INJURIES OF THE EYE AND TO VISION
Good vision is
vital in sports and most occupations, although the blind have
accomplished remarkable tasks. Good vision is necessary to follow
a monitor screen, read a dial, observe a moving object, etc, and
perceive subtle movements of a sports opponent. In athletics,
good vision is equally a safeguard from injury in anticipating a
defensive move in contact sports. Badminton and racketball,
especially, have a high incidence of eye injuries, usually
occurring in inexperienced or nearsighted players not wearing
The clinical picture may be one of commotio retinae, corneal
abrasion, hematoma and laceration of the lid, hyphema, traumatic
mydriasis, and vitreous and subconjunctival hemorrhage. Eye
injuries also have a high incidence in basketball, especially
where jumps under the backboard place the eye in jeopardy of an
opponent's fingers or elbow, or even of the ball.
Some cases have been reported of explosive ocular injuries as
the result of curious children cutting into a liquid-center golf
ball (2000-2400 psi) containing suspensions of metal. Concussion
to an eye frequently results in anterior and/or posterior chamber
hemorrhages. These may be noticed on gross inspection, but any
complaint of blurred vision requires careful ophthalmoscopy. Slow
bleeding may require several hours to obscure vision. Except for
the most minor eye or visual injuries, ophthalmologic
consultation should be sought.
Injuries of the Lids and Conjunctiva
for cuts, edema, and skin changes. Note position of the lid
relative to the anterior orbit and record degree of ptosis.
Evaluate degree of exophthalmos or enophthalmos and the distance
between orbits. Inspect for conjunctival edema, pallor, foreign
bodies, petechiae, and vascular injection both on the anterior
eyeball and posterior lid surfaces. Note any conjunctival
congestion, bogginess and episcleritis.
Abrasions and Lacerations. Conjunctival abrasions
usually result from dirt or an opponent's fingers. A severe
concussion to the orbital area usually results in injury and
edema to the affected lid. Swelling may be so severe that the lid
cannot be opened by either the patient or doctor. If this occurs,
the patient must be referred to an ophthalmologist without
further evaluation. Hematomas of the lid always require the
exclusion of an associated orbital fracture. Proptosis after
injury may be associated with retrobulbar hemorrhage.
Traumatic splits in the lid may expose deep tissues. These
require immediate cleaning, covering with a sterile pad, and
referral for suturing. Linear splits in the lid or a torn tear
duct usually require the attention of a plastic surgeon because
they take special surgical experience to avoid trouble for many
years. If a vertical split through the circular lid muscles and
the palpebral cartilage is not repaired expertly, a troublesome
V-notch lid scar can result.
Subconjunctival Hemorrhage. When the eye is struck with
a fist, elbow, knee, ball, puck, or any blunt object larger than
the eyeball itself, the result is usually swelling, eyelid
ecchymoses, and bright-red subconjunctival hemorrhage. Other
causes include harsh rubbing with a finger or nicking the
conjunctiva with a sharp object. There is usually no visual
disturbance or eye pain. Although frightening in appearance, the
patient should be reassured that subconjunctival hemorrhage is
not serious and will disappear in 10-15 days. As with any
subcutaneous bleeding, cold packs should be applied initially,
followed by warm compresses in the late stage. Specific
medications are not required according to Grant/Cinotti and
One of the
most common facial injuries in sports is that of laceration in
the bony-prominent orbital area. The typical face mask protects
other areas quite well. Injuries in the supraorbital areas are
often deeper than first thought, frequently exposing the bony
ridge. During cleaning the wound, never shave an eyebrow for in
about 25% of cases it does not grow back or grows back most
scantily. Proper suturing often requires a plastic surgeon, as
the scar increases vulnerability and each additional scar
encourages the accumulation of dense scar tissue (eg, boxer's
Injury of the Eyeball
trauma or disease deserves ophthalmologic consultation. It is not
unusual to have rupture of the eyeball just outside the
corneoscleral margin where the sclera is thinnest. A rupture here
is often associated with subconjunctival dislocation of the lens.
Hemorrhage is a frequent complication. Mild injuries may produce
traumatic keratitis, and severe injuries may cause rupture of the
cornea. Rupture of the sphincter of the iris is also common and
diagnosed by first finding that the iris is dilated and then by
detecting a slight notch in the pupillary margin. Temporary
dilation of the pupil may result from sphincter stretching.
Sometimes the iris is torn from its attachment to the ciliary
body, producing iridodialysis. Detachment of the ciliary body may
occur, thus deepening the anterior chamber at the point of
separation. Paresis of accommodation, sometimes observed after
injury, may show improvement when acute symptoms subside. The
lens is frequently partly dislocated due to partial rupture of
the suspensory ligament. Evulsion of the optic nerve may also
occur. A well-defined hole may be seen occupying the position of
the nerve, corresponding in size to that of the disc.
Prolapse of the vitreous may occur into the anterior chamber,
usually producing a shallow anterior chamber in this area. The
lens may be dislocated into the anterior chamber, with resulting
secondary glaucoma requiring extraction. A traumatic cataract may
also result that requires surgical intervention. Rupture of the
choroid is not uncommon and usually appears as a crescentic
lesion between the optic nerve and the macula. Glaucoma
frequently follows eyeball contusion and is one of the most
serious complications. It may occur at the time of injury or
later. Traumatic enophthalmos appears as a lifeless eyeball in
its sunken orbit. The motility of the eye is sometimes seriously
reduced. Sympathetic ophthalmia is a rare complication of eyeball
The retina may be ruptured or detached with or without tear.
Commotio retinae may follow injury, resulting in edema of the
retina that appears gray and cloudy while the macular region
assumes a dark red color in comparison with surrounding retina.
In traumatic retrobulbar neuritis, the optic nerve suffers a
low-grade traumatic retrobulbar inflammation that may be so
slight as to be noted only by careful study of the blind spot
(which may be enlarged).
Traumatic Cataract and Complications
cataract usually results from a rupture or disturbance of the
capsule or lens from any injury allowing the aqueous or vitreous
fluid to come into contact with lens fibers. The result is a
partial or complete loss of transparency of the crystalline lens
or of its capsule.
Traumatic cataracts are usually caused by penetrating foreign
bodies, but a blunt blow on the orbit or even to the side of the
head may cause cataract. Soon after capsular laceration, the lens
fibers near the tear begin to swell and cloud. Later, the lens
substance oozes into the anterior chamber and appears as gray
fluffy-appearing masses which are dissolved and eventually
absorbed on coming in contact with the aqueous. In time, the
major portion of the lens substance may be absorbed and the pupil
again becomes almost black. In most cases, however, the capsule
scars and closes, stopping the process of absorption before
liquefaction is fully accomplished.
Many cases pursue their course with few signs of inflammation,
but a successful termination is often prevented by the
development of an iritis caused either by direct injury or by
pressure of loose or swollen lens matter. Septic matter may also
be introduced into the eye either at the time of injury or later,
which gives rise to an iridocyclitis, a panophthalmitis, and even
an orbital inflammation. If not prevented, a secondary glaucoma
Contact Lenses in the Unconscious Victim
lenses offer a special hazard with the unconscious or injured
person. Here, a warning bracelet or identification card helps to
alert first-aid attendants of the presence of the lenses. When
possible, ask the injured to remove the contacts, as an awkward
search by another party may do more harm than good. For the
unconscious victim who is unable to remove the lenses himself,
the eye should be examined with a small flashlight. By focusing
the beam of light from the side, the edge of the lens will often
become visible. Most disengaged contact lenses will be found
under the upper eyelid. The doctor places the tip of a finger on
the athlete's lower eyelid, pulls down and laterally, then pushes
the upper lid against the top of the lens. The lens should eject;
if not, a small suction cup can be used for assistance.
Sun or Snow Blindness. Ultraviolet injury is often seen in prolonged
skiing, yachting, welding, and outside work when glasses with
filtering lenses do not prevent sustained reflection of the sun's
rays from snow, water. or metal. Considerable ultraviolet
exposure results in small multiple corneal epithelial
Concussion. Concussion injuries (eg, a ball) may result
in hyphema with hemorrhage between the cornea and iris from
damage to the small vessels of the iris. It should always be
considered serious. Symptomatology includes blurred vision,
aching eye pain, severe eye redness with intense dilatation of
the pericorneal vessels, and photophobia. In a short time, blood
settles below from gravity to form a "fluid level." There is
danger of secondary hemorrhage into the anterior chamber that may
be more dangerous than the initial hyphema. If secondary
hemorrhage does not occur, absorption usually takes place in a
Hyphema and Hematic Corneal Infiltration. After eye
trauma, the patient may complain of eye pain, fuzzy vision, and
present red or black blood over all or just the inferior aspect
of the iris or pupil. Referral should be made to an
ophthalmologist who usually suggests hospitalization, sedation,
and careful observation for several days until the hemorrhage
clears. Prior to referral, an eye pad should be applied over the
closed lid. Cases of hematic discoid infiltration of the cornea
are nearly always of traumatic origin. Contusions of the anterior
segment of the eye or penetrating wounds may be followed by a
disturbing picture of "blood stain". After 10 or more days, it
may simulate an anterior dislocation of the lens. The cornea
slowly recovers its transparency in 3-24 months.
Abrasion. Protective reflexes tend to prevent extensive
corneal abrasions, but even minor lesions are quite painful,
result in blurred vision, photophobia, excessive lacrimation, and
usually require some hospitalization. They are commonly the
result of scratches from a fingernail, ball, piece of equipment,
or contact in sports and always present a threat of possible
visual impairment. A topical dye is required for positive
diagnosis. Uncomplicated cases heal in 4-6 days with only
first-aid treatment. The clinical picture is one of an extremely
red eye, pain, photophobia, and excessive lacrimation. First aid
consists of an eye ointment, a firm pad over the closed lid, and
Traumatic and Striate Keratitis. Injuries to the cornea
may establish a general inflammation of the membrane, but more
frequently they cause loss of substance of the cornea and thus
produce corneal ulcers. These ulcers heal quickly if small and
not affected. They present little pain and leave only a temporary
opacity proportionate to their extent. If they are extensive,
even if superficial like a severe abrasion, they may be extremely
painful if the corneal epithelium is removed. Once infected, they
exhibit characteristics of a suppurating ulcer. An injury causing
bending of the cornea may show a number of fine gray streaks
(striate keratitis), more or less perpendicular to the corneal
injury, noticed from a few hours to a week or more after the
Laceration. Lacerations of the eyeball from sharp or
pointed objects result in eye pain and visual impairment. On
examination, the cornea will appear cut, present an irregular
corneal reflex, possibly exhibit a tear-shaped pupil with a small
ebony tip at the apex of the tear, or the iris may exhibit a hole
from perforation. A cold pack should be applied immediately,
followed by a protective shield, a loose patch, and referral to
an eye surgeon.
bodies within the eye are especially common under windy and/or
dusty conditions. Foreign bodies are frequently imbedded in the
cornea because it occupies nearly two-thirds of the space between
the opened eyelids and a much larger proportion of that space
when the eyes are partly closed as during squinting in bright
sunlight or when the entrance of a foreign body is anticipated.
The tissue of the cornea tends to retain particles that may
penetrate it, but the conjunctiva and subconjunctival tissues are
so loose that imbedded particles easily expel spontaneously.
Once a foreign body becomes imbedded in the cornea, it causes
irritation and usually a suppurative inflammation by which it
becomes loosened and easily drops out or is wiped away by the
lids. If, however, it lies at the bottom of a considerable loss
of substance, it may lie there for some time, although quite
detached from corneal tissue. Under these circumstances, it
becomes a source of painful irritation causing chronic eye muscle
weakness, blurred vision, photophobia, excessive lacrimation,
conjunctival redness, and the development of vessels in the
adjoining pericorneal space. These vessels press against the seat
of the foreign body and give an appearance of a chronic
phlyctenular ulcer or superficial vascular keratitis.
Management. Most superficial unembedded debris can be
washed out with clean water, a weak saline solution, or a
commercial eye wash (eg, Cramer's). For this purpose, a bulb
lavage is a helpful tool in the emergency kit. If gentle
irrigation is not adequate, a light patch should be applied and
immediate referral to an ophthalmologist should be made.
Eye Injuries Produced by Indirect Trauma
Papilledema. Papilledema following skull
fracture, especially a depressed fracture, is sometimes seen, but
swelling of the disc and hemorrhages are rare. Vision is usually
not affected, and visual fields are typically normal. The
papilledema usually disappears in 1-3 weeks after intracranial
pressure is reduced.
Occipital Injuries. Complete blindness may be a
temporary result in occipital injuries because of physical shock
affecting the neurons correlated with the damaged cortical
neurons. There is usually complete restoration of function of all
but the definitely destroyed neurons. Vision may be permanently
lost if hemorrhage involves the visual centers. Fracture through
the optic canals may result from cranial trauma without fracture
of other bones of the skull. Blindness of one eye or both may
follow even if the nerves preserve their normal appearance for a
period after the accident.
Concussion injuries of the eye may result in retinal hemorrhages, retinal
tears and disinsertions, choroid ruptures, and optic nerve
Retinal Hemorrhage and Choroidal Ruptures. Retinal
edema and bleeding usually occur in the macula or temporal area.
Resolution usually occurs in a few weeks without radical
treatment. A choroidal rupture exhibits as a whitish
circumscribed area near the disc in ophthalmoscopy because the
herniation allows underlying sclera to be viewed. Strenuous
physical activity must be restricted for 2-5 weeks.
Retinal Dialysis and Detachment. While disinsertion of
the retina likely occurs at the time of concussion, retinal
detachment may not occur for weeks or even months after the time
of injury. Initially, the area of retinal dialysis will appear
red, well defined, and near the periphery of the retina, usually
on the lateral aspect. Early diagnosis of retinal dialysis may
save the patient's vision if cryotherapy or photocoagulation can
be effectively applied. In the later stage, the detached retina
will present a gray appearance with dark vessels and require
surgical intervention. Once retinal detachment has been
corrected, further contact sports are ill-advised as recurrence
is quite frequent.
INJURIES OF THE EAR AND TO HEARING
and many occupations and recreational activities have their share
of injuries to the external ear. Even in mandatory-helmet sports,
lacerations and abrasions are seen. These may be due to an
opponent's fingernail or a player bending the ear during the
placement of a helmet. This latter injury may not be
uncomfortable at first, but after hours of practice, the folded
ear may swell and bleed at the crease, producing intense pain and
many months of sensitivity.
cauliflower ear has in past years been commonly associated with
boxing, its incidence is much higher in wrestling. The condition
itself is the result of untreated or poorly treated hematoma. The
clinical picture progresses from (1) injury to the ear causing
persistent, throbbing pain that lasts long after the causative
event, (2) possible fibrocartilage fracture, (3) swelling, local
heat, tenderness, followed by the development of a hematoma after
several hours, initially between cartilage and overlying skin,
visible to the naked eye, (4) tissue hardening and the
development of early fibrous tissue in about 14 days, and (5) the
resulting keloid mass, development of new cartilage, and
permanent deformity of the external ear characterized by skin
wrinkling, thickening, and contraction at the site of injury.
Professional Care. First-aid consists of ice packs and
pressure bandages during the healing stage. Hirata condemns
straightforward incision, although a common practice, as it opens
the area to secondary infection, chondritis, and perichondritis
due to the relative avascularity of the cartilage. Referral for
aspiration, several drainings if need be, is preferred. Following
aspiration, some authorities recommend irrigating the aspirated
area with a solution of hyaluronidase to reduce swelling and
edema of injured tissues. Several trainers have found that
hyaluronidase is more effective if "driven in" with iontophoresis
After aspiration, or even if aspiration is not necessary, a
pad of folded gauze about 2-inches thick, covered with collodion,
should be applied to the bruised ear and supported by an ace
bandage. Before the pressure pad is applied, a loose plug of
cotton should be inserted within the middle and exterior thirds
of the external canal. The pressure pad should remain in place
for 3-5 days in which time daily monitoring is made to assure the
swelling is subsiding. Prevention lies essentially in the use of
proper head gear, but care must be taken that the ear cap is
properly fitted or this in itself creates a hazard.
External Ear Disorders Associated with Water
Otitis Externa. External otitis (swimmer's ear) is commonly seen in
competitive surface swimmers. The cause is a breakdown of the
normal cerumen barrier due to constant exposure to warm water.
Itching and discharge are the first symptoms. Infection in the
skin of the external auditory canal quickly leads to
inflammation, erythemia, edema (which hides the drum), acute
tenderness, and a mild cellulitis that matures rapidly to a firm
furuncle that is extremely painful and tender, usually requiring
antibiotics and sedation. Each attack destroys some cerumen
glands, which encourages further attacks.
A chronic mild itching encourages "ear picking" which tends to
spread the infection. Diffuse otitis externa is typically a
bacteria, fungi, or allergic disorder. Pool work must be
restricted until healing is complete. Many otolaryngologists
recommend careful monitoring of the pool chlorine content and the
instilling in each ear of half-strength Burrow's solution after
each pool session to prevent infection. Others suggest a
commercial antifungal preparation or a solution of 90% isopropyl
alcohol and 10% vinegar or 5% glacial acetic acid for
External Barotrauma. During a diving descent below 30
feet when the ear is protected by ear plugs or a hood, a negative
pressure develops that causes the drum to bulge outward, usually
without discomfort or rupture. Capillaries within the external
canal may break to form small blisters in the skin of the
exterior canal to present a roughened surface. People so
afflicted should be advised to avoid scuba diving. If diving is
continued, some help can be obtained by avoiding ear plugs or
cutting a hole in the hood to allow water to enter the exterior
Exostoses. Exostoses are another affliction often seen
in swimmers, especially cold water swimmers, which often
predispose to otitis externa. The superior aspect of the canal
just lateral to the pars flaccida of the drum is a favorite site
of these benign bony tumors of the exterior canal. They are
neither the cause nor the effect of the otitis directly. They are
usually asymptomatic and rarely cause complete canal blockage,
but they do encourage otitis externa because they interfere with
cerumen passage and inhibit water within the ear to drain
outward. Ear plugs may help in prevention and avoid continued
growth, but surgical removal may be necessary.
Miscellaneous Disorders of the External Ear
Insects in the Ear. An uncommon but frightening experience is an
insect buzzing within an ear. Treatment can be provided by
placing the patient in the side position with the affected ear up
and syringing or pouring warm vegetable oil or water into the
external auditory meatus. This will usually float out the
Lacerations. In any case of laceration of the pinna,
secondary infection is always a danger due to the poor resistance
of the relatively avascular cartilage exposed. Appropriate care
must be made to avoid permanent and ugly scarring.
Canal Collapse. Due to relaxation of soft-tissue
support, the medial end of the condral cartilage may drop forward
to narrow the lateral end of the external canal. The resulting
slit can easily be opened with a speculum, but normal cerumen
passage is inhibited, leading to infection and possible otitis
Trauma-Related Middle Ear Disorders
depends upon the integrity of the external canal, the drum, the
air chamber of the middle ear, the windows, the mobile chain of
ossicles, the auditory nerve, and the perceptive higher centers
in the brain. Any abnormality of one or more of these factors can
impair hearing. Treatment of most all middle-ear disorders
consists of keeping the ear dry (difficult with swimmers and
divers), using preventive irrigation, using an appropriate
therapy to decongest the tissues, managing any infection present
by appropriate means, and seeking otologic consultation when
Middle-Ear Barotrauma. In rapid pressure changes such
as in diving or an airplane descent, the drum herniates inwardly
if the eustachian tube does not afford pressure equalization. The
negative pressure within the middle ear causes slight hemorrhages
and extracts fluids from adjacent tissues. A weakened drum may
rupture in a deep descent, resulting in severe vertigo as water
enters the middle chamber. Prevention is made by avoiding clogged
ears or nasal congestion prior to descent. When on the surface, a
diver may help unblock an eustachian tube by laterally flexing
the neck away from the affected side and pulling the pinna or
skin of the neck up and down on the affected side.
Alternobaric Vertigo. Alternobaric vertigo sometimes
occurs during a rapid diving ascent where eustachian tube
blockage causes middle-ear pressure buildup. In severe cases, the
drum may rupture. The associated rotary vertigo, vertical
nystagmus, and severe disorientation may produce panic. An
experienced diver will usually recognize the early signs of
dizziness and slow his ascent accordingly.
Drum Perforation. In addition to the barotraumatic
forces described above, a concussive blow on the ear can result
in traumatic perforation of the drum and possible ossicle damage.
Special audiometric tests are usually required to determine the
exact degree of resulting deafness. Slightly perforated drums
usually heal spontaneously if kept dry. There is slight scar
development. During healing, care must be taken while blowing the
nose. Flying and deep diving should be avoided.
Ruptured Round-Window Membrane. An aqueduct connects
the cochlea and the subarachnoid space. In some people, this
aqueduct is large enough to allow a free flow of cerebrospinal
fluid within the scala tympani. As the aqueduct's opening is near
the round-window membrane that separates the inner and middle
ear, a forceful Valsalva maneuver or an attempt at autoinflation
(causing transient increase in blood and cerebrospinal pressure)
can transmit cerebrospinal fluid pressure to an extent to rupture
the round window membrane. Once this occurs, fluid escape causes
the hair cells to malfunction, the ear feels full or "dead," a
loud tinnitus is perceived, deafness (unnoticed when under water)
occurs especially with high tones, and vertigo and nausea usually
manifest and are associated with spontaneous nystagmus and a
staggering gait. During diagnosis, differentiation must be made
from Meniere's disease or a viral infection of the middle
Otitis Media. Common earache is rarely trauma oriented;
it is usually secondary to pharyngitis. Otitis media is the
result of the normally air-filled middle ear chamber with an
intact drum becoming filled with fluid because of impaired
eustachian tube function. This is usually the result of an
inflammation spreading from a sore throat via the eustachian
tube. A feeling of fullness in the ear progresses to pain and a
degree of deafness. As pressure builds within the chamber, the
drum appears thick and red (blood) or yellow (pus) prior to
The common cause in swimmers is poor technique; ie, not
expelling air when the nose is under water. Ocean, lake, or pool
water irritates the nasal mucosa, resulting in nasal congestion
and infection. For the same reason, scuba divers should never let
water enter the mask. An ear where fluid leakage is seen should
never be plugged, just lightly covered with a sterile pad.
Trauma-Related Inner Ear Disorders
disorders are characterized by vertigo, tinnitus, and hearing
loss. Acute viral labyrinthitis is usually secondary from a cold
or gastrointestinal infection, not trauma. Hearing loss is rarely
associated, but vertigo is usually severe. It is usually
self-limiting in 1-3 weeks.
Referred Earache. A common cause of earache is often
not within the ear itself but from the adjacent temporomandibular
joint, especially in gum-chewers and brace-wearers having
subclinical arthralgia of this joint. Chronic tonsil, pharynx, or
larynx inflammations are also common causes of referred pain to
the ear. Other causes include cervical subluxation, sternomastoid
and masseter trigger points, dental problems, and an abnormally
long styloid process.
Inner-Ear Barotrauma. Injury to the inner ear is
usually of an intrinsic nature as it is well protected by
surrounding bone. Impairment is usually the result of abnormal
pressure changes or fistulae.
Meniere's Syndrome. The syndrome features endolymphatic
hydrops from pressure changes in inner-ear fluids. Symptoms
include paroxysmal dizziness, tinnitus, and a degree of deafness.
The latter two may originate unilaterally and progress to both
ears. It is often secondary to a number of metabolic disorders,
but a common cause (primary or secondary) often overlooked is a
cervical or upper thoracic subluxation. Differentiation must be
made from CNS vertigo and benign paroxysmal postural vertigo.
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Neurological Implications of Sports Injuries. New England
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Arthur PB : General Management of On-Field Injuries. ACA
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Bowerman JW: Radiology and Injury in Sport. New York,
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Philadelphia, F.A. Davis Company, 1977.
Copass MK, Eisenberg MS: The Paramedic Manual.
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Rutledge BJ: Injuries to the Cranial and Central Nervous
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