Sport and Exercise Medicine: The UK trainee perspective (A BJSM blog series)
By Dr Stan Baltsezak
Preface: BJSM readers can access the ‘Online First’ article relating to wicketkeeper Marc Boucher’s serious eye injury here; he was struck by the bails and suffered irreparable visual loss. This paper will be one of 4 relating to cricket injuries in the upcoming July BJSM.
You are providing sideline care, your player gets poked in the eye and your are confronted by blood and a player panicked by loss of vision in that eye. Are you ready?
In North America, basketball, baseball, and racket sports were the highest risk sports for ocular injuries among amateur players (1,2). In Scotland, 48% of patients admitted with sports related ocular trauma were from racket sports. Football was responsible for 33% of admissions (3). In boxing, serious injuries include hyphaema, angle recession, posterior subcapsular cataract, retinal detachment and orbital fracture (1).
How to examine the eye after trauma
Initial eye examination after blunt trauma must be done immediately at the sport venue. Eyelids are assessed for bruising and laceration. Visual acuity should be recorded for both eyes (Ability to perceive light, movement, finger count at 1 metre, and, if Snellen’s chart is unavailable, a distance from the available readable text should be recorded). Gross visual field assessment should be performed to evaluate injury to posterior structures of the eye.
A simple torch is used to evaluate anterior structures of the eye (look for hyphaema). Difference in the depth of anterior chamber may suggest a leaking wound (e.g. corneal laceration). An Irregular pupil is often seen after contusion. It may indicate injury to the iris, ciliary body, or vitreous prolapse. Corneal abrasion can be detected under blue light after fluorescein staining.
Direct and consensual response to light is checked. In cases where there is significant damage to the optic nerve, a relative afferent pupillary defect will be observed.
Eye movements are checked for presence of diplopia which may indicate orbital fracture (e.g. orbital floor fracture leading to restricted ipsilateral upgaze and less often downgaze) as well as injury to ocular muscles and nerves. Orbital floor fracture also leads to infraorbital nerve anaesthesia.
An ophthalmoscope can be used to assess red reflex (injury to the lens, cornea, vitreous haemorrhage, and retinal detachment will affect it). Fundoscopy is performed to evaluate for presence of vitreous haemorrhage, vitreous detachment, and retinal tears. The optic disc is examined for swelling and haemorrhage.
Important!
A methodical eye examination after trauma will help to ensure rapid recognition of severe injury, enabling appropriate management. If in any doubt, immediate ophthalmologist referral is absolutely essential.
Although some eye trauma assessment can be learned during emergency medicine placement, we recommend a short attachment at the local eye injury department for all SEM trainees.
Tip: There is now a range of ophthalmological Apps designed to assist the “out-of-office” clinician. Easy to use, Snellen chart apps facilitate rapid and effective eye assessment in the prehospital environment.
References:
1. MacCumber MW. Management of ocular injuries and emergencies. Lippincot-Raven, 1998.
2. Jones, NP. One year of severe eye injuries in sport. Eye 1988;2:484-487.
3. Barr A, Baines P, Desai et al. Ocular sports injuries: the current picture. Br J Sports Med. 2000 December; 34(6): 456–458
Dr Stan Baltsezak is a Specialty Registrar year 6 in Sports and Exercise Medicine. He is currently working at the Kellgren Centre for Rheumatology, Manchester Royal Infirmary.
Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.