Eye injuries in squash: a preventable disease rAICHAEL EASTERBROOK, FRCS[C]* As more Canadians are taking up squash the incidence of eye injuries is increasing dramatically. Over 2½ years, 23 cases from one urban practice were examined. Almost half of the group required inhospital treatment. Five patients sustained a permanent decrease in vision; these cases involved three corneal scars, one cataract and one macular cyst. Patients wearing glasses or hard contact lenses appear to be more susceptible to serious eye injury. Experience does not appear to reduce the likelihood of eye injuries; the patients in this study had played squash for 5.6 years on the average. Consequently the medical profession must take the lead by encouraging squash players to use protective equipment now available to reduce the incidence of these injuries that pose so much personal hazard.

Table I-Summary of details of 23 patients Time played Injuring Wearing (years) instrument spectacles Injury 3.5 Racquet No Lid laceration, corneal abrasion, macular edema 32 Racquet No Iritis, corneal abrasion, 2 51 Engineer corneal scar 2 Yellow ball No 3 32 Manager Subconjuntival retinal hemorrhage 11 Hard ball No 4 43 Stockbroker Iritis, cataract, angle

Case Age Occupation 1 32 Manager

rneA3Iian

8

18

Student

First game

Yellow ball No

Although the game of squash is 125

years old, only in the last 3 or 4 years have we seen such a tremendous interest in it in Canada. Associated with increased participation in this very active sport has been an increase in eye injuries. This paper reviews cases from one downtown practice in an attempt to profile those players at most risk. As well, I will review eye protection at present available and suggest that many of these eye injuries are preventable.

9 22 Student 10 38 Salesman 11 25 Student

2

12 32 Merchant

1.5

Kard ball

No

13 28 Reporter

6.5

Racquet

No

14 31 Salesman 15 30 Stockbroker 16 40 Physician

.5 .25

2 10 10

Hard ball No Yellow ball No Hard ball No

Yellow ball No Hard ball No Hardball No

Methods

Between July 1, 1974 and Dec. 31, 1976 all squash eye injuries seen by myself either in my own office or two downtown Toronto hospitals were reviewed. I was particularly interested in how long each patient had played squash, as well as the cause and extent of the eye injury. Whether patients . teacher, University of Toronto; staff ophthalmologist, Toronto General and wellesley hospitals. Consultant ophthalmologist, Princess Margaret Hospital. Presented at the annual meeting of the Canadian Ophthalmological Society, CaJgary, June 1977. Reprint requests to: Dr. M. Easterbrook, Suite 303, 1849 Yonge St., Toronto M45 7Y2

Corneal abrasion, hyphe-

ma, macular edema Iritis Hyphema Hyphema, angle recession, cataract Hyphema, angle recession, retinal hemorrhage Lid, subconjunctival hemorrhage Hyphema Hyphema Subconjunctival hemorrhage

Final vision 20/20 20/25 20/20 20/30

20/20

20/20 20/20 20/20 20/20 20/20 20/20 20/20 20/20

Subconjunctival

21 32 Merchant 22 35 Management consultant 23 28 Teacher

3 3

Racquet Racquet .2

No No

Yellow ball No

Note: Cases 5, 6,7, 17, 19 wore glasses or contact lenses

298 CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118

hemorrhage Lid laceration Lid laceration

20/20 20/20

Hyphema

20/20

wearing glasses were more susceptible to eye injury was a question I hoped to answer. Results Over this 2½ year period I examined

23 patients, 11 of whom were treated as hospital inpatients. Of the 23, 12 were businessmen, 7 were professionals and 4 were students. There were 22 men and one woman. These occupation and sex ratios probably reflect the players seen in downtown Toronto.

FIG.

1-White

arrows

point

to

brow

Causes of the ocular injuries sustained were fairly evenly divided between the raquet, hardball and softball (9, 8 and 6 respectively). These 23 patients ranged in age from 18 to 51 with an average of 32. The time that each player had been involved in the game varied from one game to 32 years with a mean of 5.6 years. Details of all players are summarized in Table I. Table II summarizes their ocular injuries. It is to be expected that injuries

laceration

caused by

would be more severe in cases where spectacles are shattered. Only 2 of the 18 patients not wearing spectacles sustained permanent decrease in vision (cases 2,4). Of the 5 patients wearing glasses or contact lenses, 3 were left with vision less than 20/20 (cases 5,7,19). The details in these 5 cases will be described, as it appears that injuries suffered by those who wear glasses are more likely to lead to permanent ocular damage. * A 34-year-old general practitioner (case 17) who had played squash for

metal

FIG. 2.-One of many pieces of hardened spectacle glass removed from conjunctiva of patient in case 6.

glasses frame, case 17. ih

FIG. 3-Lid laceration from broken hardened spectacle glass lens, direct hit with squash racquet, case 7.

FIG. 4-.Corneal laceration with iris prolapse, case 7.

- Lid FIG. 5 and subconJnnctival hemorrhage, corneal scar and iritis, patient had played 32 years (case 2).

FIG. 6-Lid hemorrhage and laceration, case 1, who also sustained a corneal abrasion and macular edema. CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118 303

4 years was crowding the "T" and ran into a backhand racquet. He developed a full-thickness skin laceration over the bridge of his nose from his metal frames (Fig. 1). * A 42-year-old lawyer (case 5) who had played for 1 year received a direct blow from a forehand hardball. His hardened lens came out of his frame but did not shatter. He subsequently developed a hyphema, lid laceration, angle recession and a persistent macular cyst. His final vision was 20/25. * A 32-year-old lawyer who had played for 7 years was hit directly by a racquet (case 6). His hardened lenses shattered, with subsequent corneal and lid abrasions; final vision was 20/20. Fig. 2 shows one of the many pieces of spectacle glass I removed from his lower conjunctiva. * A 28-year-old lawyer who had played for 6½ years was struck by a yellow dot ball directly (case 19). His hard contact lens was lost. He developed a hyphema, vitreous hemorrhage and a corneal scar. Final vision was 20/100 unaided, or with a contact lens 20/25. * A 25-year-old law student who had played for 10 years was struck directly by a racquet (case 7). His

hardened lens shattered with subsequent corneal laceration, iris prolapse and corneal scar; final vision was 20/30 with a hard contact lens (Figs. 3,4). Discussion

Although squash eye injuries have been reported from Great Britain and Australia,1"'3'4 only recently have we seen eye injuries in large numbers in Canada. Squash is becoming very popular with new courts opening every week; at present there are 75 000 players and 750 courts across Canada, according to Squash Ontario. Although the ball is small and light, it moves at a tremendous speed.5 The wood racquet itself may become a dangerous weapon (Table III). It is not surprising that a small missile struck by a highvelocity wood racquet in a confined space causes eye injuries to players who are not wearing proper ocular protection. In this series the injuries varied from the rather typical lid and subconjunctival hemorrhage (Fig. 5) to lid lacerations, minor (Fig. 6) and severe (Fig. 3); this patient sustained a corneal laceration with prolapse of iris as well). Only 2 of the 18 patients not wear-

FIG. 7-Nylon frame with rubber bridge, recommended for

ing spectacles sustained any permanent decrease in vision. However 3 of the 5 patients wearing glasses or contacts sustained some permanent decrease in central vision. The impression, supported by a recent study from Austra-

FIG. 8-Metal frame with rubber covering.

spectacle wearers.

FIG. 9-Solari eye guard, plastic, may be padded, posterior view. 304 CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118

FIG. lO-Protec eye guard plastic; padding provided as In Fig. 9.

ha,' is that injuries in patients with glasses tend to be more serious: in the Australian series one case was associated with a choroidal tear, two patients had penetrating. injuries and one patient sustained a penetrating injury with a traumatic cataract. Several of these patients with glasses raised the question of their hardenedglass warranty. The warranty says specifically that in cases of any injury to the eyeball $5000 will be paid only if such injury results in permanent total loss of vision - that is, no light perception. As well however, the warranty will cover up to $5000 for any medical or surgical expenses in excess of the expenses paid by provincial or private health plans in cases of any such permanent and total injury to the eye. What type of protection is available? For those who have to wear spectacles a nylon sports frame with a rubber bridge (Fig. 7) gives good protection and would prevent a brow laceration as seen in case 17 (Fig. I). Because the frame will collapse on impact, the chance of a temple snapping into the eye is certainly reduced. As this study demonstrated, hardened-glass lenses

may shatter; therefore the player should insist that the optician insert 3 mm centre thickness plastic in these nylon frames.6 Most opticians retail these frames and plastic lenses for less than $50. For those who do not wear glasses there are two basic types of protection on the market, metal and plastic. The metal frame (Fig. 8) certainly gives adequate protection but it is somewhat uncomfortable and many players have rejected it for plastic frames. One type of plastic protection, the Solari eye guard, is shown in Fig. 9. The inside can be padded, and it certainly is comfortable. Another protection available is the Protec, which also can be padded (Fig. 10). It is light and appears to be the eye guard that is most comfortable and acceptable to squash players I have spoken to. These metal and plastic squash guards cost $13 to $15 at optical and sports stores in Canada. In summary, over 2½ years I saw 23 cases of significant eye injury, 11 of which required hospitalization. Of these cases, 5 had some decrease in vision; 3 of the 5 players wearing glasses or hard contact lenses sustained

an injury with permanent reduction in vision. Only 2 of the 17 nonspectacle wearers lost any permanent vision. There appears at present to be adequate eye protection; it is the responsibility of the medical profession to encourage players to wear this protection at all times; as well, we must encourage clubs to provide such protection outside each court. Only in this way will we reduce the incidence of these significant eye injuries. I wish to acknowledge with thanks the generous help of the medical photography department of The Wellesley Hospital and the assistance of Anne Marie Malone in the preparation of this paper. References 1. NORTH IM: Ocular hazards of squash. Med I Australia 1: 165, 1973

2. INGRAM DV, LEWKONIA I: Ocular hazards of playing squash racquets. BrIt .7 Ophihal 57: 434, 1973 3. BRONSTEIN JL: Eye injuries in sport. Practitioner 215: 208, 1975

4. MOORE MC, woRTHLEY DA: Ocular injury

in squash players. Australian .7 Ophth 5: 46, 1977 5. SCRIVENER AR: Impact-resistant lenses. Brit I

Physiol Optics 28: 26, 1973

6. CHRIsTIANsoN MD, PARKER JA: Material and thickness: important parameters in spectacle lens impact resistance. Presented at the annual meeting of the Canadian Ophthalmological Society, Calgary, June 1977

Primary management of ocular trauma J. DONALD MORIN, FRCS[C]

Ocular trauma is common, and unfortunately in recent years the incidence of eye injuries has not substantially decreased. This is despite preventive measures such as public education, industrial safety programs and eye protection devices. In one year alone 30 000 eye claims were submitted to the Ontario Workmen's Compensation Board. In 1975, 12 children lost eyes in hockey. Fortunately only a few eyes are completely lost; nevertheless ocular trauma of varying extent is a frequent emergency problem. Early correct diagnosis and treatment will avoid making the eye injury worse and help relieve patient and doctor from the terrifying expectation of blindness. In the management of a patient with ocular trauma, the first step is to record the visual acuity. The visual acuity should be determined with a Snellen chart, if possible, but if the patient canReprint requests to: Dr. J.D. Morin, St. Michael's Hospital, 30 Bond St., Toronto M5B 1W8

not read the Snellen chart the physician should determine at what distance the patient is able to count fingers, see hand movements or determine accurate light projection. Vision should be measured with spectacle correction if available, but if the patient's spectacles are broken the doctor should record the vision as the patient looks through a pinhole held before his eye while he reads the Snellen chart. Immediately after an eye injury, there is a great tendency to squeeze the eye shut and blink vigorously. This can be overc6me by a drop or two of local anesthetic, such as tetracaine or cocaine. Once the patient has relaxed and opened his lids, it is possible to measure the visual acuity and inspect the anterior ocular structure. If the lids still will not open, one may need a lid retractor to hold them apart. This can be improvised by bending paper clips over a snap. Gently retract the lids to see whether the cornea is clear and intact; if not, patch gently and send the patient directly to hospital for an ophthalmologist's care. Once the cornea has been found satisfactory, check the red reflex with an ophthal-

moscope to determine whether there is a cataract, foreign body or intraocular hemorrhage. If a foreign body has struck the eye, details of what the foreign body is, when it struck the eye and what has occurred since the injury should be ascertained. It is important to locate the foreign body or the site at which the foreign body struck the eye. It is easy to see a foreign body on the limbus, but on the cornea this is more difficult and it may be seen only with oblique light or with fluorescein staining. If beneath a lid, it may be seen only after the lid is flipped over. Once located, the corneal foreign body should be irrigated free or lifted free with a swab. If this fails, use a #25 disposable needle, which is the most readily available corneal spud. While removing the corneal foreign body, as much rust ring as possible should be removed. If this is difficult, rather than persist, patch the eye and remove the remainder the next day after the inflammatory process has loosened the residual rust ring. As long as there is rust present on the cornea, a foreign body sensation will persist, a larger

CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118 305

Eye injuries in squash: a preventable disease.

Eye injuries in squash: a preventable disease rAICHAEL EASTERBROOK, FRCS[C]* As more Canadians are taking up squash the incidence of eye injuries is i...
2MB Sizes 0 Downloads 0 Views