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Jeffrey Stevens MD
Averal Medical Group Ophthalmology
Amare
Stoudemire
More than 30,000 children sustain sports related eye
injuries each year.
The average professional baseball fastball travels at 95
miles per hour.
The average hockey puck travels at 95 mph.
90 percent of eye injuries are prevented by using
protective eyewear.
Roughly 30% of these injuries are from individuals
playing basketball.
Don’t Worry!!
The eye is easy!!
Remember these points!! • Know the Basic Exam
• Know Basic Anatomy
• Know Basic Differential
• If in doubt (Wills Eye Manual) and or call your
friendly eye specialist.
History
Past Eye History
Vision-near card
Pupils
Confrontation Visual fields (Count fingers in
periphery)
Eye Movement
Eye Pressure (tonopen)
External exam topical- anesthetic (fluorescein/
cobalt blue light source- if needed.)
External exam
Direct Ophthalmoscope- Fundus Exam
Near Card
Smart Phone App
Light Source to see if equal in size and response and
symmetry.
Light source can even be your smart phone in a pinch.
Have patient cover one eye
Have him/her fixate on your
nose.
Check each side inferior and
superior quadrant with
movement or number of
fingers.
Have patient follow finger movement in
up, down and each lateral side gaze.
Look at pupillary reflex in both eyes to
see if it is displaced in either eye during
movement.
Displaced
light reflex
on left gaze
Normal 8-21 mmHg.
Tonopen easiest method in emergency setting
Topical anesthetic needed.
No pressure on eyelid or eye when taking pressure
Repeat if pressure is high, or not repeatable.
Tonopen may need to be recalibrated.
With concern for ruptured globe do not take pressure.
For Swollen lids, patients in intense pain or
photophobia a lid speculum or lid retractor can be
helpful to inspect the eye.
If there is suspicion of ruptured globe, and the patient
is not being cooperative, it is better to CT scan the
patient and call the Ophthalmologist instead of risk
more damage to the globe. Shield the eye and call.
Look at all external eye structures,
Compare between eyes.
For internal structures, Intraocular
Foreign body, ruptured globe, CT scan
can be helpful.
For Lid lacerations important to identify if
medial lacrimal canaliculi/punctum are
affected.
Direct exam- Easier with a panoptic.
Difficult for most non eye specialists without dilation.
If you can’t see the fundus, that is OK, just go off of
history and the rest of the exam and call if there is any
suspicion the patient needs to be seen right away.
If you would like practice, ask an eye specialist to allow
you to follow him/her for a couple of hours to practice
the direct ophthalmoscope on dilated patients.
Anyone is welcome at any time at our office • Avera Medical Group Ophthalmology, Plaza 2, Suite 202, Sioux Falls, SD
57105. Phone: 605-322-3790.
Corneal/Conjunctival abrasion
Subconjunctival hemorrhage
Orbital fracture
Hyphema-(blood in the eye)
Ruptured globe.
Concussion
15 year old female while playing
basketball. She has excruciating left eye
pain after a teammate accidently poked
her in her left eye.
She has difficulty opening the left eye,
tearing, 10/10 sharp pain, and 20/400
vision.
Signs/Symptoms: Very Common- From direct trauma, or foreign body.
Signs- Sudden severe sharp eye pain, foreign body
sensation, decreased vision, tearing, redness,
periocular edema (swelling), photophobia.
Patient may want to hold eye shut.
May spontaneously debride after healing days later.
Diagnosis/Treatment:
Direct exam- eye care providers and most urgent
care/Emergency departments have flourescein and
anesthetic to examine, stain the abrasion and
observe with a woods lamp (cobalt blue light
source).
Topical antibiotic to prevent infection- erythromycin
ointment TID. Drop- ofloxacin, polytrim QID until
healed.
If high risk of infection –vigamox, zymar 4xday
Moxeza 2xday.
Remove foreign body if it is the cause.
Usually heal in 1-2 days.
12 year old
boy poked in
left eye while
wrestling an
opponent.
What is it-Blood within or under the
conjunctiva. “Eye Hematoma”
Almost always benign.
Conjunctiva may billow and prevent the eye
from completely closing initially.
Most common with trauma
Can also be spontaneous with
anticoagulation.
Treatment- • Cool Compresses.
• Artificial tears.
18 year old college football
player sustaining facial trauma
after getting tackled after his
helmet fell off.
Assessment:
• Basic Eye exam: Focusing on these parts.
• Vision- Risk for Traumatic optic
Neuropathy. (Damage to Optic Nerve)
• Eye Pressure: Increased eye pressure
can occur from Retrobulbar hematoma.
(Ocular compression syndrome)
Emergent Canthotomy needed to relieve
compression
• Extraocular Movement: Muscle
entrapment can be caused from a
fracture, most common with small
inferior fracture.
• Enophthalmos- Eye is sunken in due to
extensive posterior orbital fracture.
• CT Scan of Orbits/Facial bones required.
Treatment:
Observation:
• Edema of periocular tissue,mild
proptosis, mild extraocular
restriction/mild diplopia can be
due to edema and can improve
with time, usually 1-3 weeks.
• Orbital heme and emphysema
(air within orbit) will improve.
Counsel patient not to blow nose
for a time.
Surgical repair of orbit:
• Enophthalmos (more than 2 mm
of difference.
• Intraocular muscle entrapment-
Needs to be urgent if stimulating
the Oculocardiac reflex
(tachycardia nausea)
• Orbital Rim step off- Orbital rim
fracture that is apparent by
touch/exam.
12 year old with
blurred vision
and pain in his
left eye after
hockey game. In
the concessions a
teammates plastic
spoon shattered
while playing
drums with it, and
a splinter hit him
in the left eye.
Foreign body, sharp object, or blunt trauma, punctures
the globe and causes an “Open Globe”.
Signs- misshapen eye on examination and or CT/MRI
study, new pupillary irregularity, Decreased vision,
Corneal or scleral Laceration, Intraocular Foreign body
on imaging study.
+Seidel test -fluoroscien stain shows fluid draining
from the .
Treatment- Do not touch the eye. Shield the eye and
emergently contact nearest ophthalmologist for
evaluation and surgery.
Antiemetics may be recommended to prevent vomiting
and valsalva.
Patient should be put NPO for surgery.
Ophthalmologist may want IV antibiotics. After
affirmation of ruptured globe full examination and
surgical repair will be performed in the OR.
Fluorescein is
moving away from
wound, showing
fluid leaking from the
intraocular contents.
8 year old
boy playing
baseball gets
hit in the left
eye with the
baseball.
Blood in the anterior chamber usually related to
trauma.
Can cause blockage of the trabecular meshwork,
corneal blood staining, and amblyopia in children.
Symptoms- Pain, decreased vision.
Signs- Layered blood in the anterior chamber, 8 Ball
(complete hyphema), poorly responsive pupil,
increased intraocular pressure.
Diagnostics-check intraocular pressure, Sickle Cell
prep for African descent.
Refer to Ophthalmology emergently.
Restrict movement to prevent rebleed, stirring up
blood cells. Pt. may need to be hospitalized and put on
bed rest. Elevate head of patient to allow blood to
settle.
Lower increased intraocular pressure with topical
medications, and or oral diamox, methazolamide or IV
mannitol. • Surgery may be needed if IOP is elevated for too long if the blood is not receding. Low
surgical threshhold for Sickle patients and pediatric patients.
25 year old
semiproffesional
basketball player gets
hit in right eye with an
elbow.
He notices sudden
inferior ”curtain” of
lossed vision with
multiple new floaters
that do not resolve with
time.
Fundus examination is
shown.
Painless sudden loss or
blurring of vision.
Associated symptoms:
New floaters, flashing
lights, curtain of blurred
vision that does not move
or change.
Gradual worsening of
peripheral vision.
Associated with trauma,
High Myopes (near
sighted) Family history,
History in other eye.
Retinal detachment can
happen when blunt force
causes vitreous adhesions
to tear the retina causing a
retinal break.
Retinal breaks allow fluid
to enter between the
retina and underlying
choroid causing the retina
to detach.
Lack of choroidal blood
supply to the retina causes
the retinal to degenerate
and die, causing
permanent loss of vision.
Retinal death can
decrease central vision in
less than 48 hours.
Assessment/Treatment
• Urgent evaluation by an
ophthalmologist/Retina
specialist. Call nearest
ophthalmologist or
Emergency room with
Ophthalmologist on call.
• Counsel patient to limit
activity, bed rest may be
advisable if a retinal
detachment is highly likely.
• Retinal laser retinopexy, with
or without gas retinopexy or
retinal surgery may be
required (scleral buckle, or
pars plana vitrectomy.)
Definition-
Concussions are mild
brain injuries usually
due to head trauma.
• Concussions can cause
long term brain
dysfunction, but usually
are self limiting and can
resolve without long
term disability as long
as the brain has time to
recover/heal without
sustaining repeated
injury and or strain.
Concussion Facts
(CDC):
>3 million US cases/ year.
5-10% athlete experience
one in a sport season
<10% of sport related
concussions involve a Loss
of Consciousness
Football > risk for males
(75% chance for
concussion)
Soccer > risk for females
(50% chance for
concussion)
Ocular Findings
• Decreased/Increased
Saccades with less accuracy-
Difficulty reading/ affect eye
hand coordination.
• Convergence/Divergence
Insufficiency- Difficulty
focusing to read or see in the
distance. Variable or constant
diplopia can occur with
increase in asthenopia (eye
pain) and
headaches/migraines.
• Phorias can be unmasked
causing a tropia (lazy eye)
chronic diplopia, inability to
focus both eyes together.
Treatment:
• Observance- Most Ocular
symptoms will resolve with time
as the brain trauma heals.
• If a visual abnormality is found:
Eye exercises for Convergence
insufficiency can improve ability to
focus for reading after recovery time is
over for concussion.
Prism glasses can improve reading,
diplopia and headaches by improving
fixation of phorias, tropias and
Convergence /divergence
insufficiencies.
A bifocal add or readers for near can
relax accommodation and can
sometimes help with reading and
headaches.
Know when it is important for an emergency referall to an eye
specialist.
If you don’t exactly know what is going on with the patient’s eye; if
the patient has rapid onset of pain and decrease in vision loss
(constant) not variable refer emergently. Call and sometimes a
picture is helpful to rule out emergent transfer. Any question of
globe rupture shield eye and contact eye surgeon ASAP.
Facial Trauma usually requires a CT scan, orbital fractures should
have an eye exam.
Concussions- can sustain ocular/vision findings that can persist.
Evaluation and treatment by an Eye specialist may prove helpful.
Hayreh,S. Management of Ischemic optic Neuropathies. Indian journal of ophthalmology. 201159(2) :123-136.
Ehlers, J, Shah C. Wills Eye Manual 5th edition 2008.
Kaiser P, Friedman N. Pineda R. Massachussetts Eye and Ear Infirmery Illistrated Manual of Ophthalmology 2nd
Ed. December 2003.
American Academy of Ophthalmology Basic Clinical Science Series, Neuophthalmology, Cornea, Pediatrics
2007.
Netter. Netter Atlas of Human Anatomy 2007. netteranatomy.com
https://www.willseye.org/sports-eye-injuries
http://www.cdc.gov/traumaticbraininjury/data/index.html
