¦^.^

Eye injuries in Canadian hockey T.J. Pashby, md, crcs[c]; R.C. Pashby, md; L.D.J. Chisholm, md, frcs[c]; J.S. Crawford, md, cm,

Summary: Increasing public concern led the Canadian Ophthalmological Society, in January 1974, to form a committee to study the incidence, types and causes of hockey eye injuries and

to devise means of such injuries. Retrospective and current studies were undertaken, and face protectors were tested. In both pilot studies, sticks were the commonest cause and the highest number of eye injuries was in players 11-15 years old. An average of 15% of all injured eyes were rendered legally blind. Cooperation with hockey authorities has resulted in changed rules and their sticter enforcement, and formulation of standards for face protection approved by the Canadian Standards Association. In this interim report the committee recommends that all amateur hockey players wear eye protectors and

reducing

urges ophthalmologists to in efforts to improve the

protective equipment.

participate

design of

Hockey, Canada's national sport, is one of the world's fastest games. Eye in¬ juries are less common than other types of injury in hockey, but their results can be disastrous. As stated by Hayes:1 "Injury in sport has often been referred to as an occupational ha¬ zard Many of the risks taken are unnecessary and could be reduced with¬ out changing the nature of the acti¬ ..

.

vity." Analysis of sports injuries at The Hospital for Sick Children, Toronto, showed that in 1967 most occurred during ball games; by 1973, however, more injuries resulted from hockey than from baseball, football and soccer combined. In 1973, approximately 500 hockey injuries were treated at the hospital. Of these, 33 required adFrom department of ophthalmology, The Hospital for Sick Children, Toronto Presented in part at the 38th annual meeting, Canadian Ophthalmological Society, Ottawa, June 1975

17, Reprint requests: Dr. T.J. Pashby, 20 Wynford Drive, Don Mills. ON M3C 1J4

mission; 200

were caused by sticks and almost 100 by pucks; more than 50 almost all due to sticks involved an eye. Most of the patients were 8 to 15 years old. In 1974, 479 hockey in¬ juries, 46 involving an eye, were treated at this hospital; 214 were caused by sticks. Marchant, Roy and Warshanski's2 study of British Columbia amateur hoc¬ key 1963-72 reported eye involvement in almost 1% of all hockey injuries, whereas Toogood and Love3 in 1966 recorded eye injuries in 9%. In 1974, reports of hockey injuries in Ottawa4 and throughout Ontario5 stated that two-thirds were due to sticks, with 5% eye involvement in the former and 2% in the latter. A study of Canadian and

.

.

doms

each eye injury treated between 1972 and July 1, 1973. Infor¬ mation requested included the player's age and the date and type of injury; whether the injury had occurred dur¬ on

July 1,

ing organized

or

unorganized hockey;

whether it was caused by a stick, puck, or other means; whether hospitaliza¬ tion was required and for how long; and visual acuity before and after in¬ jury. The results of this study were reported at the COS 1974 annual

meeting. In February 1974 we became guest members of the Canadian Standards Association (CSA) subcommittee on protective equipment for hockey; this includes CSA members, representatives of the Canadian Dental Association, American intercollegiate hockey during sporting-equipment manufacturers, Ca¬ the 1970-71 season6 reported 85% of nadian Athletic Trainer Association, injuries were accidental and 15% drew Canadian Amateur Hockey Association penalties. It cited similar findings in (CAHA), Canadian General Electric the Greater Edmonton area.7 Company and the Ontario Medical As¬ At the suggestion of Dr. J.P. Harsh- sociation. The object of this subcom¬ man, past-president, the Canadian Oph¬ mittee is to produce and standardize thalmological Society formed a com¬ face protectors for forwards and demittee in January 1974 to investigate fencemen. As face protectors became available, eye injuries in hockey. The impetus came from COS members' letters, they were obtained through the CSA stories in the media and suggestions by subcommittee or directly from manu¬ concerned parents that something be facturers for testing. We examined the done to solve this problem as a public- products in the eye clinic at The Hos¬ health measure. The objectives were to pital for Sick Children, using the Prostudy the number, types and causes jectochart and the Goldman perimeter of hockey eye injuries and duration of to determine their effect on central and hospital stay. The data were to be anal- peripheral vision. The protectors were yzed to devise and recommend safety further tested by one of us (R.C.P.) regulations. A preliminary report by under actual game conditions. In July 1974, on the suggestion of the committee was presented in 1974.8 Whether hockey eye injuries can be the COS Council that a current study reduced by changing and enforcing the be undertaken, we mailed a further rules of the game, by providing pro¬ questionnaire to the members. In addi¬ tection with a mask, or by a combina¬ tion, forms were sent to every Cana¬ tion of the two are the questions we dian medical school with a postgradu¬ ate ophthalmology program; we asked hope these studies will help resolve. the chairmen of the departments of ophthalmology to acquaint ophthal¬ Methods mological residents with our study The problem was approached in two and enlist their cooperation in comways: a questionnaire circulated to pleting questionnaires. Simultaneously, the 525 COS members and tests of enquiries were directed to professional face protectors. and federal amateur hockey associa¬ The questionnaire asked for a report tions in Canada and the USA conCMA JOURNAL/OCTOBER 4, 1975/VOL. 113 663

FIG. 1.Examples of hockey face-protectors and helmets now available.

mmaaat

Plastic-covered wire mesh. A without visor and B with visor (clear zero power

shield, Lexan).

'mmsmmm

liliiisIS ¦IBIit

cerning visual testing and present and contemplated visual standards for players. Retrospective study (1972-73) Seventy-five of the 525 COS mem¬ bers canvassed sent in reports, covering injuries to 287 players (Table I); only one eye had been injured in each case. Injuries were most numerous in the 11-15-year age group (Table II). Only 139 respondents stated whether the eye injury had occurred during organized hockey (97 cases) or unorganized hoc¬ key (42). The majority of eye injuries had been caused by sticks (Table III). Table IV reveals the most striking finding of this study; 13.7% of those for whom visual acuity after injury was reported were now legally blind in the injured eye. (Subsequent refer¬ ences in this article to legal blindness refer to one eye only in each player.) Hospitalization for eye injuries totalled 996 days. Current study (1974-75) Completed questionnaires are still coming in; by June 19 this year, 114 doctors, including some ophthalmologi-

Helmet with visor attached: C does not protect the lower part of the face; D and E incorporate jaw protection. Perimetry studies showed minimal restriction of fields of vision with D and no restriction with C and E.

cal residents and nonophthalmologists, had reported a total of 253 injured players (Table I). As in the 1972-73 study, no player sustained injury to more than one eye. Reports included 19 from British Columbia, 16 from Alberta, 18 from Saskatchewan, 2 from Manitoba, 158 from Ontario, 12 from Quebec, 2 from New Brunswick, 16 from Nova Scotia, 3 from Prince Ed¬ ward Island and 7 from Newfoundland. Compared with the findings in the 1972-73 study (Table II), eye injuries in the lowest age group were almost halved and in the highest age group were almost doubled; the percentages in the other age groups were virtually unchanged and again the highest in¬ cidence was in the 11-15-year age group. Injuries reported in organized hockey totalled 162, and unorganized hockey accounted for 40. The percen¬ tage of injuries caused by sticks de¬ creased and of those caused by pucks increased (Table III). The incidence of legal blindness (Table IV) was higher than in the 1972-73 study. Incidence of players rendered legally blind showed a progressive increase with age (Table II); Table III indicates that sticks were the primary cause of legal blindness.

664 CMA JOURNAL/OCTOBER 4, 1975/VOL. 113

Hospitalization for eye injuries totalled days. Standards, regulations 899

The CSA subcommittee for protec¬ tive equipment for hockey has been drafting new standards for this season. Protectors are recommended for eyes, teeth and face. Eye protectors have been subdivided into clear shields, meshwork (wire) shields and a com¬ bination of both. The subcommittee has set standards for size, position, visual resolution, prismatic deviation, haze, luminous transmittance and peri¬ pheral vision. In the fail of 1974 numerous face protectors became available. One of us

(R.C.P.) experienced no visual prob¬ wearing a clear zero power shield (Lexan) attached to a CSAapproved helmet (Fig. 1C) while playlems while

ing in the University of Toronto interfacuity hockey league during the 197475 season. As the story of hockey eye injuries appeared in the media, parents became aware of the dangers and many young hockey players began wearing the Lexan visors. By Novem¬ ber 1974 dealers had trouble meeting

the demand.

Rules regarding face protectors were changed at the CAHA's annual meet¬ ing and were enforced during the 1974-75 hockey season. Rule 25 (b),9 that face guards could be worn only in the case of face injury certified by a doctor was rescinded. Rule 24 (d),9 which states that face protectors may be worn providing they create no potential danger to opponents, has been added. The CAHA further recom¬ mended use of CSA-approved guards

when available. The survey revealed that some pro¬ fessional and amateur hockey associa¬ tions prohibit the participation of play¬ ers with very poor vision in one eye. For example, the national, central and western leagues bar players with only one seeing eye or with one eye in which central vision is 3/60 or less. The World Hockey and US Amateur Hoc¬ key associations set no visual stand¬ ards. The CAHA10 does not approve of players or officials with only one

seeing eye. However, one wonders, no ocular examination is re¬ quired, how many boys with good vi¬ sion in only one eye are playing or¬ ganized hockey. The response from the Canadian Intercollegiate Athlete Union was gratifying (22 Canadian universities re¬ plied); however, only Dalhousie and the University of New Brunswick sub¬ ject their varsity players to an eye ex¬ amination and none of those replying have visual standards, although all would welcome them. Most expressed great interest in our study and stated that they intend to introduce mandatory eye examinations for players. when

Discussion

Hockey is a hard-hitting sport. The average young hockey player fires a slap shot at 22 m/s, and this strikes with an energy of 38 J (28 foot pounds). The present Lexan face pro¬ tectors, when struck by a puck with an energy of 40 J, flex approximately 6 cm but do not fracture. The significance of the number and severity of eye injuries in our study looms larger when one considers that 2 to 4% of the general population is amblyopic;11 according to this estimate, 12 000 to 24 000 of the 600 000 players registered with the CAHA last year12 are on

unilaterally amblyopic. Depending

the degree of amblyopia, an injury to the normal eye could be tragic. These figures underline the recom¬ mendation (see below) that wearing an eye protector should be mandatory for any player with an amblyopic eye. In fact, some minor hockey leagues in Massachusetts and Illinois are making face protectors mandatory for all play¬ ers

The otitis drop designed to penetrate wox.

coly mycin otic

The only Botic with thonzonium bromide to help the active ingredients get right to the site of infection even through cerumen and debris. .

DESTROYS COMMON PATHO¬ GENS Provides the broad-spectrum bactericidal actions of colistin

sulphate and neomycin sulphate. REDUCES SWELLING, RELIEVES ITCHING.Also contains theproven benefits of hydrocortisone acetate.

Composition: Each ml. contains Colistin base activity 3.0 mg. (as the sulphate); neomycin base activity 3.3 mg. (as the sul¬

phate); hydrocortisone acetate 10.0 mg.;

with perforated eardrum or in long stand¬ ing otitis media because of the possibility of ototoxicity caused by neomycin. Contraindications: COLY-MYCIN OTIC- is contraindicated if there is a history of sen¬ sitivity to any of its components, or in tubercular, fungal, and most viral lesions, especially herpes simplex, vaccinia and varicella. Supplied: 5 ml. bottles. Full information is avaliable on request.

thonzonium bromide 0.5 mg.

Dosage: Instil 4

drops b.i.d.

Precautions: If sensitivity or irritation oc¬ curs, medication should be discontinued promptly. Overgrowth of resistant organ¬ isms is possible. Use with care in cases

WARNER/CHILCOTT Laboratories Co. Limited Toronto, Canada

(personal communications). indicated, our study, like others,

As

CMA JOURNAL/OCTOBER 4, 1975/VOL. 113 665

Table I -Type of Injury in hockey players with eye damage 1974-75 study (253 players) 1972-73 study (287 players) No. %of total Injuries No. %of total Injuries 31.1 180 43.3 207 Soft-tissue damage 2.8 15 2.7 13 Qrbltul fracture 8.5 49 5.4 26 :Corneal abrasion 2.2 13 1.9 9 Contest laceration 13.0 75 5.2 25 iris damage 18.3 11)6 ltQ 91 Ilyphema U 17 33 11 Traumatic glaucoma 11 Lens damage 4.5 26 21 Vitreous hemorrhage 5.4 31 1.9 1) Secular damage 2.8 16 *.5 12 0ioroldal damage 3.3 19 4.4 21 Retinal damage 0.3 2 .2 0.4 Optic-nerve damage 0.7 4 1.3 +6 Rupturedgiobe vs 471 Total InjurIes Percentage totals not 100 because of rounding

with eye

it Table Il-Ag. legally determined NIPi

Age Under 11 years 11-15 years 16-20years Over 20 years Not stated Total

107273 stzKty No. %otthosstated 40 233 32.0 54 263 45 17.8 N) 118 26?

and those with an eye

1574-75 study Re. %oftheseststud 2.3 12.2 33.2 75 24.5 56 69 30.1 24 253

3)74-75 study of players with a legally blind eye No. %oftbosestated 15.2 5 18.2 6 27.3 9 39.3 13 4 37

Percentage totals not 100 because of rounding

Table Ill-Cause of Injury lit legally determined blind Cause StIck Puck. Other ffotstated total

otomotile slowsthegutfast COMPOSITION: Each tablet and each 5 ml of liquid contain 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine aulfate. INDICATIONS: Acute and chronic diarrhea; whether functional, or aaaociated with conditiona auch aa gaatroenteritia, irritable bowel ayndrome, regional enteritia, ulcerative colitia, infectioua diarrhea and diarrhea following drug therapy. Alao may provide effective inteatinal control in patienta following gaatric aurgery, ileoatomy or coloatomy. CONTRAINDICATIONS: Jaundiced patienta or patienta hyperaenaitive to the componenta of Lomotil. WARNINGS: Keqp out of reach of children aince accidental overdoae may cauae aevere reapiratory depreaaion. The uae of LOMOTIL in children leaa than two yeara of age a not generally recommended. PRECAUTIONS: Uae with extreme caution in patienta with cirrhoaia, advanced hepatic diaeaae, or abnormal liver function teata. Diphenoxylate HCL may potentiate the action of barbituratea, tranquilizera, and alcohol. Concurrent uae of LOMOTIL with MAO inhibitora may in theory precipitate hypertenaive criaia. Aaaeaa riaka/benefita priorto uae during pregnancy, lactation or in women of childbearing age. Diphenoxylate HCL and atropine aulfate are excreted in breaat milk. Adminiater with caution to patienta who are receiving addicting druga or who areaddiction prone.Addiction to diphenoxylate HCL ia theoretically poaaible at high doaage; however, no addicting liability haa been noted in patienta. Recommended doaage ahould not be exceeded. There ahould be atrict obaervance of the contraindicationa and precautiona relative to the uae of atropine. In children, aigna of atropiniam may occur even with recommended doaea. ADVERSE REACTIONS: Are relatively uncommon; moat frequently, nauaea; leaa frequently, drowaineaa, dizzineaa, vomiting, pruritua, akin eruption, reatleaaneaa, inaomnia, bloating and crampa have been reported; and rare incidencea of numbneas of the extremitiea, headache, blurring of viaion, awelling of guma, euphoria, depreaaion and general malaiae have occurred. Many of theae might be aymptoma of diaeaae being treated; accurate differentiation a often impoaaible.

r# with sy. damage and In those with an eye

19724$ study No. %of those stated 7L$ 176 19.4 46 15 6.3 50 287

found the stick the cause of most injuries. While CAHA rule changes may reduce the incidence of stick injury, we should also attack the problem in its earliest stages. Coaches and managers of minor leaguers should have proper attitudes; they should insist that their charges keep their sticks down at all times and bench offenders. Any coach who encourages a player to use a stick for intimidation must be removed from hockey. As Gordon Juckes, CAHA executive, pointed out: "Rules are fine but attitude and education of coaches and referees are more important because kids ape their adult leaders. You can do more to end violence by changing attitudes than by legislating. Legislation is only good if it is enforceable." Perhaps, as ex-hockey player Bert Foote suggested in letters to us and various professional associations, the end of the hockey stick should be en-

1574.75 study No. %of those stated 137 62.3 68 30.9 6.8 15 33 253

1974-75 study of players with a legally blind eye No. %of those stated 58.9 20 38.2 13 2.9 1 3 37

larged, blunted, and covered with plastic or latex. Eye injuries due to pucks could also be eliminated if use of eye protectors were enforced. The 1975-76 CAHA rule changes should greatly decrease the incidence of stick-induced injuries by imposing minor, major and match penalties for touching a puck with the stick above shoulder height, contacting without injury with the stick above shoulder height and by injuring with the stick above shoulder level (rule 53). Match penalties will be assessed against players who grab another's face-protector. Hockey experts at a panel discussion of eye injuries in hockey at the 38th COS annual meeting stated that aggressive hockey is different from dirty hockey. At this meeting the CAHA stated its appreciation of the work done to evaluate the need for facial protection and develop adequate equipcontinued on page 674

666 CMA JOURNAL/OCTOBER 4, 1975/VOL. 113

DOSAGE AND ADMINISTRATION: ADULTS: the uaual initial doae a 5 mg (2 LOMOTIL tableta) 3 or 4 timea daily. (20 mg/ 24 houra in divided doaea ia the maximum recommended doaage.) CHILDREN: an adequate pediatric daily doae of LOMOTIL (to be given in divided doaea 3 or 4 timea daily) determined by the childa age ia aa followa: 2 to 5 yeara 6.0 mg (12.5 ml). S to 8 yeara 8.0 mg (15.0 ml). 8 to 12 yeara 10.0 mg (20.0 ml). NOTE: THIS ISTOTAL DAILY MEDICATIONTO BE GIVEN IN 3 OR 4 DIVIDED DOSES. Wolume of LOMOTIL Liquid containing approximate total daily doaage of diphenoxylate HCL. 5 ml ia equal to approximately 1 teaapoonful. AVAILABILITY: TABLETS: 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine aulphate in bottlea of 100, 500. LIQUID: 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine aulphate/5 ml in 60 ml (2 oz.) bottlea.

Product monograph available on request

Searle Pharmaceuticals Oakville Onta

which he controls. Physicians may also use that corporation to provide services to other doctors, thus allowing the corporation to earn income. Another advantage in this arrangement is that the corporation not only charges the physician the costs of providing services to him, but adds a markup of, say, 10 to 15%. In effect, if a physician accounted for $20 000 worth of expenses, the service corporation could legitimately ask him to pay up to $22 000 - the extra $2000 going into the safe harbour of corporate profits, taxable at the lower rate. Such a corporation could also use spouses as shareholders, who might receive dividends. This would not be allowed if the company was a "professional corporation" in which the shareholders would have to be of that profession. Such a service corporation must, however, not be perceived as simply a means of avoiding taxes. The Department of National Revenue does not look kindly upon the tax dodge. A recent ruling (April 1975) on a husband-and-wife working relationship in a medical practice may be important to the solo practitioner. In seeking the advance ruling, the individuals in the case explained that a wife, who had been managing her

doctor-husband's office for several years, was considering forming a company for the purpose of selling her clerical and managerial services to her husband, and making them available to others. Mrs. X would be a controlling shareholder and an employee of the company. Her husband would be a customer of that company. How would the tax department look upon Dr. X's making tax-deductible payments to his wife's company for services she provides? Wifely duties The ruling was favourable. The rationale stated that since Mrs. X was capable and intended to carry out the required duties as an employee of the company, since the proposed arrangement was more than a device to avoid paying taxes and in that the wife would thus be enabled to extend her expertise to other offices, there would be no objection to Dr. X's claiming the payments he makes to his wife's company as a legitimate, deductible expense. The ruling is important in that, for the first time in a specific set of circumstances, the Department of National Revenue has publicly conceded that a facilities company can be used even in a solo practice - a position which was implicitly recognized in the

earlier-released (November 1974) interpretation bulletin IT-189. In the past the tax department seemed rarely to question the setting up of a management corporation for two or more physicians. This current ruling has apparently officially extended this policy to the solo practitioner. What concerns Freamo about this ruling is that some doctors may try to use the device in the case of a wife who never shows up at the office. "That is doomed to failure," says Freamo. Whatever the pros and cons of incorporation, this method would allow yet another option from the partnership or proprietorship form of business organization. It is clear that the greatest applicability of incorporation would be among physicians earning high incomes. It is not so clear how applicable it would be for moderate earners. Assessing incorporation is complex, but if there is one simple rule of thumb that may be applied, it may be this: is the individual physician able, or willing, to trade income today for a bigger, tax-deferred nest egg tomorrow? (Assuming, that is, that tax laws and rules remain relatively unchanged.) If the answer is yes, then just possibly incorporation might be worth a look. If the answer is no - forget it. U

HOCKEY EYE INJURIES continued from page 666 ment. The parents' role in choosing proper equipment, insisting on properly trained coaches and knowing the league structure in which their boys play was stressed. The medical profession should aid in the development, standardization and use of protective equipment and should provide coverage for amateur players as a public health measure. We recommend:

* That preseason examination for visual defects be mandatory. * That players with extraocular injury undergo intraocular examination. * That eye-protectors be mandatory for any player with an amblyopic eye. * That eye-protectors be recommended for all hockey players. * That only CSA-approved eyeprotectors be sold. * That the CSA set standards for goal-keepers' masks. * That rules to keep the hockey stick below face level be adopted and

enforced and that coaches punish any players breaking these rules. We are grateful to Miss Helen Haffey, director of medical records at The Hospital for Sick Children, Toronto, who provided the data of sports injuries treated 1967-74.

Table tV-Visual acuity after Injury In players with eye damage

zwzqs study (287 players) Visual acuity p0/40 en /200 . pe.Ception jgah blind stated legally blInd

No. 9 7 6 2 10 8 20 146 13.7

1t74*75 st(25.players) Vlual acuity 20/40 20/60 20/100 Legal blindness 26/200 20/400 lRtlOg f.flgars Rend mvemehts tight perception No light Perception Total lega.j. blInd T.t.l sta of those stat.d legally blind kittated Total

674 CMA JOURNAL/OCTOBER 4, 1975/VOL. 113

No. in 47 10 9 6 3 7 5 8 7 37 225 25S

References 1. HAYES D: Risk factors in sport. Human Factors 16: 454, 1974 2. MARCHANT L, Roy E, WARsHAwsKI JR: Sport

Safety Research, 1973-74. UBC school of phys educ for Fitness Amateur Sport Branch, Dept Nati Health & Welfare, 1974 3. TOooooi T, LOVE WB: Hockey injury survey. Can Assoc Health Phys Educ Rec I 32: 20, Dec 1965, Jan 1966 4. Corror.t CE, NEWMAN JA: Facial Injuries In Hockey: Summary. U of Ottawa, Jan 1974 (unpublished) 5. HAs.rs.us DE, CAMERON J, PARKER SM, et

al: A study of hockey injuries in Ontario. Ont Med Rev 41: 686, 1974 6. HAYas D: The nature, incidence, location and causes of injury in intercollegiate ice hockey. U of Waterloo, 1972 (unpublished) 7 Raavas JSH: A study of the incidence, nature and cause of hock. injuries in the greater Edmonton metropolitan area. U of Alberta, 1970 (master's thesis) 8. CHIsHoLM L, CRAWFORD J, PASHBY R, et a!:

Eye injuries in hockey. Can Med Assoc I 111: 501, 1974

9. CANADIAN

AMATEUR

Hocxav

AssOcIATION:

Hockey Rules 1973-74, Toronto, p 28 10. Idesi: p 70

11. WYBAR K: Ocular motility and strabismus in

Systems of Ophthalmology, vol 9, edited' by DUKE-ELDER 5, London, Kiinpton, 1973, p 294

12. CANADIAN

AMATEUR

Hocaav

AssocIATION:

Registration report, 1974-75 season. Vanier City, CAHA, 1975