HEAD, NECK, AND SPINE

Evaluation and Management of Sports-Related

Eye Injuries
James P. Toldi, DO and Justin L. Thomas, MD
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and improved return to play guidelines.

Abstract It should be noted that the pediatric age
Ocular injuries occur at a high rate in the United States and are a common group is disproportionately affected by
complaint in the emergency department (ED). The CDC estimates that the sports-related eye injuries likely due to
annual rate for all-cause ocular injuries presenting to the ED is approxi- the high percentage of this age group
mately 37.6 per 10,000 (1). The personal impact of ocular injury is an participating in sports.
obvious one which necessitates urgent evaluation and possibly emergent Different sports can be risk stratified
ophthalmologic evaluation for vision preserving intervention. Specific based on low-risk, high-risk, and very
sports and recreational activities increase the risk of injury; these include high-risk classification schemes. Low-
sports involving projectiles (i.e., target shooting, racquet sports, hockey risk sports are those that do not utilize
pucks, lacrosse) as well as combat sports (i.e., martial arts, boxing, wres- equipment that could potentially cause
tling). Sideline physicians should be aware of the sports setting and be blunt or penetrating trauma (i.e., a ball,
prepared for ocular injuries with the proper sideline equipment. Prompt puck, bat, stick, racquet) and no body
recognition, management, and referral can lead to decreased morbidity in contact. Lower-risk sports include swim-
this select population. ming, track and field, and gymnastics.
High-risk sports use the aforementioned
equipment that increases the risk for ocular injury. Basketball,
baseball, soccer, lacrosse, tennis, racquetball, hockey are all ex-
Epidemiology of Sports-Related Eye Injuries amples of high-risk sports. Very high-risk sports include box-
Musculoskeletal injuries may be the most common sports- ing, martial arts, and wrestling, where ocular injuries occur at
related injuries, but eye injuries carry a high risk of morbidity a relatively high rate due to the violent nature of the sport. Bas-
and lifelong sequalae. Ocular injuries disproportionately affect ketball was shown to be the leading cause of sports-related oc-
younger males compared with the general population according ular injuries among ED patients sampled between 2010 and
to the Nationwide Emergency Department Sample. These data 2013 (1). Overall, open wounds of the adnexa (i.e., eyebrows,
from more than 900 hospitals and approximately 30 million eyelids and lacrimal apparatus) were the most common injury
emergency department (ED) patient visits per year showed followed by contusions of the eye and superficial wounds
81.3% of patients with sports-related ocular trauma were (1). The trend remained the same in basketball with open
males with a mean age of 20.1 years (1). More than half of adnexal wounds being most common followed by superficial
the patients presenting, males and females included, were wounds (1).
younger than 18 years. Traumatic eye injuries are the leading
cause of noncongenital blindness in those younger than 20 years.
Despite the lack of literature over the past 20 years on sports- Ocular Anatomy
related ocular injuries, there has been a notable 26% decrease The anatomy of the eye is very complex with many integral
in the incidence of pediatric ocular injuries from 2006 to 2014 working parts that are prone to injury in the athlete. The com-
(2). This is likely in part due to improved safety technology plete detailed anatomy of the globe, orbit, and vascular and
lymphatic supplies are out of the scope of this article, but a
general description of the major components will be described
here to review the major anatomy. Figure 1 depicts a general
University of South Alabama Sports Medicine, Mobile, AL
description of ocular anatomy which the sports medicine phy-
Address for correspondence: James P. Toldi, DO, University of South sician should be familiar with.
Alabama Sports Medicine, 1601 Center St Ste. 2n, Mobile, AL 36604; E-mail: In terms of injury patterns, the eye can be divided into the
Jtoldi@health.southalabama.edu. anterior and posterior segments. Each segment lends itself to
1537-890X/1901/29–34
different examination techniques for the suspected injuries.
Current Sports Medicine Reports Vascular supply to the eye is provided by branches of the oph-
Copyright © 2020 by the American College of Sports Medicine thalmic artery which originates off the internal carotid artery.

www.acsm-csmr.org Current Sports Medicine Reports 29

Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

Figure 1: Schematic diagram of the human eye. Available from:
https://commons.wikimedia.org/w/index.php?curid=1597930.
The anterior chamber is composed of a thin transparent
mucous membrane (conjunctiva), a protective fibrous mem-
brane (sclera), the transparent cornea, the aqueous humor,
and the iris. Since the eye is globular in nature the sclera and
choroid are parts of both the anterior and posterior chambers.
The conjunctiva is contiguous with the posterior surface of the
eye lid (palpebral) conjunctiva and is prone to both injury and
infection (3). The sclera is a protective fibrous outer layer that
is contiguous with the cornea anteriorly and the optic nerve
posteriorly. It is composed entirely of collagen and makes up
the white part of the eye. The cornea acts as the eye's outer-
most lens as well as a protective layer. The iris is positioned
in front of the lens and separates the anterior and posterior
chambers. It is responsible for controlling the amount of light
entering the eye.
The posterior chamber is composed of the lens anteriorly,
retina posteriorly, and jelly-like vitreous humor which helps
maintain the globe like structure of the eye (3). Light refraction
and accommodation are the main functions of the lens (3). This
focusing is accomplished by a muscular structure known as the
ciliary body which changes the shape of the lens by contracting
and relaxing. The retina is responsible for processing light infor-
mation and sending it to the brain via the optic nerve.
Supplies
The basic “eye kit” is something that sideline physicians
should carry with them and helps with the initial diagnosis
and management of eye injuries. An ophthalmoscope, vision
chart, light source with cobalt blue light, cotton swabs, eye
shield, sterile saline, contact lens remover, fluorescein dye,
and loupes or magnifying glass are examples of the equipment
one should have at his/her disposal (4). Ringside equipment for
lateral canthotomy and cantholysis may be considered for the
boxing or mixed martial arts (MMA) events.
30 Volume 19  Number 1  January 2020
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History
Firsthand observation of the event is the most helpful part
of the injury history; this helps determine velocity and direction
of the inciting blow. If the physician is not present, focused
questions of the sport and any projectiles help aid in determin-
ing extent of damage and diagnosis. Video review and a history
from the athletic trainer, if available, also aid in history and di-
agnosis. Instances where glasses or goggles have broken may be
concerning for penetrating injury. Foreign body sensation, tear-
ing or photophobia may indicate a corneal abrasion or foreign
body. Contact with organic matter may increase risk for infec-
tion. High velocity, blunt trauma from balls, pucks, or bats may
clue the clinician into the possibility of an orbital fracture and/
or retrobulbar hematoma. Pain with extraocular movement,
epistaxis, or diplopia may be indicative of an orbital fracture
with muscle entrapment. The most common mechanism of in-
jury is blunt trauma to the eye (1). It is important to always in-
quire about tetanus immunization history.
Physical Examination
A focused eye examination will facilitate proper diagnosis
and management in the setting of eye injury. First, visually ex-
amine for any obvious deformity, foreign bodies, eyelid lacera-
tions, facial bone deformity, erythema, or hematomas. Visual
acuity should be done first as this is considered the vital sign
of the eye (5). This can be done using a hand-held Snellen chart.
Confrontational visual fields should be tested in all four quad-
rants which can help diagnose injuries to the retina, optic nerve
or central optic pathways. Test extraocular movements through
the six cardinal positions to help determine ocular muscle or cra-
nial nerve injury. An entrapped inferior rectus muscle from an
orbital floor fracture can result in limited vertical range of mo-
tion. It is important to ask the patient about diplopia since this
can sometimes be a subtle finding. If diplopia is present, it is typ-
ically worse when looking toward the affected side (5). Eye pain,
decreased visual acuity, loss of anterior chamber depth, or a
teardrop-shaped pupil in the context of penetrating trauma
should raise concern for the possibility of globe rupture or trau-
matic lens dislocation (5,6). If this is suspected, the examiner
should be careful to avoid placing pressure on the globe. The pa-
tient should be given precautions against straining and Valsalva
pressure and an eye shield should be placed to protect the eye
from further injury.
A penlight is used to test pupil reactivity and to test for
a relative afferent pupillary defect (RAPD). A RAPD is when
the affected eye paradoxically dilates when exposed to light
but constricts when the contralateral eye is exposed to light.
This is indicative of a retinal or optic nerve injury. A light
source can help to quickly examine the anterior chamber for
blood (hyphema) and foreign bodies which can lead to globe
rupture. If either is suspected, then a more thorough examina-
tion should be done with a slit lamp. When using a basic light
source to examine the eye be sure to direct the light perpen-
dicular to the globe, illuminating the anterior chamber.
This will help visualize a potential hyphema. Palpate for
step-offs or subcutaneous crepitus which may occur sec-
ondary to orbital rim or facial fractures. Table 1 gives a
brief overview of signs and symptoms that would require
immediate ophthalmologic consultation.
Eye Injuries in Sport
Table 1.
Signs and symptoms of vision threatening injuries that require
immediate Referral (4).
Sudden Decrease in or
Loss of Vision Loss of Visual Field
Pain with eye movement Photophobia
Diplopia Proptosis/Enopthalmos
Light flashes or floaters Irregularly shaped pupil
Hyphema Embedded foreign body
Halos around lights Laceration of lid margin or near
medial canthus
Suspected globe 360° Subconjunctival
perforation hemorrhage
Corneal Abrasion
Corneal abrasions are one of the most common eye injuries
encountered. Recent data show that approximately 27% of U.S.
pediatric-related ocular injuries presenting to the ED are sec-
ondary to corneal abrasions (7,8). Symptoms include pain,
foreign body or gritty sensation, and photophobia or tearing.
They can be diagnosed using a cobalt blue light or woods
lamp and fluorescein dye. With fluorescein staining, an abra-
sion will appear yellow under normal light and green under
cobalt blue light (9).
Goals of treatment include prevention of infection, pain
control, and speed of healing (9). First-line treatment is eryth-
romycin ointment as it provides antibacterial coverage, serves
as a physical barrier, and provides lubrication to the eye. It is
important to educate the patient that this will blur his/her vi-
sion, but his/her vision will likely already be compromised
from the abrasion. Pain management can best be achieved
with topical nonsteroidal anti-inflammatory drugs (NSAIDs)
or oral narcotics for larger abrasions and occasionally topi-
cal cycloplegics. Evidence does not support the use of
cycloplegics for uncomplicated corneal abrasions, but they
may be considered for traumatic iritis to help reduce the pain
from ciliary muscle spasm (9). Antibiotics should be used for
3 to 5 d depending on response. Choice of antibiotic selection
will be based on whether or not the patient wears contact
lenses. Erythromycin ointment is first line for noncontact lens
wearers, followed by Polytrim drops or sulfacetamide (9). For
contact lens wearers, Pseudomonas and other gram-negative
coverage are needed since lenses are usually colonized (9). As
Pseudomonas are frequently found in the environment, individ-
uals coming into contact with organic matter should be covered
as well. This is accomplished with fluoroquinolones or amino-
glycosides. Ciprofloxacin, ofloxacin, and gentamicin are com-
monly used and are both available in ointment and drops.
Antibiotic regimens are usually dosed four times daily until
the patient is asymptomatic for 24 h (9). Topical NSAIDs
should not be used for more than 1 to 2 d as they may be as-
sociated with corneal toxicity (9). A recent Cochrane review
by Wakai et al. (10) for topical NSAIDs use in traumatic cor-
neal abrasions did not show clinically relevant pain reduc-
tion, which should be taken into consideration as topical
NSAIDs are expensive. It should be noted that topical anesthetics
should not be used as they slow healing, are toxic to the cor-
neal epithelium, and mask worsening symptoms (11).
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A recent Cochrane Review in 2016 on patching for corneal
abrasions did not show any improvement in pain, symptoms,
or healing when compared with nonpatched individuals (12).
Evidence also shows that there may be an increased risk of
having temporary monocular vision loss. If there is concern
for recurrent eye rubbing or exposure, then patching may be
considered. Based on clinical experience, large corneal abra-
sions or shearing injuries, where the epithelium separates from
the basement membrane, may warrant eye pressure patching
to limit the mechanical irritation and agitation from the un-
derside of the lid. This should be applied only until the athlete
can get to a higher level of care and should never remain lon-
ger than 24 h. Bandage contact lenses can be used in the same
manner but are not part of the usual sideline supplies.
Corneal Foreign Body
Foreign bodies can cause a multitude of problems, includ-
ing corneal abrasions, globe rupture, conjunctivitis, and iritis.
Carefully inspect the eye, including everting the upper and
lower lids. Point-of-care ultrasound may be of benefit for de-
tecting corneal foreign bodies or substances that may have
penetrated the cornea or globe. If copious amounts of dirt are
in the eye, judiciously irrigate with sterile saline, preferably using
a Morgan Lens and topical anesthetic, such as proparacaine and
tetracaine, if available. A Morgan Lens is a device that is placed
over the globe and within the lids to provide a continuous lavage
to the cornea and conjunctiva, while floating on a layer of irriga-
tion solution and never physically touching the cornea. Only a
physician with experience using a Morgan Lens should be utiliz-
ing this device on the sideline. A moistened cotton swab helps to
remove debris as well. If the concern for a retained foreign body
remains after the initial examination, a slit lamp examination
should be performed to more thoroughly evaluate the eye and
guide definitive treatment. After removal of penetrating foreign
bodies, treatment is the same as for a corneal abrasion. If the for-
eign body is metal, a rust ring may result if left in for too long. A
burr drill may be used for attempted removal of the rust ring by a
skilled physician. This is not typically performed on the sideline.
Subconjunctival Hemorrhage
Subconjunctival hemorrhages are one of the most common
ocular problems seen in the ED or physician's office. They are
usually asymptomatic and occur spontaneously; therefore
they can be more visually alarming to patients than they actu-
ally are. Minor eye trauma (i.e., rubbing) or Valsalva maneu-
vers, such as coughing, sneezing, or straining are the usual
causes. They usually spontaneously resolve within 2 to 3 wk.
However, if the hemorrhage involves the entire sclera or hem-
orrhagic chemosis is present, there should be a high index of
suspicion for globe rupture (5), and immediate referral is
required. Hemorrhagic chemosis is a collection of blood
within the substance of the conjunctiva. These also can oc-
cur from a small laceration to the conjunctiva, such as from
a fingernail to the eye. With this finding, visual acuity should
be checked in addition to a thorough examination looking
for any signs or symptoms of a ruptured globe (see below for
further discussion).
Hyphema
Commonly caused by blunt trauma, hyphemas are anterior
chamber hemorrhages caused by microvascular damage to the
Current Sports Medicine Reports 31
iris (13). Examination of the eye will show a layer of gross
blood in the anterior chamber. Figure 2 shows the layering
of blood in the anterior chamber. Spontaneous hyphemas
can also occur in patients with bleeding diathesis and sickle
cell anemia. Since these usually occur in high force injuries,
there should be concern for penetrating trauma, orbital
fracture, abrasion, and/or retinal injury (13). Initial man-
agement includes elevating the head of the bed above 45 de-
grees, discontinuing all NSAIDs or anticoagulants, and bed
rest for 4 d (11). Urgent ophthalmology consult is war-
ranted due to the risk of extensive bleeding that may result
in glaucoma or corneal staining (11). If complications, such
as glaucoma, do occur, pressure-lowering medications (i.e.,
topical beta-blockers, IV mannitol, topical alpha agonists
and oral, IV or topical carbonic anhydrase inhibitors) (5)
should be used under the ophthalmologist’s care.
Orbital Fracture
In a recent study by Harling et al., the epidemiology of eye
injuries in 85,000 patients was analyzed to quantify and char-
acterize sports-related eye injuries. Orbital fractures accounted
for approximately 9.5% of all sports-related ocular trauma
from January 2010 to December 2013. Despite ocular fractures
being a small proportion of ocular injury, they are a significant
injury with a high risk of morbidity and vision loss. Most or-
bital fractures are secondary to blunt trauma from sports equip-
ment, with the highest risk coming from a ball that is smaller
than the orbital rim, such as a racquetball. The inferior orbital
floor, and less commonly the medial wall, is usually fractured
secondary to increased pressure within the orbit causing the
orbital bones to break at their weakest points. Signs and symp-
toms include enophthalmos (posterior displacement of the
globe in relation to the orbit), periorbital ecchymosis, painful
Figure 2: Layering of blood seen in the inferior portion of the
anterior chamber.
32 Volume 19  Number 1  January 2020
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extraocular movements, upward gaze restriction, and diplopia
caused by inferior rectus muscle entrapment. Hypoesthesia in
the distribution of the infraorbital nerve also may be seen. Sen-
sation can be tested just below the lower eyelid to see if this has
occurred. Advise the patient to avoid blowing his/her nose as
this can result in significant subcutaneous emphysema. All
patients with suspected orbital fracture should be evaluated in
the ED for a more thorough evaluation and definitive treat-
ment. Computed tomography with thin cuts is gold standard
for diagnosis.
Due to the force that is usually associated with these injuries,
the clinician should have a high degree of suspicion for other
possible sustained ocular injuries. Approximately one third of
orbital fractures also are associated with other significant ocu-
lar trauma such as abrasions, traumatic iritis, hyphema, lens
dislocation, retinal tear or detachment, and vitreous tear. All
fractures should be referred to an otolaryngologist, oral-
maxillofacial surgeon, or ophthalmologist for more definitive
surgical treatment. Surgery is usually determined on a case-
by-case basis. Immediate repair is warranted for fractures with
nonresolving oculocardiac reflex, pediatric “white-eyed” blow-
out fracture, evoked diplopia with gaze, and early enopthalmos
or hypoglobus (14,15). Others can be monitored until the
swelling decreases before deciding on surgical management.
Retrobulbar Hematoma
Suspicion for a retrobulbar hemorrhage should always be
present in the setting of blunt ocular trauma, in the athlete
with bleeding diathesis, sickle cell anemia, or on anticoagulant
therapy. Anytime there is facial trauma, retrobulbar hemor-
rhage should be included in the differential diagnosis. Signs
and symptoms concerning for retrobulbar hemorrhage include
eye pain, proptosis, decreased visual acuity, increased intraoc-
ular pressure (IOP), and a RAPD. Because of the enclosed
space, there is a risk for compartment syndrome that can lead
to blindness. This is an ophthalmological emergency and needs
immediate consultation for lateral canthotomy and cantholysis
to prevent compartment syndrome. Decompression should oc-
cur within 2 h of decreased visual acuity to prevent permanent
vision loss (14). Increased IOP can progress to irreversible optic
nerve and retinal ischemia, resulting in blindness (5). The ring-
side clinician should strongly consider carrying equipment for
such a procedure to boxing or MMA events because the trans-
port time to the ED alone may result in permanent vision loss.
We suggest ringside physicians be competent in this skill. If
there is an associated orbital floor fracture, the risk of vision
loss drastically decreases from the resulting pressure relief
through the fracture site.
Retinal Injury
Traumatic retinal tears usually occur after blunt force to the
orbit or globe, causing a transient increase in IOP from globe
compression. This may result in traction between the vitreous
and retina leading to separation of the retina from the choroid.
Endurance athletes (secondary to sustained increased IOP)
and persons with myopia (traction injury due to the increased
length of the globe) are at increased risk of retinal tears. Ret-
inal vessel disruption can occur, leading to retinal and/or
vitreous hemorrhages.
Signs and symptoms include flashes of lights, floaters, a cur-
tain in the field of vision, and decreased peripheral and/or central
Eye Injuries in Sport
visual acuity (11,15). Floaters can be described as fine dots, veils,
cobwebs, clouds, or strings (16). If available, point-of-care ultra-
sound is a helpful tool to diagnose a retinal tear and/or a vitreous
hemorrhage. Emergent evaluation by an ophthalmologist is indi-
cated for retinal repair by a retina specialist.
Globe Rupture
Globe rupture can result from various mechanisms includ-
ing blunt trauma from a ball, fist, or penetrating trauma from
a BB gun or fingers as in basketball. Signs and symptoms con-
cerning for globe rupture would be complete circumferential
subconjunctival hemorrhage, hyphema, loss of anterior cham-
ber depth, pain with extraocular movements, decreased visual
acuity, irregular or teardrop-shaped pupil, and afferent pupil-
lary defect (5). Protrusion of intraocular contents also may be
seen. Immediate management would be to place a metal eye
shield or a hard barrier over the eye, such as the bottom of a
paper cup, and seek immediate ophthalmological care. Any
protruding foreign bodies should not be removed in the field.
Avoid placing topical anesthetic or fluorescein in the eye if
globe rupture is suspected as these can be toxic to the retina
and intraocular contents. Care should be made to not apply
any pressure over the orbit when securing the shield. If using
tape, make sure it is adhered to bony prominences such as
the forehead and maxillary prominences. Antiemetics and an-
algesics should be scheduled to prevent Valsalva and further
herniation of ocular contents. Tetanus vaccine also should
be administered.
Consideration must always be made for a condition called
sympathetic ophthalmia. This is a rare condition that results
in bilateral acute anterior uveitis days to years after penetrating
ocular trauma. Inflammation of the injured eye begins first,
followed by the sympathizing eye, secondarily (16,17). Symp-
toms include floaters, photophobia, redness, or blurry vision
(18). Urgent consultation is warranted with initial treatment
consisting of systemic and topical corticosteroids with most re-
quiring long-term steroid-sparing immunosuppressive agents
(19). Older references recommend enucleation or evisceration
of the eye with prior trauma as part of the management, but re-
cent literature generally discourages this practice (19).
Eyelid Lacerations
Laceration of the upper and lower eyelids, as well as the lacri-
mal duct or sac, is not uncommon (4). Injuries may be sustained
following blunt trauma but also may be seen with penetrating in-
juries. A competitor wearing glasses with an impact to the face
puts them at risk for such injuries. The astute clinician should al-
ways be concerned for other injuries, such as globe rupture, cor-
neal injuries or foreign bodies in such situations. The laceration
can be a sign of a penetrating injury which can be easily missed
if the primary focus is on the laceration only.
Many sports medicine physicians do not have the experi-
ence or expertise to manage complicated lacerations. Specialty
referral is needed for lacerations involving the lid margin, the
lacrimal duct or sac, involving the under surface of the lid,
or within 6 mm to 8 mm of the medial canthus. Wounds associ-
ated with ptosis, orbital fat prolapse, the tarsal plate, or levator
palpebrae also should be referred (5). Time to primary closure
is 12 h to 36 h which allows the sports medicine physician opti-
mal time for referral if other vision-threatening emergencies
have been ruled out (20). Many partial thickness lacerations
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involving less than 25% of the lid can be left to heal through
secondary intention along with judicial use of topical antibi-
otic ointment (20). The ointment also helps prevent exposure
keratitis which can lead to corneal ulcers and permanent vi-
sion loss. Large lacerations can be closed with 6-0 or 7-0 chromic
gut absorbable sutures using a buried mattress technique. This
technique simplifies postoperative care and reduces potential
complications (20). We recommend against repairing the lid
margins on the sideline to avoid poor cosmetic outcomes.
UV Exposure
Certain sports such as long-distance running, hiking, snow,
or water sports can predispose the individual to excessive UV
light, increasing the risk of UV-related eye damage. Sunlight is
divided into long wave ultraviolet (UVA) and short wave ul-
traviolet (UVB) wavelengths; UVB is stronger and has more
damaging effects to the eye (21). Excessive exposure to UV
light is implicated in age-related cataracts, pterygium, skin
cancer adjacent to the orbit, photokeratitis, and corneal de-
generative changes. It also may contribute to the development
of macular degeneration (21). Acute ocular burns may occur
secondary to prolonged sun exposure in snow or water sports,
as well as from the reflective nature of the snow and water.
Classic signs are photophobia, intense pain, and a delay in
symptom onset (7). Fluorescein staining will show fine
punctate lesions (11). Treatment includes systemic pain re-
lievers and topical antibiotics (5–8). Referral is indicated if
there is a corneal epithelial defect (5). Preventing acute and
chronic injuries from UV light is as simple as wearing sunglasses
that absorb all forms of UV light. In sports with an increased risk
of damage to sunglasses, shatter-resistant, polycarbonate lenses
should be used.
Prevention and Regulations
The National Collegiate Athletic Association (NCAA) rec-
ommends athletes use protective eye wear in high risk sports
but official rules differ between sports. In 2005, it was man-
dated that protective goggles be worn in women's lacrosse
(4). Starting with the 2013 to 2014 season, the National
Hockey League (NHL) mandated all players with less than
25 games of NHL experience wear a visor affixed to their hel-
met, but players commonly do not wear face or eye protection
if not enforced (22). It is a requirement by the NCAA to wear
full-face cages in collegiate hockey. There is a standard to
manufacturers developing and producing athletic eye protec-
tion that must comply with the American Society for Testing
Materials or the National Operating Committee on Standards
for Athletic Equipment (23). For many years, The American
Academy of Pediatrics and American Academy of Ophthal-
mologist have set forth a joint policy for protective eyewear
in young athletes. The most recent policy, published in 2013,
states that functionally one-eyed athletes should wear protec-
tive eyewear during all sports, regardless of risk. A function-
ally one-eyed athlete has a corrected visual acuity of 20/40
or worse in the affected eye (24).
Return to Play Guidelines
There are no set guidelines or standards for determining
when the athlete is allowed to return to activity. Corneal abra-
sions and foreign body injuries are tolerated relatively well. If
there is no functional or binocular vision loss, then the athlete
Current Sports Medicine Reports 33
Table 2.
Return to Play Recommendations Following Ocular Injury.
Injury Return to Play
Corneal abrasion/foreign body May return to play if no functional or binocular vision loss.
Subconjunctival hemorrhage If minor without symptoms may return to play. If circumferential and concerns for other injuries,
cannot return to play and must be cleared by ophthalmology.
Hyphema Should not return to competition. Must be cleared by ophthalmology before return to play.
Orbital fracture Should not return to play. Must be cleared by ophthalmology and ENT before return to play.
Retrobulbar hematoma Should not return to play. Must be cleared by ophthalmology before return to play.
Retinal injury Should not return to play. Must be cleared by ophthalmology before return to play.
Globe rupture Should not return to play. Must be cleared by ophthalmology before return to play.
iEyelid laceration May return to play if minor injury not requiring sutures and no functional or binocular vision loss.
UV exposure and burns May return to play if no functional or binocular vision loss.

may return to play. In general, the eye should feel comfortable
and have adequate vision (7). Most other injuries require con-
sultation with a specialist who will determine when the athlete
can return. Table 2 gives an overview about return to play rec-
ommendations based on condition.
Conclusions
Overall, ocular injuries are common in sports, and the side-
line physician should be prepared and adept at initial evaluation
and treatment. The physician also should have a full under-
standing of the physical examination of the eyes and surround-
ing structures and be able to recognize the features of an injury
that mandate more urgent ophthalmological evaluation. It is
prudent that all athletes participating in very high-risk sports,
and even special situations in high-risk sports, wear protective
eye equipment because ocular injuries can have devastating
long-term sequalae.
Neither of the authors, J.P.T. nor J.L.T., have any financial
relationships to disclose.
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34 Volume 19  Number 1  January 2020 Eye Injuries in Sport

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