Keep Your Eye on the Ball!

The World Cup kicks off this summer and the Commonwealth Games are coming. Add international tennis tournaments, motor racing, and cycling and 2026 is shaping up to be a summer of sports.

That means it’s likely to be a season of ocular trauma, too; clinicians can expect to see more patients presenting with sports-related injuries. From the humble football (or ‘soccer ball’ to American audiences) to the well-timed left-hand jab, danger to the eyes is omnipresent in sport.

“One of the most common injuries is blunt ocular trauma from a football kicked at the face, or a tennis/squash ball that hits the ocular region,” said James E Neffendorf MD. “The nature of the injury can vary widely—from a mild, isolated commotio retinae to severe intraocular bleeding (such as a total hyphaema) or a retinal detachment.”

“Posterior segment injuries are much rarer and more severe: for instance, commotio retinae with Berlin’s oedema, retinal tear or detachment, and vitreous haemorrhage,” said H Burkhard Dick MD, PhD. “It is crucial to perform dilated fundoscopy and to examine the patient immediately if they report photopsia, floaters, or any visual field defect.”

‘Harmless’ equipment can threaten sight

The noted ophthalmologists interviewed for this article stressed the importance of remembering how ocular trauma can result from the most innocuous actions. Simple, everyday sports equipment can cause catastrophic damage capable of threatening an athlete’s career.

José L Güell MD, PhD described treating a well-known tennis player who was slowly developing secondary cataract following ball impact. The patient had visited several surgeons, but none of them wanted to propose surgery because the patient was young and amongst the 50 top players in the world.

“The question was: should I use a multifocal lens? The eye works and he doesn’t have presbyopia, but he would have it if I did surgery,” Professor Güell said. “Would he need perfect near vision as well as distance vision?

“The decision to do surgery was hard because his vision was quite good, despite that when the sun was in front of him, he had disturbances due to posterior capsule opacity. Fortunately, everything went well.”

Dr Neffendorf described a “particularly unfortunate case” involving a young adult who had a sports scholarship at a top university. The patient sustained an accident with an elastic resistance band, which, under tension, slipped off a bar and snapped into their face, with catastrophic results.

“It resulted in a bilateral retinal detachment that required multiple surgical procedures,” Dr Neffendorf said. “The retinal detachments were fixed, but the reduced vision meant their sporting career was over. It was an eye opener about what’s at stake for athletes and the risk posed by seemingly harmless equipment.”

Managing myopia in athletes

The risks posed to athletes by harmless equipment are one concern, but common conditions can also have an oversized impact on their sight. The most notable example is myopia, as even small, uncorrected refractive errors can significantly affect visual performance.

“When examining a high-performing athlete with uncorrected myopia, in addition to the usual procedures, we pay particular attention to contrast sensitivity, binocular vision and stereopsis, and dynamic visual acuity and oculomotor function,” Prof Dr Dick said.

“Soft contact lenses are preferable because of better optical quality and a smaller possibility of visual field constriction than rigid gas permeable lenses. I also emphasise that a strict hygiene regime should be adhered to (‘no water and no overnight wearing’).”

According to Prof Güell, myopic athletes need to maximise their perceptual processing and decision making, reaction time, and spatial awareness. This can make them demanding patients as a result—but rewarding ones, too.

“One professional padel player I treated had become intolerant to contact lenses. Surgery was successful, but there was residual low myopia in the left eye, and she felt her shot precision on her left side had been reduced,” Prof Güell said.

“We needed to re-operate twice to achieve an extremely low residual error. The second time was just 0.25 dioptres of a residual cylinder to reach the comfort level for her left-hand shots. It shows how much precision athletes demand.”

Always keep an open mind

Whether the patient is an athlete at the top of their game or a patient who walked in after a five-a-side game went wrong, the approach towards treatment remains the same. The attitude of athletes—and their ability to appreciate injury as a challenge to be overcome—is motivating for the surgeons interviewed, but insights apply to any patient with a sports-related eye injury.

“Keep an open mind when assessing a patient with trauma during sport,” Dr Neffendorf said. “All patients should have a dilated fundal examination—it is not uncommon that I will find a small retinal tear lurking in the periphery of the retina.”

“Inform these patients about the increased long-term risk of glaucoma, cataract, and retinal detachment, which need to be documented for insurance purposes—not only for professional sports people. In more complicated cases, surgery such as anterior chamber washout becomes necessary,” Prof Dr Dick said.

James E Neffendorf MA (Cantab), MBBS (Lond), MD (Res), FRCOphth is a consultant ophthalmologist, cataract, and retinal surgeon based in London. james.neffendorf@nhs.net

José Luis Güell MD, PhD is head of the Cornea, Cataract, and Refractive Surgery Department at IMO Grupo Miranza in Barcelona, Spain. jose.guell@imo.es

H Burkhard Dick MD, PhD is Chairman and Head of the University Eye Clinic, Bochum, Germany, and President of the ESCRS. dickburkhard@aol.com