The Fight Over Sight

Eye injuries are rare, but can be life altering. Is mandatory eye protection necessary for certain competitive sports?

By David Hill

David Hill is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 11.9, December 2001, http://www.momentummedia.com/articles/tc/tc1109/sight.htm

When the Tidewater League of Independent Schools in southeastern Virginia first mandated that all field hockey players wear protective eyewear, some members of the Norfolk Academy team showed up in racquetball goggles. Hard-pressed to find gear to meet the new rule, the athletes were doing the best they could. Some even came to practice with eyewear made for skeet shooting.

After some research, coaches, administrators, and the school's head athletic trainer found goggles made for lacrosse that would suffice. And this fall, Norfolk and others in its league completed their third year of requiring protective eyewear in field hockey.

For years, eye doctors have urged athletes to use protective eyewear in many sports. While some of their efforts have succeeded (for example, face guards are now common in ice hockey), most other high school and collegiate sports have dismissed protective eyewear as impractical or unnecessary.

But that may be changing. The NCAA is deciding whether or not to require protective eyewear for women's lacrosse, and the Massachusetts Interscholastic Athletic Association (MIAA) and some other leagues around the country already require protective eyewear for all field hockey players.

Similar pushes for protective eyewear could come to even more sports. Many regional youth baseball leagues require face guards for batters and fielders. Some people on both sides of the issue ask, if only rhetorically, why not do something about basketball's finger-in-the-eye phenomenon by at least encouraging more use of sports goggles? The American Academy of Ophthalmology (AAO) recommends just that for basketball, and it is pushing for eye-protection mandates in youth sports, particularly baseball, with hopes that the practice will then continue into older age groups, including high school and college. In all instances, the moves are controversial.

As intermediaries between healthcare and sports programs, athletic trainers may find themselves pulled in conflicting directions. Doctors, athletes, coaches, administrators, and parents turn to you for advice, help, and perhaps advocacy. Answers won't be easy to come by. Here is a look at how the eye protection issue is shaping up for two sports on the forefront of the debate.

LENSES FOR LACROSSE
In June 2000, a proposal came before the NCAA's Committee on Competitive Safeguards and Medical Aspects of Sports to begin mandating protective eyewear in women's lacrosse championship play. The proposal was referred to a special panel of coaches, officials, athletic directors, and organizers of the championships from each NCAA division, plus a representative of US Lacrosse. The Women's Lacrosse Protective Eye Wear Project Team, as the panel is known, is collecting data on whether there is a need for more protection, whether appropriate eyewear is available for college play, and how a rule change could affect the sport.

This isn't the first time US Lacrosse has encountered the eye protection issue. Several years ago, at the request of some parents and coaches in youth leagues, the organization specified that optional protective eyewear is allowed but the gear must meet a standard for sports protective eyewear set by the American Society of Testing and Materials (ASTM). ASTM's sports facilities and equipment division developed a standard for lacrosse eyewear, and manufacturers started offering them.

A major question now is whether the standard is appropriate for the college women's game, where the athletes are stronger and ball and stick speeds are presumably much higher than in youth leagues. Another concern is whether protective eyewear might give women lacrosse players a greater sense of security and lead to more risk taking--negating the restrictions on checking and stick handling that distinguish the women's game from the helmeted, padded men's game.

"Even though it's illegal, will they tend to risk checking around the head if eye protection is mandated?" asks Nancy Burke, ATC, Athletic Trainer at South Lakes High School in Falls Church, Va., Chairwoman of the Women's Lacrosse Protective Eye Wear Project Team, and US Lacrosse's representative to the team.

Experience in central New York state suggests that won't happen. Goggles have been required by Section III of the New York State Public High School Athletic Association for several years and, according to Doug Rowe, who has been Head Coach of girls' lacrosse at Baldwinsville (N.Y.) High School for 11 years, play hasn't become more aggressive or dangerous. In Rowe's view, goggles make sense as the athletes become stronger and more confident, sending sticks and balls flying with ever greater speeds. And even if mandated eye protection were followed by helmets, it need not spell the end of the girls' and women's game, Rowe believes, because rules against checking and high-sticking could be retained and enforced--just as spear-tackling with the helmet was outlawed in football.

As for player acceptance, "If you don't allow the kids to make it an issue, they're fine," Rowe says. "We tell them, 'A rule's a rule. Put 'em on.'"

MASSACHUSETTS MANDATE
The Massachusetts directive requiring eye protection for field hockey has also had its share of question marks. The rule was first announced in February 2000 on the heels of lawsuits over devastating student-athlete eye injuries in New England. It then was suspended a year until sport-appropriate goggles could be found. Now implemented, some coaches are fighting the rule.

Donna Woodcock, winner of two state championships in two different divisions as Head Coach at Greenfield High School in western Massachusetts, says the effect on vision frustrates many players. The model that meets all MIAA-recommended standards fogs up, especially at night, she says. Woodcock estimates she's had only three or four players suffer eye injuries requiring stitches in her 20 years at Greenfield and believes too little research was done to justify a mandate that singles out field hockey.

"Let's get a database to see what the number-one injury is, what sports these injuries occur in, and what the options are to decrease the likelihood of injuries in athletics," she says. "I don't think a thorough study has been done on the situation."

Massachusetts State Field Hockey Coaches Association President Leda Levine, of Mansfield High School, says that coaches fought the rule, but they see little hope of an immediate repeal. If eye protection is so vital, don't single out field hockey, she adds. "Do it with every sport that has a flying object. Don't discriminate against a girls' sport."

U.S. Field Hockey, the sport's national governing body, takes no position on the matter, Communi-cations Director Howard Thomas says. It's waiting to see research on injury rates and the effectiveness and safety of protective eyewear at certain levels of the sport.

THE ADVOCATE ARGUMENT
Other people say there's no point in waiting. "The difference between a one-eyed person and a two-eyed person throughout their life is enormous," says Paul Vinger, MD, a Boston-area ophthalmologist who helped the MIAA study eye injuries and served as a consultant to at least one manufacturer and a certification group. "If there's a risk that's easy to avoid in order to prevent a catastrophic loss, it's senseless not to do something about it."

That's how the AAO sees the eye-protection question, says Stuart Dankner, MD, a Baltimore pediatric ophthalmologist and eye-safety spokesman for the organization of eye physicians. Injury is the top cause of blindness in children, and many blindness-causing injuries occur during sports participation, Danker says. The AAO is focusing first on major sports with the largest number of injuries that lead to blindness--baseball and basketball--but it recommends eye protection for most sports.

For example, Dixie Youth Baseball now mandates helmet-mounted face shields for its 500,000 players when batting. That mandate not only practically eliminated face and eye injuries, but cut its insurance premiums by half and found players replacing the fear of getting hit by a pitch with a focus on their skills, Dankner says. The move faced opposition in the proposal stages, but that disappeared once coaches saw the shields in action. Now, a similar mandate is before Baltimore's city government for its youth baseball leagues, and eye protection for girls' lacrosse has been discussed in Maryland.

"That hard lacrosse ball can fit right into the socket of the eyeball, and the injuries caused by such an impact can be devastating," Dankner says. "I can't say we see a lot of these types of injuries, but when we do see them, they tend to be very severe. Why not protect the girls? You can still have the female rules [limiting checking] if you want them, but I don't think there is any reason why they can't wear that protection. The same would go for field hockey."

THE ATHLETIC TRAINER'S ROLE
Whether or not more leagues and schools mandate eye protection in various sports, athletic trainers will face questions about the debate and the equipment. What is your role in deciding whether protective eyewear is necessary? Should you take the safety-first side and advocate it for all athletes? Should you point out that sports have inherent risks, and that trying to protect for every possible occurrence can quash competition and take the fun out of athletics? Should you raise the issue of an increased sense of security perhaps leading to rougher play and other injuries? Is there a middle ground? And what should an athletic trainer do to help athletes and coaches reach and implement their decisions?

"The issue of wearing goggles is about prevention," says Christine Brown, ATC, PT, Athletic Trainer at Wayland High School in Massachusetts and a member of the MIAA Sports Safety Committee. "It's important, and it works. We should do it, as long as the eyewear doesn't cause any injuries."

Brown says that the mandate probably reduced injuries to her school's field hockey players in just the first few weeks of the season, and that some players and coaches who were skeptical began appreciating the equipment more as the season progressed. Goggles, however, take some getting used to, and the models available either fog up or restrict peripheral vision, she adds.

Other athletic trainers would like to see more scientific data on eye injuries before putting a mandate in place. "Is there proof that goggles are effective?" asks Jon Almquist, ATC, Specialist for the athletic training program in the Fairfax County, Va., Public Schools and Chairman of the Secondary School Athletic Training Committee for the National Athletic Trainers' Association. "You would assume that the answer is yes, but we do not have the data to actually support that. We can only assume that if the person has goggles on, the eye won't be injured to the extent that it is without them."

Fairfax County schools are considering whether to require protective eyewear in girls' lacrosse this coming spring and for field hockey next fall. That, coupled with the district's extensive athletic training program--covering 98 percent of events--and a computerized injury record-keeping system, means that Fairfax County may be able to provide some hard data on the question in a few years.

Another approach is to require protective eyewear for any athlete needing to guard a recovering eye or a remaining healthy eye. "Because we do have some eye gear, maybe some kids are playing who couldn't play before because they're now better protected," says Boston College Senior Associate Head Athletic Trainer Donna Bennett, LATC.

Bennett has helped athletes find gear--sometimes by working with optometrists and opticians on custom models--that balance adequate protection with wearability and comfort. She also helps the athletes solve problems with goggle use. To fight fogging, for instance, an old trick of soapy water on the glass followed by a good rinse seems to help, Bennett says.

At the Norfolk Academy, Head Athletic Trainer and Assistant Director of Athletics Chad Byler, ATC, chose to act as an advocate who explained the injuries, their causes, and available options. A benefit of this approach is that going through the decision process may make fellow athletic trainers, administrators, and coaches examine other safety factors, some of which may be more important, he says. In the case of field hockey in his region, poor field maintenance often caused balls to bounce dangerously high. In some games, officials were not consistently enforcing high-stick rules. And at Norfolk, when the skill level of the players was taken into account, it was clear that coaching proper, stick-to-the-ground and head-up technique would be no panacea.

"We have seventh-grade girls who have never played field hockey, and all of a sudden they have a stick out there and they're swinging it around," Byler says. "In a perfect world, the sticks are down on the ground, the fields are perfectly flat, and the referees are magnificently trained. But we don't live in a perfect world."

Almquist agrees that athletic trainers should take a proactive stance. "The athletic trainer's role is to raise the issue and continually evaluate injuries," he says. "If you see something wrong, look into it further. It could also just mean that you need to tell officials and coaches that your athletes are getting a lot of eye injuries. Then let them come up with the reason and perhaps fix their own problem. That's all within the scope and practice of an athletic trainer."


SIDEBAR ONE: A PUSH FROM PARENTS

At Norfolk Academy in southeastern Virginia, the push for goggles first came from students' parents. After a string of serious eye injuries, parents of players at the private school began writing to the headmaster about protective eyewear for field hockey and girls' lacrosse players.

Chad Byler, ATC, Norfolk Academy's Head Athletic Trainer and Assistant Director of Athletics, researched the matter and developed proposals. His headmaster said to go with a mandate in field hockey and lacrosse, and other members in the academy's league decided they'd do the same, eventually agreeing to a conference-wide rule.

The field hockey establishment, including some coaches, opposed it, but field hockey at Norfolk Academy went from nine major eye injuries in three years to none since the rule took effect two years ago. That includes 90 girls in grades seven through 12 playing daily, Byler says.

The goggles are now standard equipment, and the mandate ensures that aesthetics and fear of looking different won't win out over safety. "A teenaged girl doesn't want to be the strange one out there," Byler says. "If everyone wears them, they think, 'OK, everyone else is looking weird, so I can look weird.'"


SIDEBAR TWO: DOCTORS GO FOR GOGGLES

The American Academy of Pediatrics and the American Academy of Ophthalmology issued a joint statement in early 1996 titled, "Protective Eyewear for Youth Athletes." The organizations recommend mandatory protective eyewear for all functionally one-eyed individuals and for athletes who have had eye surgery or trauma and whose ophthalmologists recommend eye protection. They strongly recommend protective eyewear for all other athletes and include a list of types of protection for 24 sports. For field hockey and women's lacrosse, they recommend sports goggles with polycarbonate lenses and add that helmets with full-face protection should be optional for women's lacrosse.

A smaller list for many major sports, complete with which certification labels to look for, is on the Web site of the American Academy of Ophthalmology at www.aao.org.


SIDEBAR THREE: CHOOSING THE GEAR

If you fire a squash ball going 90 miles per hour at a pair of industrial protective spectacles, one of two things can happen, according to Paul Vinger, MD, a Boston ophthalmologist and sports protective eyewear consultant. In one scenario, the impact breaks the frame, but the polycarbonate lens remains intact. However, a piece of that broken frame--or the intact lens--could still strike the wearer's eye.

Vinger's second scenario occurs when the lens is made of tempered glass or allyl plastic resin instead of the more impact-resistant polycarbonate. In this instance, the impact of the squash ball shatters the lens into hundreds of tiny bits that fly toward the eye. Tempered glass and allyl plastic are common in some prescription glasses or high-end sunglasses, while polycarbonate is more common in shooting glasses. Despite the varied materials in the eyewear, the wearer does not receive adequate protection in either scenario.

This, according to Vinger, is why not just any protective eyewear is correct for athletes. Vinger is author of a June 2000 article in The Physician and Sports Medicine entitled, "A Practical Guide for Sports Eye Protection." In the article, Vinger makes a case for sport-specific eye protection. Others, including coaches and athletic trainers, say sport-specificity isn't so critical, as long as some basics are kept in mind. What follows is a starting point for athletic trainers trying to navigate the protective-eyewear sea, whether for a whole team or a few players who need or want the gear.

Seek lenses made of polycarbonate, a plastic developed originally for the aerospace industry. "Polycarbonate is about 20 times stronger than plastic. It's almost bullet-proof," says Joseph Koltun, a New York City optometrist who specializes in prescription sports eyewear. "In airplanes, the pilot's window is probably made out of some sort of polycarbonate."

Look for products that meet developed standards for sports equipment. An organization familiar to many athletic trainers and coaches, the National Operating Committee on Standards for Athletic Equipment, certifies much of the protective equipment used in high-contact sports such as football, ice hockey, and men's lacrosse. For other sports, the American Society of Testing and Materials (ASTM) has standards for many other pieces of eye and face protective equipment. For example, the F-803 standard is for models intended for use in selected sports, including women's lacrosse, field hockey, racket sports, basketball, and for baseball fielders.

Other ASTM standards cover ice hockey goal tenders, other ice hockey players, paintball, youth baseball, and skiing. For sports without a specific standard, the American Academy of Ophthalmology suggests using the F-803 standard.

Some people suggest seeking out products that have been further tested in laboratories (ASTM standards certify only that the products have been designed and manufactured to certain standards). For eyewear, there is the Protective Eyewear Certification Council (www.protecteyes.org), which tests the products in an independent laboratory. Some manufacturers, however, say PECC certification isn't necessary as long as the products meet the ASTM standard.

The lens should extend beyond the orbit of the eye to the top of the cheekbone and bottom of the brow. This helps prevent the lens from being pushed into the eyeball. Some designs have brow pads above the lenses.

Not all designs can be worn over prescription glasses. Athletes who wear prescription glasses may need larger models. Prescription protective sports eyewear is available but is usually costly and must be custom made.

When possible, use goggles made for the specific sport. "If you put on a racquetball goggle and go out on a field hockey field, that goggle might not be able to tolerate a hit from a ball or stick," says Chad Byler, ATC, Head Athletic Trainer and Assistant Director of Athletics at Norfolk (Va.) Academy, which is in its third year of mandated protective eyewear for all field hockey players.

In humid or cold weather, be aware of fogging. In an early-season Massachusetts field hockey game this fall, the officials called a time-out after a few minutes and instructed the players to wipe off their lenses. Snug-fitting goggle-style models will generally offer greater peripheral vision, but they may be more fog-prone than more open designs.

While many designs are sold as one-size-fits-all, some coaches have found that's not true, especially with smaller athletes. Some makers are responding with sized eyewear, so it might pay to have fitting sessions if they can be arranged.

Shop around. While some eye doctors had warned that manufacturers would not develop a field-hockey-only model out of a belief the market was too small, some makers have done just that and are seeking feedback from athletes and coaches, says Leda Levine, Head Field Hockey Coach at Mansfield High School and President of the Massachusetts State Field Hockey Coaches Association. Levine, not a fan of her state's new eye-protection mandate, is keeping track of features she'd like to see added to the model her team is using, such as more size options, better headbands, and a place for the players' names. "I have to admit that the goggle is not perfect, but compared to what it was three years ago, this is an excellent product. It'll be worn for lacrosse because it's better than the lacrosse goggle."