Sports vision: What and how to prescribe ophthalmic products

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Introduction:

The changing face of sports from the old conservative amateur approach to a dynamic professional business has created many opportunities. The unprecedented interest of the media and the globalisation of television and the internet have made sports a major marketing tool. Like elsewhere in the world, athletes and coaches are investigating all the different legal (and sometimes illegal) options available to them to enhance performance and give them that edge over their competitors. This resulted in organisations identifying what is called key performance indicators. Sports vision is regarded as one of these indicators ^1,2.

The role of vision in sports performance is a topic that has always attracted considerable attention and has been studied quite extensively over the years. Quite recently statements and announcements made by a number of high profile professional sporting organizations and individuals on the contribution of sports vision to their success certainly resulted in even more public awareness.

In 1986 Reichow and Stern ³ formulated the following definition: Sports vision encompasses performance orientated comprehensive vision care programmes involving the education, evaluation, correction, protection and enhancement of the athlete. Each of these areas should be addressed in a performance oriented manner. This means that the practitioner should consider all his or her services from a performance standpoint. Improved visual performance resulting in enhanced athletic performance must be the ultimate goal of sports vision. Judging from all the enquiries I am receiving from optometrists there is indeed a keen interest to be involved in this discipline with the biggest market being the recreational athlete and children.

Early studies on sports vision originated in the disciplines of sport science and sport psychology. In optometry it seems that behavioural optometry has claimed it as part of their domain and that is certainly scaring away the more traditional optometrist. The reality is that optometry is the only profession that can provide the whole range of sports vision services. Sherman ⁴ already referred to the unique role that optometry can play in providing sports vision. He stated that the optometrist routinely provides vision care to athletes at different levels and this care should include corrective eye wear, protective eye wear and visual training to reinforce the role of optometry in enhancing sports performance. Furthermore, the notion that sports vision is only for the elite athlete is definitely not true, and as mentioned before most potential patients are children and the casual athlete.

Optometry is indeed the only provider for corrective and protective eye wear, while testing and training are also done even by people with sometimes very little training or education. All optometrists could (should) be able to provide corrective and protective eye wear. It only takes a different mind-set, knowledge of product ranges and a sound knowledge of the different sporting codes to understand the different demands and limitations for a given sport. In many sports, correction and protection go hand in hand. You cannot just think correction without considering protection ¹.

Recent experiences prompted me to write this article. I saw several patients who are recreational squash players wearing semi rimless frames. In a game like squash it is not the ball but the opponent’s racket that is the main cause of ocular injuries and wearing semi rimless frames create serious risk of ocular injuries. I am sure that this was not done deliberately but the issue of participating in sport was not addressed in the patient’s case history. More than 90% of people needing a prescription for sport are recreational athletes and not knowing this will put your patient at risk. Too often we concentrate on the few patients who are professional athletes. Doing a proper case history to find out if the patient does participate in sport is non-negotiable.

To understand peoples’ needs and the options available to you requires an intimate knowledge of the particular sport. On a recent conference I mentioned the fact that one of the sports responsible for the most ocular injuries in the USA, is angling and people laughed. Soon after I received a mail from someone who had just seen such a case.

The aim of this article is therefore to revisit the relevant principles involved in prescribing corrective and protective eye wear for people participating in sport. The greater involvement of optometry and ophthalmology in sports vision research during the 1970’s was guided by two aspects. First of all, the significant progress made in the development of soft contact lenses resulted in contact lenses becoming the primary visual correction for athletes. According to Lieblein⁵ a survey done by Bausch & Lomb in 1977 found that 86% of professional baseball, football, basketball and ice hockey players needing vision correction used contact lenses. More than 50% of them used soft contact lenses. During the late 1980’s a series of articles appeared describing considerations for fitting athletes with contact lenses for specific sports ⁶.

The second aspect concerned awareness of the risk of eye injuries in sport and about the role primary care practitioners play in the prevention of such injuries through education and the provision of protective eye wear. Vinger ⁷, in a study on ocular injuries in ice hockey players, and Vinger & Tolpin⁸ in a study on racket ball players drew attention to the incidence of serious eye injuries in sport. They were amongst the first to recognise that eye injuries in sports pose a substantial, but preventable risk. Estimates on the type and number of ocular injuries due to sports have largely been retrospective in nature and based on emergency room statistics or on information collected at large eye hospitals in the USA. These estimates may be as high as 100,000 eye injuries each year ^9,10. With the emphasis on prevention of such injuries, several studies reported on the use and development of eye protection standards ¹¹, and also resulted in a position statement by the International Federation of Sports Medicine ¹². This report provides guidelines for routine visual examinations, the identification of eye injury risk factors in sports and the factors to consider when prescribing corrective and protective eyewear for sports. Vinger probably has done more than anybody else to promote eye safety in sports and he was the driving force behind most of the efforts to test and develop eye protectors and produce universally acceptable safety standards. His original study published in the well-respected Duane’s Clinical Ophthalmology in 1985 has later been updated by Vinger ¹³ himself.

The best way to approach this issue would be to first of all establish the athlete’s needs. Combine that with the requirements for the specific sporting activity and the available products and you should have a satisfied customer. It sounds very simple, but once you begin to apply these principles many questions arise. Considering the wide range of sporting activities, visual demands, level of risk and environmental conditions, it is no easy task to make the proper recommendations. Add to this the plethora of ophthalmic products available and the choice becomes even more complex and difficult. It is therefore important to follow a systematic approach in assessing the three variables namely, the athlete, the sporting environment, and the available products.

The case history:

Effective patient counselling begins with a thorough case history to determine specific needs. Factors such as gender, age and level of participation should all be considered. Comprehensive education and recommendations on the use of various products will establish the practitioner as a valuable resource, and will ensure that your patients return to you. The athlete should be guided to make an informed decision about the best option for his or her individual needs. If spectacles are an option, the athlete should be counselled on the best lens characteristics, frame designs, tint characteristics and protection factors¹⁴.

Each sport presents with its own visual requirements and demands, and it is important to understand this before making any recommendations on visual correction and/or protection. It is common practice to start off by dividing sports into contact and non-contact sports, and you will find this even in optometric literature^14,15. Ferreira¹ clearly showed this kind of risk assessment to be totally inadequate in the world of sports vision. The angling incident referred to before, serves as a prime example of this. Therefore we need to follow a different approach in optometry when we consider the nature of the athletic activity and environmental factors that may come into play, to make an informed decision in providing corrective and/or protective eye wear.

Nature of the sports activity:

The practitioner is obliged to consider and analyse the specific sports activity and to understand the rules of the sport. Certain sports prohibits the use of spectacles and even goggles, while others may demand the use of protective eye wear. Rules are changing all the time and the practitioner should remain informed of these changes. Rugby is one of the latest sports to allow the use of goggles and a player from New Zealand used it in the 2020 World Cup. [Figure 1].

Figure 1. Goggles that rugby player used.

In field hockey the goal keeper is allowed to wear a protective mask, but now other players may also use masks “for short corners”. [Figure 2].

Figure 2 Hockey players wearing masks for “short corner”

You should be able to do a comprehensive task analysis on each sport to understand the visual requirements and limitations. An approach I find useful is to first of all, divide sports into active or sedate sports. Active is all sports where movement is required by the athlete and where visual response time is important. Sedate sports may require limited or no movement. These are sports such as billiards, lawn bowls, croquets, chess, shooting sports and gaming [i.e. computer games – will come back to this later]. Whatever the sport, the basic requirement remains comfortable and stable vision and protection against ocular injuries and environmental factors.

Environmental factors:

Erickson¹⁴ has made a whole list of the different environmental factors that should be considered. These factors also include the need to protect against ocular injuries. I have included several examples to assist the practitioner in his or her evaluation.

The presence of ocular hazards

This include all racket sports such as squash, tennis, badminton and also other sports such as ice hockey, hockey, cricket and baseball. Remember, quite often it is not the ball or puck, but the stick or racket that is responsible for ocular injuries. You should now also include angling on this list, since it has recently been named as the second highest risk sport for ocular injuries in the USA¹⁶. Mountain biking, cross country biking and cross fit also form part of this list.

The need for protection from impact for the eye, face and head.

This is mostly associated with contact sports such as rugby, boxing, oriental arts and American football, but also quite applicable in non-contact sports as mentioned above. This aspect emphasises the need to know the rules of the specific sporting activity. Many sports in the USA allow for protective head gear or goggles, and in sports such as ice hockey, racket ball, American football and fencing, it is even compulsory. Sports where it is not compulsory such as baseball and angling are now reporting the highest number of ocular injuries¹⁶. Sports emanating out of Europe were very slow in their awareness of ocular injuries. Take cricket for example: For many years batsmen were allowed to wear groin guards, but it is only recently that they allowed protective head gear. It is still not compulsory and it is not only batsmen but also players fielding close to the wicket that should be included. The current coach of the SA Proteas, Mark Boucher, is a classic example where his was hit in the eye by a bail from the wickets and caused ocular contusion and permanent scarring to his one eye.

The need for protection from solar radiation.

This is probably the one aspect all practitioners know about, and therefore we sell sunglasses. In a study done in 2003, again with cricket players, Ferreira showed that the choice of sunglasses was determined by – whatever the sponsor provided! Moore and Ferreira¹⁷ pointed out that there are several considerations required in selecting sunglasses for a specific sport. The most important being impact resistance to avoid ocular injuries.

Issues of visibility and mechanical forces with protection.

This aspect relates to the previous one and temples may be replaced by head bands to provide stability. [Figure 3].

The aspect of visibility often refers to the density of the tint. Moore and Ferreira¹⁸ clearly showed that high density tints may impact on visual evoked responses. Therefore it should be avoided in sports where visual acuity is critical. Another aspect that is often raised is the colour of the tint. I had the opportunity to visit the Adidas factory in Austria and we had a long discussion on this and they admitted to choose colours most people prefer in the European environment and it seems to relate to better contrast. If we take golf as an example: The courses are lush green and brown lenses provided a better contrast. Here in South Africa players seem to prefer grey or green lenses where our environment may often be more brown than green. Notwithstanding this Moore and Ferreira ¹⁷ found that choice of tint remains a very subjective issue. Visibility also plays an important role in most water sports and most athletes would wear protective goggles to keep water out of their eyes. In water polo it also protects the athlete against eye gouging.

Issues with sunlight conditions (variability and glare).

This again relates to solar radiation, but requires other considerations if the sporting environment is subject to glare from flat surfaces, affecting performance. In such cases Polaroid lenses are preferred by most people and will apply to all water sports, as well as sports where tarred roads, snowy or sandy environments come into play. Be careful though, since these lenses do block out light rays in the horizontal direction it can impact on depth perception. Therefore, it is not advisable for sports such as downhill skiing or for sports where athletes need to get information from liquid crystal displays (LCD), such as with boating and cycling¹⁹.

Issues with artificial lighting (colour perception and glare).

The most interesting case I had was someone playing indoor beach volleyball in Gauteng and had problems with the overhead lights. One may certainly consider an anti-reflex coating with tinted lenses, but nothing more than grade B. Another simple solution is to simply wear a cap.

Temperature issues that may affect ophthalmic products.

This only applies to extreme conditions, either hot or cold. The most common complaint is that of fogging and sweat with the wearing of protective goggles. In extreme cold conditions, one should be careful not to prescribe contact lenses. One should also refrain from using goggles with hinged temples.

Humidity conditions, especially low humidity with contact lens wear.

This again applies to extreme cold, very dry or hot conditions that may cause contact lenses to dry out and cause severe ocular discomfort.

Altitude factors that may affect oxygen transmission in contact lens wear. Mountaineering is becoming more popular by the day and I had several patients who climbed Kilimanjaro. High altitude means less atmospheric oxygen and therefor contact lenses should be avoided.
Dust and foreign body danger.

This applies to many outdoor sports, and protective eye wear should be encouraged in all these cases unless the rules the sport prohibits the wear of spectacles or goggles.

Sweat, fogging, and precipitation effects with ophthalmic products.

This is quite often the case with indoor sports such as squash, as well as billiards or snooker, when there is no air conditioning. Many sports such as cricket, hockey and athletics are now providing indoors options and these conditions will require additional considerations.

This list is by no means complete, but may assist the practitioner to make more informed decisions.

Prescribing for the athlete

They present at various ages and different levels of participation in sport related activities. It is important to note that eye protection is equally important for novices and experts. Vinger¹³has shown that the perception that experienced players is less at risk is a fallacy. Apart from needing eye protection, a considerable number of athletes will also need some kind of visual correction in conjunction with protective eyewear. People with only one eye or with a previous history of eye injuries should be regarded as high risk, and special attention should be given to safety precautions.

From my own experience, it is obvious that sporting activities are currently one of the main reasons why people would want to wear contact lenses. Not only is it regarded to be much more convenient and safer than spectacles, but it also allows for the use of protective eyewear in conjunction with the contact lenses. The athlete’s personal preference and the nature of the sporting activity are the most important factors in prescribing contact lenses. Several of my own patients would wear toric disposable lenses for daily wear and normal spherical disposable contact lenses for their sporting activities. In some cases the patients would even use daily disposable lenses for their sporting activities only. The scope of this article does not allow for a full explanation of this issue, but the important point here is that in certain sports where stable vision is of paramount importance, athletes may prefer slightly reduced, but constant visual acuity and therefore avoid toric lenses that may move around because of environmental conditions.

Contact lenses are also very popular because they offer many advantages in minimising the disadvantages found with most spectacle corrections. These relate specifically to poor optics, distortion, lack of safety and comfort ¹⁴. Although this may be true for the high performance athlete, and in sports where the wearing of spectacles or goggles are forbidden, I do not find this preference with the casual athlete. They simply prefer to use their habitual eyewear, or if no correction is required, any sunglasses. The main reason for this is because practitioners do not have the mindset to enquire about their participation in sport and suggest alternatives. Quite often protective eyewear is simply considered as the provision of sunglasses, but there is far more to protection than just providing for possible harmful or irritating environmental conditions. Even in the provision of sunglasses a clear distinction should be made between what we call fun glasses (pink, blue or purple lenses), dress wear (typically fashion wear), and performance wear (sport specific products). Frames should be flexible, adjustable and comfortable, and can even come with an insert. [Figure 4]

fig-4 — Figure 4. Performance wear with insert

No metal frames should be allowed in any sport where there is a risk of sustaining an eye injury. Most international companies have developed their own high quality frame materials, and with the wide range of products available you should be able to fulfill your patient’s needs. When it comes to lenses the minimum requirement is 3mm thick polycarbonate lenses. Gregory²⁰found that a considerable number of eye injuries are caused by the athlete’s own eye wear. That is for cases where these safety aspects were ignored. Several companies are currently conducting some interesting research and soon there will be materials that are even better than polycarbonate.

Sports goggles for specific sports:

Figure 5. Swimming goggles. Note that it comes with prescription lenses that can be changed.

Sports vision correction starts with the practitioner informing the patient about the advantages of sport specific eyewear to enhance performance and to provide adequate protection against injuries and environmental conditions. The use of sports goggles is very popular in many countries, and there are numerous sports specific products that can be worn over contact lenses or can have inserts or prescriptions fitted. Most of these products adhere to specifications laid down by various Standards Authorities. Many of them are very sport specific, such as diving masks and goggles for swimming, [Figure 5] skiing, flying and cycling.

Gallaway et al ²¹conducted research on the use of goggles and found athletes to complain about factors such as loss of peripheral field of vision, slowing down of visual reaction time, visual distortions, fogging of the lenses and general discomfort. From this it should be clear that the practitioner should think carefully in selecting the right eyewear. In a study by Oberholzer and Ferreira²² the authors found that many squash players will rather wear masks than goggles [Figure 6]

Gaming:

Computer games are now recognised as a sport and presents the practitioner with a new challenge. I have several patients that are professional gaming athletes. Two of them went to China last year to participate in the World Championships. A third one has now been offered a contract with a team based in Texas, USA. He has been allowed entrance into the USA on a sports visa. These athletes are sitting behind computers for hours and at a distance of 30 cm. What would you recommend to these athletes as far as sports eyewear is concerned?

Thus with a little bit of effort and study and very little capital layout, every optometrist can provide these services. It is a win-win situation since it adds value to your practice and to your patients.

References:

Ferreira JT, 2014. Is there a place for sports vision in private practice? MIMS OPTIMAG Volume 2, pp. 22-25
Ferreira JT, 2018. An overview on the practice of Sports Vision. Optical Assistant CPD, SB Media, http://www.sbmedia.co.za September 2018.
Reichow AW, and Stern NS. 1986. Optometric trends in Sports Vision. Optometric Extention Program Curriculum II, 59 (7) 355- 368
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Erickson G. 2007. Sports Vision. Vision care for the enhancement of sports performance. Butterworth Heinemann, Elsevier. Philadelphia
Loran DFC and MacEwen CJ. 1995. Sports Vision. Butterworth Heinemann. Oxford.
Hoskin AK Yardley AM Mackey DA 2015 Recreational fishing eye injuries and eye protection Acta Ophthalmologica vol 93 issue 8
Moore, L & Ferreira, JT. Eyewear and ocular protection patterns against solar factors in cricket players. Eyesite August 2005 pp 43.
Moore, L & Ferreira, JT. The effect of tinted lenses on visual evoked responses. International journal of Sports Vision, 2001.
Morgan E. 2019. Polarized sunglasses: best for reducing glare. allaboutvision.com. downloaded February 2020.
Gregory PTS. Sussex Eye Hospital sports injuries. J. Ophthalmology 1986 70 748 – 50.
Gallaway M, Aimino J, Scheiman M. The effects of protective sports eyewear on peripheral visual field and a peripheral visual performance task J Am Optom Assoc 1986 57(4) 304-310.
Oberholzer AD & Ferreira JT. The use of protective eyewear in the game of squash. South African Optometrist, 2003 62(4) pp 159 – 165.