Eye Injury in Sport

The five sight-threatening do-not-miss presentations:

• •Open globe: history of sharp or high-velocity injury; visible globe deformity, peaked or teardrop pupil, prolapsed iris or vitreous, marked vision drop, positive Seidel sign on fluorescein. Low IOP may be present but do NOT check tonometry or palpate
• •Hyphaema: blunt trauma, blood layering in the anterior chamber, reduced vision, photophobia
• •Retinal detachment or tear: photopsia (flashes), floaters, painless curtain or shadow, peripheral or central vision loss
• •Orbital fracture with entrapment: periorbital trauma, binocular diplopia (especially on upgaze), restricted motility, infraorbital paraesthesia, enophthalmos. Bradycardia/nausea (oculocardiac reflex) = paediatric trapdoor emergency
• •Chemical injury: splash history, pain, lacrimation, conjunctival injection. Alkali far worse than acid

Minimum dataset: visual acuity each eye separately (the most important baseline); pupil shape, size, reaction, RAPD; eye movements and diplopia; visual fields to confrontation; fluorescein only if safe; IOP only after open globe excluded; contact lens status; anticoagulation and sickle cell status; monocular status; tetanus status.

If lid retraction is needed in suspected open globe, rest fingers on the bony orbital rim only (zero pressure on the globe). RAPD after trauma suggests optic nerve or severe retinal injury - same-day ophthalmology. Binocular diplopia (resolves on covering one eye) suggests muscle tethering; monocular diplopia suggests a lens or corneal cause. Avoid pupil dilation if head injury monitoring of pupil response is needed.

Do-not-miss red flags: retrobulbar haemorrhage (acute orbital compartment syndrome - proptosis, raised IOP, decreasing vision; sight-threatening within hours - lateral canthotomy and inferior cantholysis); traumatic optic neuropathy (RAPD, decreased acuity, dyschromatopsia - high-dose steroids NOT routine, specialist-led); microbial keratitis in contact lens wearers (can mimic abrasion - low threshold for urgent ophthalmology).

Visual acuity is the cornerstone - documented each eye separately, with correction or pinhole, before any other test. The only exception is chemical injury, where irrigation precedes everything.

Pitchside or first contact: visual acuity, external examination, pupil shape and reaction, RAPD, eye movements, fluorescein with cobalt blue light if available. No tonometry if open globe is suspected.

ED or clinic: full slit-lamp by ophthalmology, fluorescein with Seidel test, tonometry only after open globe is excluded, dilated fundoscopy only if no concern about pupil monitoring or iris injury.

Imaging: CT orbits (thin-cut, axial and coronal) - first-line in significant orbital trauma for suspected orbital fracture, intraocular or intraorbital foreign body, or suspected open globe (limited slit-lamp view). MRI - suspected optic nerve injury when no metallic foreign body is possible; contraindicated until metallic intraocular foreign body is excluded. B-scan ultrasound - vitreous haemorrhage or retinal detachment when fundoscopy is obscured, only after open globe has been excluded. Plain orbital X-ray is largely superseded.

Bloods: INR if anticoagulated (hyphaema); sickle cell screen in any patient of African or Caribbean descent with hyphaema (sickled cells block the trabecular meshwork and cause catastrophic IOP spikes); tetanus status for any open injury.

Sight-threatening - same-day ophthalmology:

• •Open globe: rigid eye shield (NOT a pad), nil by mouth, IV antibiotics per local protocol, tetanus, antiemetics, analgesia. Same-day surgery. Do not instil routine drops, perform tonometry, manipulate, evert lids aggressively, irrigate, pad, or apply pressure unless directed by ophthalmology
• •Hyphaema: urgent same-day ophthalmology, bed rest with head elevated 30 degrees, rigid shield, avoid NSAIDs and aspirin. Topical cycloplegics and steroids per ophthalmology. Watch for rebleed days 3 to 7. Mandatory sickle cell screen in patients of African or Caribbean descent
• •Retinal detachment or tear: same-day ophthalmology - repair window is time-sensitive
• •Chemical injury: irrigate immediately, then same-day ophthalmology
• •Orbital fracture with entrapment: same-day ophthalmology or maxillofacial. Paediatric trapdoor with oculocardiac reflex = same-day surgery
• •Retrobulbar haemorrhage with raised IOP or decreasing vision: lateral canthotomy and inferior cantholysis without delay
• •Traumatic optic neuropathy with RAPD: same-day ophthalmology; high-dose steroids are NOT routine

Time-sensitive but not same-day emergency:

• •Corneal abrasion (non-lens wearer): topical antibiotic prophylaxis (commonly chloramphenicol ointment QDS for 5 to 7 days), paracetamol. Do NOT prescribe topical anaesthetic for ongoing use
• •Corneal abrasion (lens wearer): high risk of Pseudomonas microbial keratitis - antipseudomonal cover (topical fluoroquinolone), stop lens use, urgent ophthalmology
• •Subconjunctival haemorrhage: reassure, resolves in 1 to 2 weeks
• •Traumatic uveitis or iritis: prompt ophthalmology within 24 hours
• •Orbital fracture without entrapment: maxillofacial referral; avoid nose-blowing for 2 weeks (orbital emphysema risk)

Analgesia: paracetamol first-line. Avoid NSAIDs and aspirin in suspected hyphaema. Tetanus per UK Green Book for any open eye injury.

Return to play: corneal abrasion 3 to 7 days once healed; hyphaema minimum 4 to 6 weeks ophthalmology-led with absolute eye protection on return; open globe ophthalmology-led, weeks to months, with permanent eye protection often needed for contact sport; orbital fracture avoid contact and Valsalva-loading sport for 4 to 6 weeks, no nose-blowing for 2 weeks.

Prevention: sport-specific polycarbonate eyewear meeting the relevant current standard. For squash in England, England Squash advises BS EN 18527-2:2021 standard eyewear; mandatory for under-19 competition and all doubles play. Standard prescription spectacles are NOT adequate. Monocular athletes (vision worse than 6/60 in one eye) must use eye protection at all times for any contact or projectile-risk sport.

Phase 1 (acute - protect): eye shield, drops, antibiotics, analgesia per pathway; avoid contact lens wear until cleared; avoid Valsalva in hyphaema or post-surgical recovery.

Phase 2 (recovery): light cardiovascular exercise once cleared; avoid contact, racquet, ball, and water sport until specialist clearance; vision testing and visual fields if posterior segment injury; DVLA review if visual standards reduced (Group 1 minimum: read a number plate at 20 metres, 6/12 binocular acuity; Group 2 stricter).

Phase 3 (return to sport - protected): sport-specific reconditioning; sport-specific polycarbonate eye protection mandatory for any patient with reduced vision in either eye, prior open globe, or prior hyphaema returning to projectile-risk sport.

Phase 4 (long-term): permanent eye protection for monocular athletes; annual ophthalmology review where indicated (post-globe rupture, traumatic glaucoma, retinal detachment repair); DVLA review if visual standards not met.

• •NICE CKS: Red Eye - acute red eye assessment, differentials, and ophthalmology referral pathway.
• •The Royal College of Ophthalmologists - clinical guidelines for ocular trauma including the open globe pathway and lateral canthotomy criteria.
• •College of Optometrists Clinical Management Guidelines - evidence-based UK guidance for corneal abrasion and chemical trauma.
• •BS EN 18527-2:2021 / England Squash - sport-specific polycarbonate eye protection standard; mandatory for under-19 competition and all doubles play.
• •NICE NG232 (Head injury) - apply to any associated head injury.

• •Visual acuity is the most important test - each eye separately. Exception: chemical injury (irrigate first).
• •Five sight-threatening do-not-miss presentations: open globe, hyphaema, retinal detachment, orbital fracture with entrapment, chemical injury.
• •Open globe: rigid shield (NOT pad), nil by mouth, do not palpate or check tonometry, same-day ophthalmology.
• •Hyphaema: head up 30 degrees, avoid NSAIDs and aspirin; mandatory sickle cell screen in patients of African or Caribbean descent.
• •Retrobulbar haemorrhage: lateral canthotomy and inferior cantholysis is sight-saving within hours.
• •Sport-specific polycarbonate eye protection is the dominant preventive intervention.