Sports teams need detailed exams, follow-up

Professional athletes can present challenging situations for ophthalmologists

With more than 600,000 eye injuries related to sports and recreation every year, it’s no wonder the U.S. Department of Health and Human Services has deemed “increasing the use of protective eyewear” in recreation as one of its goals for its Healthy People 2010 initiative. Numerous sports are considered a high-to-moderate risk for eye injury, including basketball, baseball, softball, lacrosse, hockey, tennis, soccer, volleyball, water polo, football, fishing, and golf. Team sports are responsible for more than half of all sport-related eye injuries, according to the Coalition to Prevent Sports Eye Injuries (Hackensack, N.J.).
Some states’ high schools do not have a sports vision program, and until recently, several professional sports teams were also without an established program. When Rolando Toyos, M.D., Toyos Clinic, Memphis, Tenn., agreed to become the team ophthalmologist of the Memphis Grizzlies and Memphis Redbird AAA baseball there were no guidelines covering eye injuries—or ones for pre-existing conditions that might impact a professional’s career. Dr. Toyos founded the Sports Ophthalmic Society of the Americas to address those kinds of issues.
“Comprehensive screening exams are important, both to rule out eye disorders and to document any existing problems,” said Neil J. Friedman, M.D., Palo Alto, Calif., a former team ophthalmologist for the San Francisco 49ers. “It is important to measure ocular dominance, stereo-acuity, and perform cover and alternate cover testing to find subtle ocular misalignments.”
With pro athlete celebrities such as Tiger Woods endorsing elective procedures (LASIK), an emphasis on perfecting sight is more in the forefront of professional team coaching staffs’ minds. If previous injuries do exist, it is obviously important to do other specialized testing as warranted (for example, gonioscopy for previous hyphema to rule out angle recession), Dr. Friedman added. “The main thing is, when you’re dealing with someone who’s making millions off their vision, you need to document everything that might be out of the ordinary,” Dr. Toyos said. “If it’s not documented, that player might be able to go through his whole career and blame the injury on his profession. I’ve seen that happen with cases of congenital cataract and peripheral retinal scars. They hadn’t been documented, and when the player goes before his union, he claims disability. There are literally millions of dollars at issue with undocumented visual problems.”
Dr. Friedman recounted an NFL injury about a decade ago; the player recovered but the injury was a career-ending one. “In that case, it was very helpful that old exam records were available and thorough,” he said. Interestingly, “during my tenure as an NFL ophthalmologist, I noticed a higher than average incidence of amblyopia in players,” Dr. Friedman said.
In his experience, Dr. Friedman said “players who reported previous injuries mainly said these were minor and related to being poked in the eye with fingers. On screening exams, I did find a higher incidence of 4th nerve palsies than in the general population, and this is related to head trauma.”

Vision baselines

Henry L. Trattler, M.D., Center for Excellence in Eye Care, Miami, Fla., has been the team ophthalmologist for the Miami Heat since its inception into the NBA. In pro basketball, an on-court injury is treated either on the sidelines or in the locker room, Dr. Trattler said. “The Miami Heat wants their players to have the best vision possible,” he said, adding his pre-season vision testing has, upon occasion, caused the Heat to pass on signing a particular player. He believes pre-season vision exams “allow us to make sure there’s no pathology there that might damage vision in the future. You need that baseline for comparison.”
Baseline visual histories can be as simple as contact lens use or as extensive as including pressure readings, visual fields and the potential visual improvements an elective surgery such as LASIK may give them, said Kevin Everett, M.D., Henry Ford Eye Care Services, Michigan, and team ophthalmologist for the Detroit Lions. “People shouldn’t be surprised that pro athletes’ vision is as developed as the rest of their bodies,” he said. “In the NFL, I can tell you by position what players’ vision is. Quarterbacks, for instance, have great natural vision. None that I know of need any kind of corrective vision.”
The consumer press has consistently speculated that Ted Williams—“the greatest baseball player of all time,” Dr. Trattler asserts—had 20/10 vision. After retiring, he became a world renowned fisherman with “a lot of world records in fishing,” Dr. Trattler said, which convinced him Mr. Williams’ extraordinary vision was not overhyped. The NFL “pretty much has a doctor on the field for everything,” Dr. Everett said. “We’re on the field for every home game.” Mostly, on-field visual problems occur when a player has a contact lens knocked out, but “there is an occasional finger in the eye,” he added. Mostly, Dr. Everett works with the internist if/when a player has a concussion. When athletes are injured, the need to align expectations with reality is often challenging. “As a retina surgeon, I’m in a bit of a different situation than a team ophthalmologist,” said Pravin Dugel, M.D., managing partner, Retinal Consultants of Arizona, Phoenix. “When someone goes to see the general ophthalmologist after an injury, the outcome is usually good news. The news is always bad when people have to see me. It’s always a career-threatening injury and potentially devastating to their future eyesight. Pro athletes will seek out LASIK for better vision, but no one chooses to have ocular trauma.”
“It’s always rewarding to hear how refractive surgery has positively affected the lives of my patients, and for athletes, it usually comes in the form of better performance due to their new freedom from glasses or contact lenses,” Dr. Friedman said. For some professional sports, perfect vision is not as necessary as in other sports, Dr. Friedman said. When an athlete does have an ocular injury, occasionally there is a push on the part of the athlete or the team to clear the player earlier than might be warranted, but those situations are few and far between, Dr. Friedman said. Dr. Trattler said he’s never had to perform surgery on any of the Miami professional players. “They have a different pain threshold than most of us,” he said. “They can tolerate injuries much more easily. One of the problems we’ve had is sitting on them when there are injuries.”
Danny Schayes, a former NBA player (1981 to 1999), was injured during the playoffs when he was with the Heat, Dr. Trattler said. “Although his vision was 20/20 and there was no paralysis, a CAT scan of the orbit found it fractured all over the rim. When I asked him how it happened, he said he’d gotten an elbow in the face a few games earlier. He said it never bothered him. People like you and I would have been unconscious from the pain,” Dr. Trattler said. Dr. Toyos is currently working with the MLB, since a lot of players wear contact lenses. Numerous players have corneal abrasions resulting from dusty playing fields or poor compliance with non-overnight wear, he said.
“When they get up to the plate, the CL is dried out, vision isn’t as good as it should be, and this is exasperated in evening games,” he said. He’s working with some players now to use a four-second count and then get out of the box and blink to help moisturize their eyes, he said.
“A certain artificial tear we’re working with can help players stare at the pitcher for 7 seconds,” he said.
The HIPPA angle

In some cases, although the physicians will not comment on a particular injury, the consumer media will publish great details about an injury. For example, just this season NBA Phoenix Suns’ leading scorer Amare Stoudemire suffered a significant injury to his right eye during a February game that resulted in multiple tears and a traumatic retinal detachment. Dr. Dugel operated on Mr. Stoudemire and consequently determined the pro was out for the rest of the season. Media outlets from ESPN to the Arizona Sun reported on it daily, compromising doctor-patient confidentiality.
“As a physician, you want to respect the privacy of the player,” Dr. Dugel said. “I never talk to the press, unless the player and team want me to.” He said keeping a player’s confidentiality about surgical procedures is much easier during the off-season and a main reason most laser vision correction surgeries are performed during that time.
There may be pressure to clear an athlete earlier than medically advisable “when the playoffs or championship are on the line, and the athletes themselves are super competitive and want to play as soon as they can,” Dr. Friedman said. Regardless of whether or not the athlete is ready to return, “we have to do what’s medically right,” Dr. Friedman said. “On the other hand, outside of ophthalmology—in radiology, for instance—I’ve heard stories of guys out there with other injuries who milk it for what it’s worth.”
Dr. Toyos often cites the case of Dee Haynes, a professional baseball player whose numbers dropped significantly during evening games.
“He had a lot of higher order aberrations. Once we could correct that, he was much more consistent no matter when the game,” he said. Mr. Haynes agreed to tell his story after the fact to help other athletes realize how vision may be impacting their performance.
Just another patient

Dr. Toyos said overall he’s a bit leery of basketball players who want LASIK because of the likelihood of scratched corneas or minor abrasions, although he has not seen any NBA players who have undergone LASIK develop flap (or other) issues. “African-Americans are more prone to inflammation when it comes to a surface procedure,” Dr. Toyos said. “They need more time to heal, and compliance on that front might be an issue, especially when it’s a procedure they don’t view as ‘serious.’”
On the other hand, MLB players “are always looking for an advantage,” Dr. Toyos said, where visual acuity is not as important as dynamic visual acuity. In basketball, some professional players don’t have 20/20 and don’t want correction. Dr. Toyos became convinced all potential professional athletes should undergo visual screening when he was asked to consult on a player the Grizzlies had just signed to a $9 million, three-year contract. Although he had been seen by an internist and orthopedist, he was just considered to have “bad hands,” and it could be worked on. “Turned out this player was completely amblyopic in one eye. If he had one eye covered, he completely lost depth perception,” Dr. Toyos said. Needless to say, that particular player wasn’t very effective, and the Grizzlies soon traded him.

Editors’ note: Drs. Toyos, Friedman, Trattler, Everett, and Dugel have no financial interests related to their comments.

Contact information

Dugel: 602-222-2221, pdugel@gmail.com
Everett: 586-247-5910, Kevcol12@mac.com
Friedman: 650-324-0056, njfmd@pol.net
Toyos: 901-683-7255, rostar80@gmail.com
Trattler: 305-598-2020, htrattler@hotmail.com