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Soccer (football) ocular injuries: An important eye health problem
1. J A Capão Filipe
1. Correspondence to: J A Capão Filipe Sports Ophthalmology Unit, Department of Ophthalmology, University of Porto School of Medicine, S João Hospital, 4200-319 Porto, Portugal; jacapaofilipenetcabo.pt

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Laboratory experiments have confirmed the mechanism of soccer ball eye injury and the feasibility of a protective eyewear in soccer

The ideal scenario for a sports (or any other) eye injury is for it never to have happened. According to the US Centers for Disease Control and Prevention, “injury is probably the most unrecognized major health problem facing the nation today, and the study of injury presents unparalleled opportunities for reducing morbidity and mortality and for realizing significant savings in both financial and human terms—all in return for a relatively modest investment.”1 The social cost of eye trauma, the most common ophthalmic indication for hospitalisation, is enormous. National projections estimate annual US hospital charges of $175 million to$200 million for 227 000 eye trauma hospital days.2 Tan, in a recent BJO editorial, commented on prevention of blindness programmes, and stated that “let us then remind ourselves of prevention of blindness programmes which have the potential to do the greatest good for the most people.”3 By carefully evaluating the underlying mechanisms, patterns, and rates of injury in a given sport, it is possible to design and implement extremely effective preventive programmes.

Soccer ocular injury is an important eye health problem in Europe and probably worldwide.4–18 In these series, contrary to previous ophthalmology teaching that eye injuries are rarely caused by balls larger than 4 inches in diameter, the large diameter soccer ball was responsible for most soccer injuries. In 1994, Vinger focused on some pertinent questions related to soccer eye injuries.19 “How is sufficient energy transmitted from the large ball to the eye to result in severe lesions in many injured players? Are the eye injuries caused by ball deformation? Does underinflation result in more eye injuries than properly inflated balls? Are sports eye protectors currently in use for racket sports sufficient to prevent injury?” In the same chapter he proposed the future method of investigation, and stated that “impact testing of balls at varying speeds and pressures, with and without various eye protectors in place, using high-speed photography, should, in combination with prospective injury studies, answer these questions over the next several years.” In fact, several years elapsed to the publication, in this issue of the BJO (p 167), of a paper about the mechanism of soccer eye injuries, where the authors tried to address some of above mentioned questions and to lead off its prevention.

## MECHANISM OF INJURY

Although the differences between the opening of the bony orbit (1.4×1.6 inches) and the diameter of a standard soccer ball (8.6 inches), the laboratory experiments carried out confirmed that soccer balls deform significantly on impact, allowing a small “knuckle” of the ball to enter the orbit and impact the globe. Still more, it was proved that the soccer ball is unique among the sports balls tested: orbital penetration is lower, but the time in the orbit is longer, and during rebound a secondary suction effect is produced on the orbital contents. The expansion of the eyeball perpendicular to the direction of impact has been proposed as the major cause of the contusion injuries.20 The suction component most likely adds to the distortion of the globe anatomy, which can explain the findings of the clinical studies, showing that soccer injuries were disproportionately severe.6,7,9,12 On the other hand, the experiments showed that soccer ball penetration is not significantly related to the size of the ball or to the pressure, and even when they are not underinflated, they can deform on impact. These results support, in part, the most important finding in our previous prospective study that soccer eye injuries affected young athletes independently of age, sex and type of soccer, level of expertise or player position.7

### Key messages

• The soccer ball is unique among the sports balls tested: orbital penetration is lower, but the time in the orbit is longer and, during rebound, a secondary suction effect is produced on the orbital contents.

• We strongly recommend that soccer protective eyewear conforming to ASTM F803 should be worn.

• The future of soccer ocular injuries prevention has already started!

The assumption that when a large object such as a soccer ball hits the eye, more energy is directly transmitted to the exposed temporal retina while the nasal retina is protected by the nose, could explain the predilection of soccer eye injury lesions to the superotemporal quadrant found in our studies. Therefore, we should not forget that it is essential to examine the peripheral retina of all eyes that have had a soccer ball contusion injury, with particular attention for that quadrant.

## SOCCER EYE PROTECTOR

If protective devices are necessary then performance standards must be written to ensure that the protective devices will meet the visual requirements of the game while reducing the probability of injury to a specified level. The majority of sports eyewear standards written in the United States comes under the jurisdiction of ASTM (American Society for Testing and Materials, http://www.astm.org/), a non-profit corporation organised, as early as 1898, for development of voluntary standards arrived at by consensus, with strict guidelines for due process, among all interested parties.21,22 With the publication of this article we have the valuable information that protectors that comply with the requirements of ASTM standard F803 (and have polycarbonate lenses) will prevent eye contact with a soccer ball.

The need for protective eyewear in soccer remained far less clear than for other sports. Their use by children or adolescents presenting underdeveloped orbital structures was already previously considered. Now, we strongly recommend that soccer protective eyewear conforming to ASTM F803 should be worn also by adults, particularly for subjects who require prescription lenses, for functionally one eyed athletes, and for those who have had refractive surgical procedures that weaken the eye. The use of protective eyewear in soccer was recently popularised by a well known professional player of the Dutch national team, Edgar Davids. This fact led a sports equipment company to develop soccer eyewear. The future of soccer ocular injuries prevention has already started!

## CONCLUSION

In this new millennium, soccer may become the most common cause of sports eye injury worldwide. As physicians and surgeons, our mindset is towards the evaluation and treatment of eye disease. Injuries are predictable and, for most of them, preventable if we all make an eye safety prescription part of our routine.

Standards are designed to be revised as experience is gained. No matter how well the protector performs on paper or in the testing laboratory, it is the use by thousands of players and continued injuries monitoring that prove the protective value or demonstrate the failures of a particular design. Since 1992 we implemented a sports ophthalmology unit in our department of ophthalmology to follow athletes with sports related ocular lesions. The observation and treatment of these patients by specially trained personnel, using standardised protocols, will allow a better care, the accumulation of important epidemiological data, and it may have a special educational role for preventive measures. Alternatively, the development of further laboratory experiments combined with a better understanding of the biomechanics of eye injury will reveal additional alterations as a consequence of soccer ball blunt injury. International and national governing bodies, such as the “Federation Internationale de Football Association” (FIFA), should also be involved in these discussions and deliberations.

In the final comment of this editorial we have to honour Dr Paul Vinger for all the work developed in sports ophthalmology. Dr Vinger has devoted years of research time to the study of eye injuries, their mechanism, and prevention. These studies have led to the establishment of standards of eye protective equipment in racket sports, ski goggles, hockey face helmets, baseball face protectors, fencing headgear, equestrian head protection, paintball, and, since this issue of BJO, soccer eye protection.

## Note in Proof

Laboratory experiments have confirmed the mechanism of soccer ball eye injury and the feasibility of a protective eyewear in soccer

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