Year on year, the incidence of sports-related ophthalmic trauma has been on an upward trajectory.12, 13 In this study, out of a total 3200 ophthalmic trauma cases uploaded onto the IGATES registry, an estimated 6.9% of patients had sports-related ophthalmic trauma. According to World Bank classifications, countries were classified as LMIC, Upper Middle Income County (UMIC), or HIC.35 Sports-related ophthalmic trauma cases are not common, when they do occur the trauma tends to be serious and frequently requires surgical intervention.13
In terms of gender affected, our study showed significant male predominance, consistent with the previous studies.14–20 Patients aged 20–39 years old were the most commonly age group, followed by children aged 6–19 years old (P > 0.05). The mean age of injury was in the 20s, which was in line with other studies.15,17–21 It is likely that children and adolescents are more susceptible to sports-related eye injuries due to their aggressive manner of playing, reduce experience and lack of appropriate adult supervision. Therefore, the adult supervision is needed for pediatric population during sports activities.
Similar to previous studies,16,20,22 we observed that closed globe injury accounted for the highest percentages of ophthalmic trauma associated with sport-related activities. Conversely, the United States epidemiology study reported that open wounds in adnexa injuries were dominant.15 Blunt trauma represented the majority mechanism of injury, this was similar to other recent studies.17,22
This multicenter study discovered that cricket was the leading cause of injury, followed by badminton and unspecified ball. This finding was different from a multicenter study in Korea that reported baseball, soccer, and hiking,17 and in the United States which noted basketball, baseball or softball, and airsoft gun, as the most prominent activities.15 While floorball was noted as the majority sports activity in Finland.20 Different and vast spectrum of popular sports activities from different countries causing this finding.
Cricket injuries occurred most often in 20–39 years old group and male patients, which were in line with other studies.23 Cricket represented the majority cause of injury and there were eight of 29 patients had poor visual outcomes from cricket injuries. This finding was different from a study by Sadiq et al,24 who noted cricket resulting severe or total vision loss in half of the eyes of cricket eye injuries study. Additionally, tip-cat game is very prevalent in rural India and might causes eye trauma. However, there are no specific data about this sports-related activity in our study.
The percentage of females participating in badminton was higher than in any other sports activity reported, this finding was similar to other studies.17 An epidemiology study in the US reported that a high number of males participated in basketball, and females participated in baseball or softball.15
We found that fishing was noted to result in poor visual outcomes in more than 50% of patients, which was similar to other studies.25 Due to its severe presentation, therefore we categorized it into the high-risk group. In 2000, at first, fishing was considered a medium-risk sports activity,26 but because of the severe eye damage, now it is considered a high-risk and dangerous sport. Fishing could affect the eyes from the fishhook, the lure striking the eye.27
This current study noted that AC injury, including hyphema, was the most common clinical finding, which was similar to recent multicenter studies in Korea,16 in the United States,25 and Serbia.13 Other common clinical findings in this study included iris injury (iris prolapse and iridodialysis). Conversely, a study by Choi et al17 reported eyelid injuries as the most frequent clinical finding. Badminton injuries resulted in the majority of AC, iris, and corneal injuries, while the others were noted due to soccer injuries.14, 28 Cricket caused the palpebral injuries, unlike other studies that reported.
Medium-risk and high-risk were the majority of sports activities. The proportion of ophthalmic trauma resulting in poor visual outcomes was the highest associated with cricket and fishing, while other studies reported paintball and airsoft guns,15 and Finnish ice hockey.20 Ocular injury in a college study suggested that basketball is a very dangerous sport due to three of eight eye injuries resulted from basketball.29
At time of presentation, the mean initial BCVA was 0.81 ± 0.89 LogMAR and the final BCVA was 0.57 ± 0.84 LogMAR (P < 0.001). Of note, 35/110 (31.8%) patients ended up blind as their final visual outcome. This result was higher compared to other studies in Indonesia (16.7%),25 and Finland (11%).20
Primary globe repair was the most common performed surgical procedure in this study, while other studies reported lid repairs as the most common procedures.20 Two-third of patients did not require any surgical intervention in our study. This was consistent with other studies that reported more than 80% of patients were treated by medical treatment alone.20 However, intravenous methylprednisolone injection for traumatic optic neuropathy could not be classified as non-surgery treatment. Yet, we did not have the specified data for this treatment in our study.
There were no previous studies analyzing prognostic factors in sports-related ophthalmic trauma. In this study, initial VA and scleral injury (P < 0.001, corneal injury, iris injury, anterior chamber injury, lens injury and posterior segment injury (P < 0.05) were found to be significant in predicting visual outcomes.
Only two patients reporting using eye protection in this study. All athletes and their parents should be made aware of the risks associated with participation in sports and the availability of certified sports eye protectors.21 Although eye protection cannot eliminate the risk of injury, appropriate eye protectors have been found to reduce the risk of significant eye injury by at least 90% when properly fitted.14, 31, 32 It would be ideal if all children and adolescents wore appropriate eye protection for all eye-risk sports and recreational activities.21 The American Academy of Pediatrics and the American Academy of Ophthalmology strongly recommend protective eyewear for all participants in sports in which there is a risk of eye injury. Protective eyewear should be mandatory for athletes who are functionally one-eyed and for athletes whose ophthalmologists recommend eye protection after eye surgery or trauma.21 The eye-injury risk of a sport is proportional to the chance of the eye being impacted with sufficient energy to cause injury. The risk is not correlated with the classification of sports into collision, contact, and noncontact categories. Instead, the risk of eye injury to the unprotected player is roughly categorized as high risk, moderate risk, low risk, and eye-safe.26
Well-recognition of sports situation, for example in squash, the player runs forward to the front of the court and then turns round to watch for the ball, which then strikes the player directly in the eye, also leading to injury prevention.17 Therefore, many studies on sports-related ophthalmic trauma emphasize the importance of wearing eye protective gear. A study in Finland reported that it is mandatory for football players to wear adequate eye protective gear while playing.20 Additionally, a study in Canada found that the incidence of eye injuries decreased after mandatory rules for the wearing of eye protection were established.33 Prevention is, therefore, the best management option and it has been suggested that more than 90% of trauma can be avoided.3 Eye protection has significantly reduced the number and severity of ophthalmic trauma.22
This study failed to show a significant association between optic nerve injury with final VA. The number of patients with traumatic optic neuropathy (TON) were eight. Five of them had visual acuity better than > 3/60. Low number of patients with TON and relatively good VA of the most of them can explain why analysis did not show a meaningful correlation with the final VA.
This multicenter study which included more than 30 centers in Asia Pacific regions, discovered that the epidemiology of ophthalmic trauma associated with sports-related has been difficult to assess until now; due to the broad variation in popularity of sporting activities between different countries and regions. The IGATES Registry has successfully recorded the data from ophthalmic trauma patients from various regions around the world. Therefore, the epidemiology of ophthalmic trauma in Asia Pacific regions can be adequately studied.34