommendations. regulations No formal -blocker drops. Patients should be should be -blocker drops. Patients Patients with sickle cell trait or disease also have a also have a Patients with sickle cell trait or disease 6 Acetylsalicylic acid and nonsteroidal anti-inflammatories anti-inflammatories acid and nonsteroidal Acetylsalicylic 7 The long-term sequelae of a hyphema can vary. A secondary of a hyphema can vary. A secondary The long-term sequelae Permanent vision loss is a devastating consequence of sports- Permanent vision loss is a devastating consequence Note: ASTM = American Society for Testing and Materials. Testing for Society = American ASTM Note: Province/territory Box 1: Formal regulations and recommendations for protective eyewear, by province or territory province by eyewear, protective for and recommendations regulations 1: Formal Box Alberta British Columbia Manitoba New Brunswick and Labrador Newfoundland Territories Northwest Scotia Nova Nunavut Ontario Island Edward Prince Quebec Saskatchewan Yukon recent Cochrane review found limited evidence for the use of the use of limited evidence for review found recent Cochrane acid and aminocaproic including tranexamic antifibrinolytics, acid. between the first 2 and 5 days after injury as a new bleed that is is that bleed new a as injury after days 5 and 2 first the between - than the initial hyphema and is asso often of greater magnitude complications, including corneal ciated with vision-threatening optic nerve damage. bloodstaining, secondary glaucoma and assessment for Predictors of a rebleed include delayed medical larger initial hyphema, longer than 24 hours after the injury, a acuity worse than elevated IOP > 21 mm Hg and initial visual 20/200.

drop may be applied, although evidence on efficacy is weak. is on efficacy evidence although may be applied, drop should be avoided as they can increase the risk of further bleed- increase the risk of further avoided as they can should be the of occlusion to owing common, is IOP Elevated ing. by the clot or inflammatory cells, and can trabecular meshwork β be controlled with topical the clinic or to the emergency department advised to return to a further worsening in vision, as if they experience immediately it may indicate a rebleed. is occurs in about 5% of cases and hemorrhage, or rebleed, visual outcomes. associated with worse higher incidence of rebleed and glaucoma. Surgery may be indi- higher incidence of rebleed and glaucoma. can be cases. Hyphemas nonresolving severe and some in cated but hospital admission managed safely in an outpatient setting of noncompliance with is indicated for patients who are at risk trauma, or have sickle bed rest, have severe associated ocular neuropathy and early cell disease. Secondary glaucoma, optic present anywhere from cataract formation are common and can follow-up is neces- days to years after injury. Therefore, annual sary after resolution. cases at 63 looked and colleagues Chandran injuries. eye related PRACTICE E780 of shatteringthelensandcausingopenglobeinjury. prescription eyeglassesshouldnotbeworn,becauseoftherisk able atmostsportinggoodsstores.Noncertified eye guardsand Standards Associationlogoforeasyidentificationandisavail- sides. ASTM F803–certified eyewear is labelled with a Canadian durable polycarbonate plastic and protect from impact on all should beusedinracquetsports,becausetheyaremadefrom eyewear forallstudents. ing thoseofOntarioandSaskatchewan,requireF803protective to the best ofourknowledge.Individual school boards,includ- remaining provincesandterritorieshavenorecommendations, approved protectiveeyewearoncourt. to consideradoptingregulationsrequiringASTMF803standard– game. Furthermore, we encourage Canadian badminton associations awareness oftheimportanceuseeyeprotectionin complications whenplayingbadminton,weencouragegreater sideration oftheriskocularinjuryandpotentiallong-term from badmintonthatwaspreventablewitheyeprotection.Incon tion whileplaying. players tomakeinformedchoicesaboutwearingeyeprotec- ness regardingtheriskofeyeinjuryinbadmintonmayhelp wear duringgames.However,increasededucationandaware- tion ofriskinjuryasreasonsfornotwearingprotectiveeye- regulations. Playersreportdiscomfort,costandlowpercep- ates theneedforincreasedawarenessandprotectiveeyewear Only eyeguardsthatmeettheASTMtechnicalstandard This case highlights a presentation of ocular trauma resulting The riskofpermanenteyeinjuryfrombadmintoncorrobor CMAJ | JULY 6,2020 7 | VOLUME 192 10. 1. References 8. 5. 4. 3. 9. 7. 6. 2.

Correspondence to:DanNiWang,[email protected] published andagreedtobeaccountableforallaspectsofthework. important intellectual content, gave final approval of the version to be design of the work, drafted the manuscript, revised it critically for Contributors: Ophthalmology (Luong,Hanson),UniversityofCalgary,Alta. Affiliations: Cumming School of Medicine (Wang) and the Division of The authorshaveobtainedconsentfromthepatient’sfamily. This articlehasbeenpeerreviewed. Competing interests:Nonedeclared. cure. EyeContactLens2011;37:160-3. Goldstein MH, WeeD.Sportsinjuries: an ounceofpreventionandapound Dain SJ.Sportseyewearprotectivestandards.ClinExpOptom2016;99:4-23. Kelly SP.Seriouseyeinjuryinbadmintonplayers.BrJOphthalmol1987;71:746-7. hyphema. CochraneDatabaseSystRev2019;(1):CD005431. Gharaibeh A,SavageHI,SchererRW,etal.Medicalinterventionsfortraumatic Surv Ophthalmol2002;47:297-334. Walton W,VonHagenS,GrigorianR,etal.Managementoftraumatichyphema. Chandran S.Ocularhazardsofplayingbadminton.BrJOphthalmol1974;58:757-60. 2015;17:063001. Cohen C, Texier B, Quéré D, et al. The physics of badminton. 2012;47:351-3. Gordon KD. The incidence of eye injuries in Canada. CanJOphthalmol Ophthalmol 1992;27:226-9. Pashby TJ.EyeinjuriesinCanadiansportsandrecreationalactivities.CanJ /2008060/t-c-g/tbl6-eng.htm (accessed2019Dec.7). 2011 Aug.30.Available:https://www150.statcan.gc.ca/n1/pub/81-595-m Most practicedsportsbyCanadians,2005. Ottawa: Statistics Canada; modified | ISSUE 27 All of the authors contributed to the conception and New JPhys