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Traumatic hyphema in badminton players: Should eye protection be mandatory?

2017; Elsevier BV; Volume: 52; Issue: 4 Linguagem: Inglês

10.1016/j.jcjo.2017.01.018

1715-3360

Micah Luong, Victoria Dang, Chris Hanson,

Child Abuse and Related Trauma

In Canada, sports account for the majority of injuries limiting daily activity in people between the ages of 12 and 64 years.1Statistics Canada. Injuries in Canada: insights from the Canadian Community Health Survey. 2011 (updated 2011 Jun 28, cited 2014 Nov 26). 〈http://www.statcan.gc.ca/pub/82-624-x/2011001/article/11506-eng.htm〉Google Scholar Although most sports injuries are musculoskeletal in nature, sports-related ocular injuries have the potential for significant vision loss and morbidity.1Statistics Canada. Injuries in Canada: insights from the Canadian Community Health Survey. 2011 (updated 2011 Jun 28, cited 2014 Nov 26). 〈http://www.statcan.gc.ca/pub/82-624-x/2011001/article/11506-eng.htm〉Google Scholar Eye trauma, often occurring through physical activity, is the leading cause of noncongenital monocular blindness in children.2SooHoo J.R. Davies B.W. Braverman R.S. Enzenauer R.W. McCourt E.A. Pediatric traumatic hyphema: A review of 138 cases.J AAPOS. 2013; 17: 565-567Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 3Rocha K.M. Martins E.N. Melo Jr, L.A. Moraes N.S. Outpatient management of traumatic hyphema in children: Prospective evaluation.J AAPOS. 2004; 8: 357-361Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Blunt trauma accounts for most sports-related eye injuries and, depending on the mechanism of injury, can cause many presentations, including hyphema. Traumatic hyphema occurs when a blow to the orbit ruptures blood vessels, supplying the iris and ciliary body, causing entry of blood into the anterior chamber.4Gharaibeh A. Savage H.I. Scherer R.W. Goldberg M.F. Lindsley K. Medical interventions for traumatic hyphema.Cochrane Database Syst Rev. 2013; 12 (CD005431)Google Scholar The severity of hyphema can range from microhyphema, a minimal suspension of erythrocytes in the anterior chamber, to total hyphema in which the entire anterior chamber is filled with blood. It is commonly observed as a layer of fresh or clotted blood along the bottom of the chamber. Hyphema can lead to permanent vision loss through secondary glaucoma, optic atrophy, and corneal bloodstaining.2SooHoo J.R. Davies B.W. Braverman R.S. Enzenauer R.W. McCourt E.A. Pediatric traumatic hyphema: A review of 138 cases.J AAPOS. 2013; 17: 565-567Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 3Rocha K.M. Martins E.N. Melo Jr, L.A. Moraes N.S. Outpatient management of traumatic hyphema in children: Prospective evaluation.J AAPOS. 2004; 8: 357-361Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 4Gharaibeh A. Savage H.I. Scherer R.W. Goldberg M.F. Lindsley K. Medical interventions for traumatic hyphema.Cochrane Database Syst Rev. 2013; 12 (CD005431)Google Scholar Based on statistics collected from 1972 to 2002, the Canadian Ophthalmology Society reports that the most common sports that cause ocular injury in Canada are hockey, racquet sports, and baseball.5Canadian National Institute of the Blind. Eye safety: overview. 2014 (cited 2014 Nov 26). 〈http://www.cnib.ca/en/your-eyes/safety/at-play/Pages/Overview.aspx〉Google Scholar Badminton accounts for the most reported eye injuries compared to all racquet sports combined in Canada.5Canadian National Institute of the Blind. Eye safety: overview. 2014 (cited 2014 Nov 26). 〈http://www.cnib.ca/en/your-eyes/safety/at-play/Pages/Overview.aspx〉Google Scholar Although it is well known that squash balls can cause significant ocular injuries, it is much less known that badminton shuttlecocks can also cause significant permanent vision loss. In this case series, we describe 5 cases of hyphema caused by badminton and review preventative measures to minimize complications in this presentation. The medical records of patients presenting to the Rockyview General Hospital Urgent Eye Clinic in Calgary from October 2013 to October 2014 were reviewed, and all cases of hyphema caused by badminton were identified. Patient age, sex, time from injury to medical care, mechanism of injury, use of eye protection, ocular and systemic history, presenting visual acuity (VA), intraocular pressure (IOP), hyphema grade (Table 1), associated ocular injuries, treatment, and follow-up were recorded.Table 1Traumatic hyphema grading scale3Rocha K.M. Martins E.N. Melo Jr, L.A. Moraes N.S. Outpatient management of traumatic hyphema in children: Prospective evaluation.J AAPOS. 2004; 8: 357-361Abstract Full Text Full Text PDF PubMed Scopus (23) Google ScholarGradeHyphema MeasurementMicrohyphemaNo layered blood; suspended red blood cells in anterior chamberGrade 1Blood presenting in less than 1/3 of the anterior chamberGrade 2Blood occupying >1/3 and 1/2 of the chamberGrade 4Blood filling the entire anterior chamber Open table in a new tab All patients suffered a direct hit to 1 eye from a shuttlecock and presented to clinic within 24 hours of the injury. None were wearing protective eyewear at the time of the injury to medical care. One patient required multiple surgeries, whereas the rest were treated conservatively. Table 2 describes the clinical presentation of each patient immediately after the injury and during the recovery process.Table 2Clinical details of patientsCaseAge, yearsSexEyeOcular InjuriesPostinjury VAFinal VARecovery Time177MODHyphema (grade 3; 5.5 mm), corneal edema, vitreous hemorrhage, retinal detachment, nonhealing neurotrophic corneal ulcerHMHMUnresolved (>7 months)212MOSHyphema (grade 1; 0.8 mm), angle closure glaucoma, corneal edema 20/20 20/2013 days315FOSMicrohyphema, iris sphincter tears, commotio retinae 20/25, −1 20/20, −128 days450MODHyphema (grade 1; <0.5 mm) 20/20, −2 20/20, −13 days530MOSMicrohyphema 20/20 20/30, +17 daysVA, visual acuity; HM, hand motion. Open table in a new tab VA, visual acuity; HM, hand motion. A 77-year-old male presented to the clinic 1.5 hours after a hit to the right eye. Initial VA was perception of hand motion (HM) OD and 20/20 OS. IOP was too low to be determined in the right eye because of ciliary body shut down. IOP in the left eye was 14 mm Hg. Grade 3 hyphema and subconjunctival hemorrhage (SCH) were observed by slit-lamp examination (SLE). The patient was started on topical prednisolone and activity was restricted. Over 6 days, corneal edema, Descemet membrane folds, and a dense clot over the intraocular lens developed in the right eye. Hyphema was reduced to grade 1; however, VA for the right eye remained at HM. An anterior chamber washout was performed, topical prednisolone was continued, and topical moxifloxacin was prescribed. On the fifth follow-up, brimonidine/timolol and homatropine were started. By 2 weeks, there was no improvement in the VA of the right eye, and a vitreous hemorrhage had developed. Since then, the patient has developed superior and inferior retinal detachments and a nonhealing neurotrophic corneal ulcer in the right eye. A 12-year-old male presented to the clinic after a hit to the left eye. Initial VA was 20/20 OD and 20/25 OS. IOP was 18 mm Hg OD and 24 mm Hg OS. Grade 1 hyphema (0.8 mm), conjunctival injection, and an oblong pupil were observed. Management included topical prednisolone and activity restriction. Follow-up after 4 days revealed reduction in the hyphema to 0.2 mm, corneal edema, and a significant increase in IOP to 31 mm Hg in the left eye. VA remained unimproved. Travoprost/timolol was prescribed alongside prednisolone. Within 2 weeks, the patient recovered full vision, and the hyphema was resolved. A 15-year-old female presented to clinic after a hit to the left eye. Initial VA was 20/20 OD and 20/25 OS. IOP was 18 mm Hg OD and 22 mm Hg OS. Microhyphema, iris sphincter tears, pigment dispersion in the anterior chamber, SCH, and commotion retinae were observed on SLE and fundus examination. Management included topical prednisolone, homatropine, and activity restriction. Within 28 days, VA had fully recovered, and the microhyphema had resolved. A 50-year-old male presented to clinic after a hit to the right eye. Initial VA was 20/20 OU; however, blurry vision was reported in the right eye. IOP was 26 mm Hg OD and 21 mm Hg OS. Grade 1 hyphema was observed. Management included topical prednisolone, homatropine, brimonidine/timolol, and activity restriction. Within 2 days, the hyphema had resolved, and VA had fully recovered. A 30-year-old male presented to clinic after a hit to the left eye. Initial VA was 20/20 OU. Blurry vision and photophobia were reported in the left eye. Microhyphema and mild conjunctival injection were observed. Management included topical prednisolone and activity restriction. After 1 week, the microhyphema had resolved, and VA was 20/25 OS. Management of traumatic hyphema aims to reduce initial bleeding and prevent secondary hemorrhage and other complications, including secondary glaucoma and corneal bloodstaining.2SooHoo J.R. Davies B.W. Braverman R.S. Enzenauer R.W. McCourt E.A. Pediatric traumatic hyphema: A review of 138 cases.J AAPOS. 2013; 17: 565-567Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 3Rocha K.M. Martins E.N. Melo Jr, L.A. Moraes N.S. Outpatient management of traumatic hyphema in children: Prospective evaluation.J AAPOS. 2004; 8: 357-361Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 4Gharaibeh A. Savage H.I. Scherer R.W. Goldberg M.F. Lindsley K. Medical interventions for traumatic hyphema.Cochrane Database Syst Rev. 2013; 12 (CD005431)Google Scholar, 5Canadian National Institute of the Blind. Eye safety: overview. 2014 (cited 2014 Nov 26). 〈http://www.cnib.ca/en/your-eyes/safety/at-play/Pages/Overview.aspx〉Google Scholar, 6Walton W. Von Hagen S. Grigorian R. Zarbin M. Management of traumatic hyphema.Surv Ophthalmol. 2002; 47: 297-334Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Secondary hemorrhage, a major complication of hyphema, usually presents 2 to 5 days after the injury and is often of greater magnitude than the initial hyphema, increasing the incidence of secondary glaucoma that could cause irreversible optic nerve damage.2SooHoo J.R. Davies B.W. Braverman R.S. Enzenauer R.W. McCourt E.A. Pediatric traumatic hyphema: A review of 138 cases.J AAPOS. 2013; 17: 565-567Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 6Walton W. Von Hagen S. Grigorian R. Zarbin M. Management of traumatic hyphema.Surv Ophthalmol. 2002; 47: 297-334Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 7Stilger V.G. Alt J.M. Robinson T.W. Traumatic hyphema in an intercollegiate baseball player: A case report.J Athl Train. 1999; 34: 25-28PubMed Google Scholar Predictors of rebleeds include delayed medical assessment over 24 hours from the injury, an initial hyphema of grade 2 or higher, elevated IOP greater than 21 mm Hg, and an initial VA worse than 20/200.7Stilger V.G. Alt J.M. Robinson T.W. Traumatic hyphema in an intercollegiate baseball player: A case report.J Athl Train. 1999; 34: 25-28PubMed Google Scholar Patients with sickle cell disease have a higher incidence of secondary hemorrhage, glaucoma, and permanent vision loss.2SooHoo J.R. Davies B.W. Braverman R.S. Enzenauer R.W. McCourt E.A. Pediatric traumatic hyphema: A review of 138 cases.J AAPOS. 2013; 17: 565-567Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 3Rocha K.M. Martins E.N. Melo Jr, L.A. Moraes N.S. Outpatient management of traumatic hyphema in children: Prospective evaluation.J AAPOS. 2004; 8: 357-361Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 4Gharaibeh A. Savage H.I. Scherer R.W. Goldberg M.F. Lindsley K. Medical interventions for traumatic hyphema.Cochrane Database Syst Rev. 2013; 12 (CD005431)Google Scholar, 6Walton W. Von Hagen S. Grigorian R. Zarbin M. Management of traumatic hyphema.Surv Ophthalmol. 2002; 47: 297-334Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 7Stilger V.G. Alt J.M. Robinson T.W. Traumatic hyphema in an intercollegiate baseball player: A case report.J Athl Train. 1999; 34: 25-28PubMed Google Scholar Retinal damage contributes significantly to poor visual outcomes after trauma although does not often present immediately as visibility may be obscured by the hyphema.8Ng C.S. Sparrow J.M. Strong N.P. Rosenthal A.R. Factors related to the final visual outcome of 425 patients with traumatic hyphema.Eye (Lond). 1992; 6: 305-307Crossref PubMed Scopus (21) Google Scholar Few studies exist in reference to badminton-related ocular injuries. Sixty-three cases were assessed at the Eye Clinic of the University Hospital in Kuala Lumpur, Malaysia, over a period of 5 years.9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar Of these cases, 57 were caused by a direct hit from a shuttlecock, and the rest were caused by rackets.9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar Of these injuries, traumatic hyphema was the most common presentation, followed by traumatic mydriasis and commotio retinae (Table 3).9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar In Malaysia, badminton was found to be the main cause of traumatic hyphema compared to other causes, including other sports, industrial accidents, and other projectiles.9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar In this study, 50.8% of cases recovered 20/20 vision; however, 11.0% recovered less than 20/200.9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar A cross-sectional survey in the Philippines reported on 23 cases of badminton-related ocular injuries over 6 months in 7 urban eye centres.10Zamora K.V. Uy H.S. Multicenter survey of badminton-related eye injuries.Phillip J Ophthalmol. 2006; 31: 26-28Google Scholar Of these cases, iritis and iridocyclitis were the most common presentations, followed by secondary glaucoma and traumatic hyphema (Table 3).10Zamora K.V. Uy H.S. Multicenter survey of badminton-related eye injuries.Phillip J Ophthalmol. 2006; 31: 26-28Google Scholar Final visual acuities were over 20/40 except for 1 case resulting in a final acuity of less than 20/80.10Zamora K.V. Uy H.S. Multicenter survey of badminton-related eye injuries.Phillip J Ophthalmol. 2006; 31: 26-28Google Scholar In a case series at the Leicester Royal Infirmary, 2 of 6 cases yielded visual acuities of counting fingers and light perception.11Kelly S.P. Serious eye injury in badminton players.Br J Ophthalmol. 1987; 71: 746-747Crossref PubMed Scopus (20) Google Scholar None of the patients in these studies wore protective eyewear at the time of injury.9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar, 10Zamora K.V. Uy H.S. Multicenter survey of badminton-related eye injuries.Phillip J Ophthalmol. 2006; 31: 26-28Google Scholar, 11Kelly S.P. Serious eye injury in badminton players.Br J Ophthalmol. 1987; 71: 746-747Crossref PubMed Scopus (20) Google ScholarTable 3Sight threatening complications from badminton in Malaysia and the Philippines9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar, 10Zamora K.V. Uy H.S. Multicenter survey of badminton-related eye injuries.Phillip J Ophthalmol. 2006; 31: 26-28Google ScholarType of InjuryNumber of CasesChandran9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar (n = 63)Zamora and Uy10Zamora K.V. Uy H.S. Multicenter survey of badminton-related eye injuries.Phillip J Ophthalmol. 2006; 31: 26-28Google Scholar (n = 23)Hyphema*Sight threatening complications also present in this case series.495Iritis—11Secondary glaucoma*Sight threatening complications also present in this case series.46Corneal edema*Sight threatening complications also present in this case series.—2Macular changes82Commotio retinae*Sight threatening complications also present in this case series.121Vitreous hemorrhage*Sight threatening complications also present in this case series.81Retinal detachment*Sight threatening complications also present in this case series.—1* Sight threatening complications also present in this case series. Open table in a new tab Over 90% of ocular injuries are preventable with appropriate eye protection, yet studies show low rates of use among athletes.12Goldstein M.H. Wee D. Sports injuries: an ounce of prevention and a pound of cure.Eye Contact Lens. 2011; 37: 160-163Crossref PubMed Scopus (22) Google Scholar In the United States, 84.6% of children do not wear protective eyewear despite engaging in sports that risk eye injury.12Goldstein M.H. Wee D. Sports injuries: an ounce of prevention and a pound of cure.Eye Contact Lens. 2011; 37: 160-163Crossref PubMed Scopus (22) Google Scholar In Australia, a survey of squash players revealed that 18.8% of adults claimed to wear protective eyewear but, of these players, only 9.4% were found to use adequate protection that did not include prescription eyeglasses, open eyeguards, industrial eyewear, and contact lenses.13Eime R. McCarty C. Finch C.F. Owen N. Unprotected eyes in squash: not seeing risk of injury.J Sci Med Sport. 2005; 8: 92-100Abstract Full Text PDF PubMed Scopus (17) Google Scholar Another survey on racquetball players indicated that the leading self-reported reasons for not using goggles were a lack of consideration for the risk of injury, the perception that low-intensity play did not warrant goggle use, cost, and discomfort.14McLean C.P. DiLillo D. Bornstein B.H. Bevins R.A. Predictors of goggle use among racquetball players.Int J Inj Contr Saf Promot. 2008; 15: 167-170Crossref PubMed Scopus (7) Google Scholar These findings suggest that exploring the protective eyewear use of patients on history, active education on injury risk, and the recommendation of appropriate protective wear would be beneficial to preventing ocular injury. Many Canadian Badminton Associations do not require players to wear protective eyewear, with the exception of British Columbia, which requires mandatory ASTM F803 protective eyewear for all junior players under the age of 19 years. In Ontario and Nova Scotia, mandatory protective eyewear is required for all junior doubles play, whereas in Newfoundland and Labrador and Northwest Territories it is required for all junior girls only when participating in mixed doubles tournaments. Regulations on protective eyewear vary between Canadian Badminton Associations and Canadian School Boards. Ontario, Nova Scotia, and Prince Edward Island School Boards require all students regardless of whether they are single or double players to wear protective eyewear that meet the ASTM F803 standards. The Newfoundland and Labrador School Board requires protective eyewear for all males and females only participating in mixed doubles events; however, students who wear prescription glasses are not required to wear protective eyewear. Both badminton associations and school boards in other provinces only strongly recommend the use of protective eyewear for children and adults. Although ocular injuries most frequently occur during doubles play and with inexperienced players, it is notable that, in 2013, the world's fastest shuttlecock velocity was recorded to be 493 km/h with the use of increasingly advanced racket technology.9Chandran S. Ocular hazards of playing badminton.Br J Ophthalmol. 1974; 58: 757-760Crossref PubMed Scopus (29) Google Scholar, 10Zamora K.V. Uy H.S. Multicenter survey of badminton-related eye injuries.Phillip J Ophthalmol. 2006; 31: 26-28Google Scholar, 11Kelly S.P. Serious eye injury in badminton players.Br J Ophthalmol. 1987; 71: 746-747Crossref PubMed Scopus (20) Google Scholar, 15Nadolny M. Shuttlecocks and balls: the fastest moving objects in sport. Official Canadian Olympic Team Website. 2014 (updated 2014 September 11; cited 2015 March 22). 〈http://olympic.ca/2014/09/11/shuttlecock-and-balls-the-fastest-moving-objects-in-sport〉Google Scholar, 16Vinger PF The mechanisms and prevention of sports eye injuries. 2010 (cited 2015 March 22). 〈www.lexeye.com/site/eye-safety.htm〉Google Scholar In consideration of these velocities, strict regulations for singles and experienced players should be explored. In Canada, the evolution of facial protection and implementation of mandatory full-face shields in minor hockey led to a significant decline in ocular injuries.16Vinger PF The mechanisms and prevention of sports eye injuries. 2010 (cited 2015 March 22). 〈www.lexeye.com/site/eye-safety.htm〉Google Scholar Hockey players who do not wear helmets or masks and those wearing only helmets sustained an equal number of ocular injuries. Mandatory helmets and facial protection reduced the number of ocular injuries in 1974–1975 to half of that in 1983–1984.17Pashby T.J. Eye injuries in Canadian amateur hockey.Am J Sports Med. 1979; 7: 254-257Crossref PubMed Scopus (24) Google Scholar, 18Pashby T. Eye injuries in Canadian amateur hockey.Can J Opthalmol. 1985; 20: 2-4PubMed Google Scholar Additionally, hockey players were 10 times more likely to sustain an ocular injury with no facial protection and 4 times as likely with partial facial protection,19Stuart M.J. Smith A.M. Malo-Ortiquera S.A. Fischer T.L. Larson D.R. A comparison of facial protection and the incidence of head, neck and facial injuries in Junior A hockey players. A function of individual playing time.Am J Sports Med. 2002; 30: 39-44Crossref PubMed Scopus (98) Google Scholar whereas no injuries were found with full-face protection. Implementation of mandatory full-face protection for minor hockey players has led to a decline in ocular injuries.20Deady B. Brison R.J. Chevrier L. Head, face and neck injuries in hockey: A descriptive analysis.J Emerg Med. 1996; 14: 645-649Abstract Full Text PDF PubMed Scopus (16) Google Scholar Eye protection should be required in badminton as well, particularly in the education system where young players are learning the sport.