Eye Protection and Risk of Eye Injuries in High School Field Hockey Peter K. Kriz, MDa, David Zurakowski, PhDb, Jon L. Almquist, VATL, ATCc, John Reynolds, VATL, MS, ATCc, Danielle Ruggieri, BAd, Christy L. Collins, PhDe, Pierre A. d’Hemecourt, MDf, R. Dawn Comstock, PhDg

OBJECTIVE: To determine if injury rates among female field hockey players differ before and after abstract implementation of a national mandate for protective eyewear (MPE). METHODS: We analyzed girls’ field hockey exposure and injury data collected from national (High School Reporting Information Online [RIO]) and regional (Fairfax County Public Schools) high school sports injury databases in 2 seasons before (2009/10 and 2010/11) and 2 seasons after (2011/12 and 2012/13) a national MPE. RESULTS: The incidence of eye/orbital injuries was significantly higher in states without MPE (0.080 injuries per 1000 athletic exposures [AEs]) than in states with MPE (before the 2011/12 mandate) and the postmandate group (0.025 injuries per 1000 AEs) (odds ratio 3.20, 95% confidence interval 1.47–6.99, P = .003). There was no significant difference in concussion rates for the 2 groups (odds ratio 0.77, 95% confidence interval 0.58–1.02, P = .068). After the 2011/12 MPE, severe eye/orbital injuries (time loss .21 days) were reduced by 67%, and severe/medical disqualification head/face injuries were reduced by 70%. Concussion rates for field hockey (0.335 per 1000 AEs) rank third among girls’ sports included in the High School RIO surveillance program. CONCLUSIONS: Among female high school field hockey players, MPE is associated with a reduced incidence of eye/orbital injuries and fewer severe eye/orbital and head/face injuries. Concussion rates did not change as a result of the national MPE. Concussion remains the most common injury involving the head and face among female field hockey players, prompting further inquiry into potential effects of adopting protective headgear/helmets.

aDivision of Sports Medicine, Departments of Orthopedics and Pediatrics, Warren Alpert Medical School, Brown WHAT’S KNOWN ON THIS SUBJECT: A previous University, Rhode Island Hospital/Hasbro Children’s Hospital, Providence, Rhode Island; bDepartments of Anesthesia and Surgery and fDivision of Sports Medicine, Boston Children’s Hospital, Harvard Medical School, national study conducted over 2 seasons by this Boston, Massachusetts; cFairfax County Public Schools, Falls Church, Virginia; dProvidence College, Providence, group of authors demonstrated the effectiveness Rhode Island; eOhioHealth Research and Innovations Institute, Columbus, Ohio; and gColorado School of Public Health and University of Colorado School of Medicine, Aurora, Colorado of mandated protective eyewear in reducing eye/ orbital, concussive, and head/facial injuries in ’ Dr Kriz conceptualized and designed the study; Drs d Hemecourt and Comstock assisted with study high school girls’ field hockey. design; Mr Almquist, Dr Collins, and Dr Comstock designed the data collection instruments; Mr Almquist, Mr Reynolds, Dr Collins, and Dr Comstock coordinated and supervised data collection WHAT THIS STUDY ADDS: Data collected from at one of the two sites; Dr Kriz and Ms Ruggieri collected and analyzed data from the two databases and drafted the initial manuscript; Dr Zurakowski carried out the statistical analyses; Drs Kriz and regional/national high school sports injury Zurakowski contributed tables and figures; Drs Zurakowski, d’Hemecourt, and Comstock reviewed surveillance databases by certified athletic and revised the manuscript; and all authors approved the final manuscript as submitted. trainers over 4 seasons has shown that The content of this report is solely the responsibility of the authors and does not necessarily reflect nationally mandated protective eyewear results the official views of Prevent Blindness America or the Centers for Disease Control and Prevention. in a greater than 3-fold reduced risk of eye/ www.pediatrics.org/cgi/doi/10.1542/peds.2015-0216 orbital injuries in girls playing high school field DOI: 10.1542/peds.2015-0216 hockey. Accepted for publication June 1, 2015 Address correspondence to Peter Kriz, MD, 2 Dudley St, Ste 200, Providence, RI 02905. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 136, number 3, September 2015 ARTICLE Field hockey remains a popular high activity (time loss [TL] .21 days exposure and injury information, and (2) school (HS) sport for girls in the and/or medical disqualification [DQ] Fairfax County (Virginia) Public Schools United States, with participation rates for remainder of season). These (FCPS) Athletic Training Program, increasing by 28% from 1990 to secondary objectives were chosen a large public school system with 25 2014.1 Although they are infrequent, because critics of protective eyewear member high schools. High School RIO’s serious eye injuries can occur, most have cited concerns that it obscures quality measures are reported commonly resulting from players peripheral vision and can lead to more annually in on-line reports (http://www. being struck by the stick or ball.2–4 aggressive play, and thus may result in ucdenver.edu/academics/colleges/ On occasion, eye injuries can be players sustaining more concussions PublicHealth/research/ catastrophic, resulting in vision loss or head/face injuries owing to ResearchProjects/piper/projects/RIO/ and permanent disability.5 In 2011, increased player-player contact. Pages/Study-Reports.aspx). The FCPS the National Federation of State High A prospective cohort study was database, captured via a district- School Associations (NFHS) issued conducted during 2 seasons of play mandated electronic medical record- a protective eyewear mandate (MPE) immediately before (fall 2009 and fall keeping program for injury surveillance, requiring all HS field hockey players 2010) and immediately after (fall was maintained by 2 authors (JLA to wear protective eyewear in 2011 and fall 2012) a national MPE in and JR). 6 NFHS-sanctioned competitions. In girls’ field hockey exercised by the ATs collected field hockey–related contrast, protective eyewear remains NFHS (effective fall 2011). The study athletic exposure and injury voluntary in non-NFHS sanctioned population was US players of HS girls’ information throughout the study. In fi competitions and other eld field hockey. Before the national MPE, addition to standard variables captured – hockey related play, as USA Field cohorts were defined by their by the HS RIO and FCPS surveillance Hockey, the National Collegiate participation in a state interscholastic systems, a variable was added to the Athletic Association (NCAA), and the league either with or without data collection: whether MPE was in International Hockey Federation have a protective eyewear mandate. As of effect in the injured player’s state of HS not yet endorsed eye protection fall 2011, all US girls’ HS field hockey attendance (before fall 2011). An among their players.7,8 players were mandated to wear athletic exposure (AE) was defined as 1 Developmental, college, and national- protective eyewear. Inclusion criteria athlete participating in 1 practice or level field hockey coaches and were HS field hockey; play occurring competition. A reportable injury was programs have voiced concern that during HS-sanctioned seasons; and defined as one that (1) occurred as MPEs will jeopardize international participating HS covered by a certified a result of an organized HS athletic recruitment efforts (as no other athletic trainer (AT). Exclusion criteria practice or competition, (2) required country mandates eyewear were injuries sustained during field medical attention from a team AT or protection) and the ability of the US hockey play unrelated to practice or physician, and (3) resulted in national teams to remain competitive fi competition; off-season eld hockey restriction or alteration of the athlete’s internationally.9 Previous studies practices or competitions; or activities participation status. For each injury, the have shown that MPE in female HS fi unrelated to eld hockey practices or AT completed a detailed report that lacrosse players results in a virtual games (eg, injury in recreational included date of injury, exposure (eg, elimination of eye/orbital injuries.10 soccer, locker room horseplay). practice versus competition), injury Given the nature of the study design characteristics (eg, body site, diagnosis, METHODS (retrospective data analysis captured severity, TL), and circumstances by prospective longitudinal leading to injury (eg, mechanism, The primary objective of this study surveillance programs, no intervention specific activity at time of injury). Both was to compare eye/orbital injuries performed, no personal data collected), databases were monitored regularly during practices and games for US informed consent was not obtained by the authors’ research teams (RDC, players of HS girls’ field hockey for 2 from study participants. Institutional JLA, and JR) to maximize compliance seasons before and 2 seasons after review board approval was granted and ensure data quality. a national MPE. Secondary objectives from Rhode Island Hospital. included examining differences As the primary objective in this between cohorts for (1) all eye/ Injury surveillance systems used in this prospective cohort study was to orbital, concussive, and head/face study included (1) High School ascertain whether athletes who have injuries; (2) concussive injuries only; Reporting Information Online (RIO), exposure to MPE are less likely to (3) head/face injuries only (excluding a validated, Internet-based data sustain eye/orbital injuries compared eye/orbital and concussive injury); collection tool developed and used by 1 with those without MPE, incidence and (4) head/face and eye/orbital author (RDC) for tracking sports injury rates and odds ratios (ORs) were injuries resulting in delayed return to epidemiologic data including athlete calculated, using the z-test to

Downloaded from www.aappublications.org/news by guest on September 25, 2021 522 KRIZ et al determine whether MPE led to including eye/orbital and concussion concussion rate for field hockey asignificantly reduced injury rate. was 0.687 injuries per 1000 AEs in players during the 4-season study Because the injury data represent the no-MPE group compared with was 0.335 injuries per 1000 AEs rates per 1000 AEs, generalized 0.647 injuries per 1000 AEs in the (Table 1), compared with 0.392 per Poisson log-linear regression modeling MPE group (OR 1.06, 95% CI 1000 AEs for the 2 seasons after the was used to compare incidence rates 0.87–1.29, P = .54). national MPE mandate and 0.282 of total injuries and specificinjury Regarding concussion, 116 injuries per 1000 AEs for the 2 types between MPE and no-MPE concussions were diagnosed during premandate seasons. Concussions groups, with the likelihood ratio test to the 2 seasons after the national MPE were the most common injury, assess significance and ORs and 95% mandate (2011/12 and 2012/13), representing 209 of 415 (50.4%) confidence intervals (CIs) to estimate compared with 93 in the 2 seasons total eye, orbital, and head/facial the effect of MPE on the risk of preceding the mandate (2009/10 and injuries collected during the 4-season injury.11 Statistical analysis was 2010/11). The concussion incidence study. Head/face injuries (excluding performed using PROC GENMOD in in the group without MPE was 23% eye/orbital and concussions) SAS version 9.2 (SAS Institute, Cary, lower than that of the group with occurred .25% more frequently in NC). Two-tailed values of P , .05 were MPE overall (OR 0.77, 95% CI the group without MPE compared considered statistically significant. 0.58–1.02, P = .068) during the 4- with the group with MPE (0.323 vs season study, but this result was not 0.252 injuries per 1000 AEs; OR 1.28, RESULTS statistically significant, although it 95% CI 0.95–1.72, P = .099). After the Overall, 206 high schools participated. suggests a statistical trend. The 2011/12 mandate, severe eye/orbital HS field hockey players sustained 415 TABLE 1 eye/orbital, concussion, and head/facial Characteristics of the Study Population, 2009/10, 2010/11, 2011/12, and 2012/13 Seasons injuries during 624 803 athletic Characteristic 2009 to 2011 2011 to 2013 2009 to 2013 exposures (0.664 injuries per 1000 Total injuries (eye/orbital, concussion, head/facial) 212 203 415 AEs). Table 1 summarizes the study Total AEs 329 601 295 202 624 803 population characteristics. Players from MPE 66, 286 295 202 361 488 fi No MPE 263 315 – 263 315 16 of 19 states that sanction HS eld High School RIO 213 240 158 810 372 050 hockey were represented. Of 206 FCPS 116 361 136 392 252 753 participating high schools, 148 (72%) High schools 180 117 206 were large schools ($1000 students). HS-RIO 130a 67 106 FCPS (25 schools/season) 50b 50 100 Of 415 injuries, 234 (56%) were Large schools ($1000 students) 68c 82 148 reported in the MPE group during High School RIO 18 32 48 361 488 AEs, and 181 were reported FCPS 50b 50 100 , d in the no-MPE group in 263 315 AEs. Small schools ( 1000 students) 42 35 58 fi High School RIO 42 35 58 Cohort-speci c injury rates and FCPS 0 0 0 corresponding ORs for total injuries States participating 14 13 16 (including eye/orbital and High School RIO 13 13 16 concussion), concussive injuries, FCPS (Virginia) 1 1 1 – – – head/face injuries (excluding eye/ Age range, y 14 18 14 18 14 18 Injuries orbital and concussion), eye/orbital Eye/orbital 22 8 30 injuries only, and severe injuries are Concussion 93 116 209 summarized in Table 2. Head/face (excluding eye and concussion) 97 79 176 Severe (TL .21 d) 16 19 35 Eye/orbital injuries recorded during Eye/orbital 3 1 4 the study period included eyebrow/ Concussion 9 15 24 eyelid lacerations, periorbital Head/face 4 3 7 contusions, and corneal abrasions. Medical DQ 11 10 21 Eye/orbital injuries occurred 3 times Eye/orbital 0 0 0 Concussion 5 10 15 more frequently in players from no- Head/face 6 0 6 MPE states compared with MPE Concussion incidence rate ratio (includes MPE, 0.282 0.392 0.335 states (before the 2011/12 mandate) no MPE, and AEs) and the postmandate group (0.080 Values are expressed as n unless noted otherwise. injuries vs. 0.025 injuries per 1000 a 39 MPE, 91 no MPE. – P b All no MPE. AEs; OR 3.20, 95% CI 1.47 6.99, = c 10 MPE, 58 no MPE. .003). The incidence of total injuries d 20 MPE, 22 no MPE.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 136, number 3, September 2015 523 TABLE 2 Injuries and Risk of Injury Stratified by MPE or No MPE Injury MPE No MPE Incidence Rate Ratio (95% CI) z-Test P Value

n Incidence per 1000 AEs n Incidence per 1000 AEs Total 234 0.647 181 0.687 1.06 (0.87–1.29) 0.544 2009 to 2011 31 0.467 181 0.687 1.47 (1.00–2.15) 0.048a 2011 to 2013 203 0.687 —— —— Concussive 134 0.371 75 0.285 0.77 (0.58–1.02) 0.068 2009 to 2011 18 0.272 75 0.285 1.05 (0.63–1.75) 0.856 2011 to 2013 116 0.393 —— —— Head/face 91 0.252 85 0.323 1.28 (0.95–1.72) 0.099 2009 to 2011 12 0.181 85 0.323 1.78 (0.97–3.26) 0.061 2011 to 2013 79 0.267 —— —— Eye/orbital 9 0.025 21 0.080 3.20 (1.47–6.99) 0.003a 2009 to 2011 1 0.015 21 0.080 5.33 (0.71–39.30) 0.104 2011 to 2013 8 0.027 —— —— Severeb and medical DQ 30 0.083 26 0.099 1.19 (0.70–2.01) 0.517 2009 to 2011 1 0.015 26 0.099 6.60 (0.89–48.23) 0.065 2011 to 2013 29 0.098 —— —— a Statistically significant. b Injury requiring time off from play for .21 days. injuries (TL .21 days) were reduced no-MPE groups, accounting for reported severe eye/orbital and head/ by 67% (3 injuries during 2009/10 acollective36%and28%ofeye/ face injuries decreased by 67% and and 2010/11 vs 1 injury during orbital, concussion, and head/face 70%, respectively, when comparing 2011/12 and 2012/13), and severe/ injuries, respectively. Overall, player- data from a 2-season time period medical DQ head/face injuries were player contact injuries were similar before and after a national MPE. between the MPE and no-MPE groups reduced by 70% (10 injuries during Mandated protective eyewear for HS (25% vs 19% of total injuries, 2009/10 and 2010/11 vs 3 injuries field hockey players is an important respectively). No statistical trends or during 2011/12 and 2012/13). injury prevention development. As in statistically significant differences were TL injuries were compared between girls’ lacrosse,10,12 epidemiologic identified for any injury mechanisms the 2 seasons premandate, the 2 studies support the effectiveness of between the MPE and no-MPE groups. postmandate seasons, and the entire 4- protective eyewear mandates in season study period (Table 3). No reducing eye/orbital injuries in HS statistically significant differences DISCUSSION field hockey. More than 64 000 HS between the MPE and no-MPE groups athletes participate in NFHS- fi were identified for each of the TL Evidence from our study con rms sanctioned field hockey.1 Additionally, that a national mandate for protective intervals. Compared with the .5000 athletes participate in NCAA eyewear among girls participating in premandate (2009–2011) results, there women’s field hockey.13 In contrast, US HS field hockey is associated with was a relative increase in TL injuries only 31 athletes are currently a 3-fold reduction in the rate of eye/ lasting 10 to 21 days and season- members of the US Women’s National orbital injuries, without significantly ending injuries in the postmandate Team.14 Despite the discrepancies in increasing frequency of player-player (2011–2013) seasons, with the these numbers, there is 1 contact head and facial injuries, majority (86%) oftheseinjuries commonality among all 3 groups: including concussion. Head/face resulting from concussion (Table 1). In they are all amateur athletes at risk injuries (excluding eye/orbital and comparison, concussive injuries made for sports-related injury. concussion) occurred .25% more up only 52% of severe (TL .21 days) frequently in the no-MPE group Micieli et al15 recently reported on and medical DQ injuries in the 2 compared with the MPE group. the impact of visors on eye/orbital premandate seasons (2009–2011). Concussions were the most common injuries in professional athletes, Table 4 compares injury mechanisms injury, representing 50% of all demonstrating an incidence of eye/ for eye/orbital, concussion, and injuries involving the head and face. orbital injuries in the National Hockey head/face injuries for seasons 2009 Although concussion rates increased League (NHL) of 0.248 per 1000 AEs to 2011 and 2011 to 2013, as well as during the 4 seasons of data during 2002/13, 3 times higher than the cumulative injuries for all 4 collection, concussion rates for MPE that among HS field hockey players in seasons. Contact with the ball and stick and no-MPE groups did not states without MPE. Unlike the remained the most common injury demonstrate a statistically significant reluctance to endorse eye protection in mechanism among both the MPE and difference. Additionally, the number of amateur elite field hockey, professional

Downloaded from www.aappublications.org/news by guest on September 25, 2021 524 KRIZ et al TABLE 3 Time to Return to Field Hockey After Injury Although concussion assessment in Injury 2009 to 2011 2011 to 2013 (All MPE) 2009 to 2013 US HS field hockey players was a secondary study objective, there MPE No MPE MPE No MPE were many significant findings and n 31 181 203 234 181 trends pertaining to concussive TL ,1 d 6.7 17.2 11.9 11.3 17.2 injury. It is important to note that in 1–2 d 16.7 13.3 12.4 13.0 13.3 our 4-year study, there were no 3–6 d 26.7 22.2 10.4 12.6 22.2 statistically significant differences in 7–9 d 30 10.6 12.9 15.2 10.6 concussion rates between groups 10–21 d 16.7 18.3 28.4 26.8 18.3 with and without MPE. Similarly, in $22 d 0 8.9 9.5 8.2 8.9 Medical DQ 3.3 5.6 5 4.8 5.6 the 2-year study performed before Season ending 0 2.8 9.5 8.2 2.8 the national mandate, there were no Missing data, n 1 1 2 3 1 significant differences in concussion Values are expressed as % unless noted otherwise. rates between the 2 groups (OR 1.05 95% CI 0.63 to 1.75, P = .86).21 ice hockey at various levels including public secondary school athletes have After the NFHS protective eyewear theNHLhasmadesignificant strides full-practice AT coverage every mandate in fall 2011, the incidence in implementing mandated visor use afternoon,20 timely access to medical rate for concussions sustained in HS over the past decade.16–18 Another care, as well as the level of medical field hockey increased from 0.285 study showed that 73% of NHL care, available to HS athletes is in concussions per 1000 AEs (seasons players wore visors as of the 2012/ stark contrast to the tertiary levels of 2009/10 and 2010/11) to 0.393 13 season, and in a relatively short medical care that professional concussions per 1000 AEs (2011/12 time, there will be 100% compliance athletes commonly have at their and 2012/13). At first glance, one with mandatory visor use among fi disposal. Despite the signi cant might infer that an eyewear protection NHL players, based on the current strides made regarding protective mandate, and perhaps the NHL grandfathering rule.19 eyewear mandates in US HS- accompanying criticisms of protective fi Although one could argue that the sanctioned eld hockey competitions, eyewear (eg, reduced peripheral risk of eye/orbital injury in amateur protective eyewear remains voluntary vision), were responsible for this field hockey is one-third the risk in in practices, non–NFHS-sanctioned increase, but a closer examination of professional men’s ice hockey, the competitions, showcases, tournaments, concussion epidemiology provides financial burden to amateur athletes and other field hockey–related play. a more likely explanation. Rosenthal who sustain an eye/orbital injury and This includes large numbers of middle et al22 reported that during the time their families may be substantially school, high school, collegiate, and period 2005/06 through 2011/12, higher compared with a professional national team field hockey players in concussion rates reported by ATs for 9 athlete because an amateur player’s the United States. The eyesight of HS sports increased from 0.23 to 0.51 disability insurance policy (if she has nearly 70 000 US players is currently at concussions per 1000 AEs, with 5 one) is unlikely to provide much risk for serious injury, to allow a select sports having statistically significant financial compensation for life- or few elite amateur field hockey players increases over this period. The authors career-altering loss of vision. to remain competitive internationally hypothesized that several factors Furthermore, because only 37% of US or to allow collegiate field hockey potentially contributed to this trend: public secondary schools employ teams to competitively recruit (1) concussion incidence actually a full-time AT and only 47% of US international players. increased; (2) increased athlete

TABLE 4 Injury Mechanism for Eye/Orbital, Concussion, and Head/Face Injuries Contact With 2009 to 2011 (n = 212) 2011 to 2013 (n = 203) 2009 to 2013 (n = 415)

Total Injuries, % MPE No MPE Total Injuries, % MPE No MPE

n % n % Total Injuries, % nn% n % Ball 36.3 11 35.5 66 36.5 35.0 71 35.7 82 35.0 66 36.5 Stick 30.7 11 35.5 54 29.8 25.1 51 28.0 62 26.5 54 29.8 Player 19.3 6 19.4 35 19.3 25.6 52 22.4 58 24.8 35 19.3 Ground 2.4 2 6.5 3 1.7 4.4 9 3.4 11 4.7 3 1.7 Goal 0.5 0 0.0 1 0.6 0.5 1 0.5 1 0.4 1 0.6 Other 1.4 1 3.2 2 1.1 3.4 7 2.4 8 3.4 2 1.1 Missing data 9.4 0 0.0 20 11.0 5.9 12 7.7 12 5.1 20 11.0 Total 100 31 100 181 100 100 203 100 234 100 181 100

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 136, number 3, September 2015 525 monitoring by coaches, medical calculations performed during our committed) may be warranted to personnel, parents, and athletes prior publication,21 a catastrophic determine the impact of protective themselves occurred secondary to injury in HS field hockey occurs every eyewear on skill level and player increased concussion awareness; and 8.3 seasons, making the likelihood of development. (3) increased coverage of games/ capturing such an injury in practices by ATs occurred.22 a relatively small sample of the total CONCLUSIONS Concussion legislation enacted in all number of national athletic exposures fi US states between 2009 and 201423 in HS field hockey exceedingly rare. Among female US HS eld hockey has inevitably led to increased Performing a prospective, players, a national MPE is . concussion education and reporting longitudinal study that collects both associated with a 3-fold reduced among student-athletes, coaches, injury and exposure data among all risk of eye/orbital injuries and parents, and school nurses: several HS field hockey participants a decreased incidence of severe authors in our study cited a significant nationally in an effort to capture eye/orbital and head/face injuries. fi increase in total number of catastrophic eye/orbital, concussion, Given the scienti c evidence concussions reported after concussion and head/facial injuries would be demonstrating that mandatory laws went into effect in their costly and resource prohibitive. protective eyewear effectively fi respective states. Similarly, with ever- Additionally, whereas we were able to reduces eye injuries in eld hockey growing numbers of primary care capture injuries and determine which players without increasing sports medicine fellowships injuries occurred in states with and concomitant injury such as nationally24 and a subsequent greater without MPE, incomplete data concussion, research now exists to availability of sports medicine–trained collection by ATs for the variable support a policy change regarding physicians for game coverage and “was the athlete wearing eye mandatory protective equipment in fi concussion clinic staffing, it is likely protection at time of injury?” eld hockey at all amateur levels. that physician reporting of sports- prevents us from determining related concussion has also increased whether players were wearing ACKNOWLEDGMENTS over the past few years. Echlin et al protective eyewear at the time of We thank the ATs who assisted with fi reported a signi cantly higher injury in MPE and no-MPE states. data collection in this study and Vito incidence of concussion with Finally, data on the number of fouls Perriello, MD, for his lifelong physician-observed games compared incurred during competition is not contributions to the fields of with games not covered by physicians captured by High School RIO, FCPS pediatrics, sports medicine, and ’ ’ in collegiate men sandwomens Athletic Training Program, or any injury prevention before his varsity ice hockey, suggesting an other national database. Although it is unexpected death in 2009. underestimation of sports concussion feasible that players were more in the scientific literature.25 aggressive when playing with eye Our study has some limitations. protection, we saw no difference in ABBREVIATIONS Randomization was not part of the athlete-athlete contact injury rates AE: athletic exposure study design, since enrollment in MPE during our study period, which would AT: athletic trainer and no-MPE groups was have been expected if play became CI: confidence interval predetermined by established state more aggressive over time. DQ: disqualification mandates for protective eyewear in Despite some limitations, our study FCPS: Fairfax County Public effect during the 2009/10 and 2010/ was able to pool and analyze data Schools 11 seasons. Additionally, small event from national and regional HS sport High School RIO: High School frequencies in specific injury injury surveillance databases from Reporting subcategories (such as severe eye/ 2 seasons before and 2 seasons Information orbital injuries [TL .21 days] and after implementation of a national Online severe/medical DQ head/face injuries protective eyewear mandate in HS MPE: mandate for protective in the MPE and no-MPE groups) girls’ field hockey, resulting in the eyewear prevented attaining statistically largest prospective national study NCAA: National Collegiate Athletic significant results. However, clinical examining the effectiveness of MPE Association significance was achieved regarding in reducing eye/orbital, concussive, NFHS: National Federation of State reduction of these injury and head/facial injuries performed High School Associations subcategories with implementation of to date. Future research evaluating NHL: National Hockey League MPE. Furthermore, no catastrophic the performance of athletes OR: odds ratio injuries were recorded during our 4- wearing and not wearing protective TL: time loss season study period. Based on eyewear (eg, goals, assists, fouls

Downloaded from www.aappublications.org/news by guest on September 25, 2021 526 KRIZ et al FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Funded in part by Prevent Blindness America grant 701-5215 and Centers for Disease Control and Prevention grant R49/CE001172-01. The authors also acknowledge the generous research funding contributions of the National Operating Committee on Standards for Athletic Equipment. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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