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Epidemiology of Sports-Related Eye Injuries in The United States
Epidemiology of Sports-Related Eye Injuries in The United States
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IMPORTANCE Ocular trauma can lead to lifelong sequelae, and sports-related ocular injuries
have been shown to disproportionately affect the young. Studies quantifying and
characterizing the incidence and type of injuries seen with sports-related ocular trauma may
be useful for resource utilization, training, and prevention efforts.
DESIGN, SETTING, AND PARTICIPANTS This retrospective, cross-sectional study examined the
Nationwide Emergency Department Sample, containing data from approximately 30 million
ED visits annually at more than 900 hospitals nationwide, from January 1, 2010, to December
31, 2013, to determine factors associated with sports-related ocular trauma.
MAIN OUTCOMES AND MEASURES Annual incidence of sports-related ocular trauma, broken
down by age, sex, mechanism of injury, and related activity, as well as factors associated with
short-term impaired vision.
RESULTS During the study period, 120 847 individuals (mean age, 22.3 years [95% CI,
21.9-22.7]; 96 872 males, 23 963 females, and 12 with missing data) presented with
sports-related ocular trauma, which was the primary diagnosis in 85 961 patients. Injuries
occurred most commonly among males (69 849 [81.3%]; 95% CI, 80.6%-81.9%) and
occurred most frequently as a result of playing basketball (22.6%; 95% CI, 21.7%-23.6%),
playing baseball or softball (14.3%; 95% CI, 13.7%-14.9%), and shooting an air gun (11.8%;
95% CI, 10.8%-12.8%). Odds of presentation to the ED with impaired vision were greatest for
paintball and air gun injuries relative to football-related injuries (odds ratio, 4.75; 95% CI,
2.21-10.19 and 3.71; 95% CI, 2.34-5.88, respectively; P < .001).
(Reprinted) E1
O
cular injuries are a significant cause of morbidity and
disability in the US population.1,2 The Centers for Dis- Key Points
ease Control and Prevention estimates that the an-
Question What activities led to the highest number of
nual rate of presentation to the emergency department (ED) sports-related eye injuries between 2010 and 2013 in the United
for all-cause ocular injury is approximately 37.6 per 10 000 States?
population.3 Eye injuries can have long-term sequelae that
Findings In a cross-sectional analysis of a nationally
affect quality of life for years and can predispose the indi-
representative emergency department database, 120 847
vidual to further injury, depression, and systemic disease.4-15 individuals presented to emergency departments nationwide
Visual impairment also poses substantial economic chal- between 2010 and 2013 with a diagnosis of sports-related ocular
lenges to patients, health systems, and payers, which may fur- injury, which was the primary diagnosis in 85 961 patients.
ther affect the patient’s access to quality care and follow-up.16-18 Basketball, baseball, and air guns were the most common causes
Sports-related activities contribute to a substantial pro- of injury, accounting for almost half of all primary sports-related
eye injuries.
portion of injuries in the ED, particularly among young
people.19-22 Although many of these injuries are musculosk- Meaning These findings may help set priorities and develop
eletal in nature, sports-related injuries to the central nervous strategies to try to reduce sports-related eye injuries among
system and eyes are not uncommon in EDs.21,23-30 Eye inju- individuals presenting to emergency departments in the United
States each year.
ries sustained in sports-related activities may differentially
affect young people, predisposing them to the possibility of
long-term sequelae and reduced quality of life.20,29,31-33
Previous efforts to estimate the national burden of
sports-related eye injuries have been hampered by inconsis- Ocular trauma was defined as a diagnosis of either blow-
tencies in how these injuries have been defined; for out fracture of the orbit, open wounds of the ocular adnexa
example, narrow definitions of the word sport, possibly or eye, superficial injury or contusion to the eye or adnexa, for-
influenced by regional and cultural differences, have exag- eign body on the external eye, burn confined to the eye and
gerated interstudy variability.5,34-37 Unclear definitions of adnexa, or injury to the optic nerve and pathways or cranial
delineations between organized sporting activities and rec- nerves III, IV, or VI (ICD-9-CM codes 802.6, 802.7, 870.x, 871.x,
reational sporting activities contribute to this variability. 918.x, 921.x, 930.x, 940.x, 950.x, 951.0, 951.1, and 951.3). These
A 2013 article by Selassie et al38 expanded the accepted defi- cases were further identified as either a primary or nonpri-
nition of sports-related injuries; using external cause of mary diagnosis of sports-related ocular trauma. Although the
injury codes from the International Classification of Diseases, acute and long-term effects of ocular injuries can be just as se-
Ninth Revision, Clinical Modification (ICD-9-CM), the authors vere or worse for patients for whom the eye-related injury is
were able to include injuries sustained during recreational not the primary diagnosis, including those associated with mo-
activities, such as swimming, running, and off-road power tor vehicle crashes, traumatic brain injury, and other polytrau-
and equestrian sports. Modifications to the ICD-9-CM imple- matic injuries, we focused much of our analysis on patients
mented in 2009 further expanded researchers’ ability to with primary diagnoses of ocular injury to more clearly elu-
characterize sports-related injury by differentiating between cidate which activities contribute most specifically to eye in-
specific team sports (eg, football, baseball, or basketball).39 jury. Patients with sports-related ED presentation were iden-
In light of these developments, we sought to estimate and tified using a list of ICD-9-CM external cause of injury codes
characterize the burden of sports-related ocular trauma in EDs compiled from examination of the literature and ICD-9-CM
in the United States from 2010 to 2013. codes available for the dates of interest (eTable in the Supple-
ment). This study was approved by the Johns Hopkins Medi-
cal Institutions institutional review board. The NEDS is an ad-
ministrative limited data set and individual patient consent was
Methods not required.
The Nationwide Emergency Department Sample (NEDS), We queried the NEDS database using the above criteria to
part of the Healthcare Cost and Utilization Project, is the identify all patients presenting to EDs in the United States be-
nation’s largest all-payer ED database; as such, it includes tween January 1, 2010, and December 31, 2013; before 2010,
data on all patients, regardless of insurance status. When details on injuries sustained while playing specific team sports
weighted to the level of the US population, the NEDS con- (eg, football, baseball, basketball) were either unavailable or
tains administrative discharge data on approximately 30 mil- not widely used, which limited their utility for the purposes
lion ED visits annually from more than 900 hospitals of this study. Data examined included visit-level data, such as
nationwide. 40 The NEDS and other Healthcare Cost and information related to the injury, diagnosis, ED-specific
Utilization Project data sets are often used by the National charges, geographic region, and expected primary insurer, as
Center for Injury Prevention and Control for the purpose of well as patient-level data, such as age, sex, and zip code–
epidemiologic statistics and surveillance, and compare based estimated income quartile. χ2 Testing was performed on
favorably with other well-established national samples, such these categorical variables to measure association, with P ≤ . 05
as the National Hospital Ambulatory Medical Care Survey considered significant. Population-specific rates were calcu-
and the National Hospital Discharge Survey.41,42 lated using data from the US Census Bureau.
The NEDS does not contain data on visual acuity, and al-
Figure 1. Rates of Primary Injuries by Sex and Age
though diagnoses of visual abnormalities may represent pre-
existing conditions, the likelihood that participants in sports 70
would have such a preexisting diagnosis is low. Multivariable 69
68
logistic regression modeling was used to explore the effect of 67
patient- and injury-level factors on the odds of impaired vi- 66 Male
65
sion, which included visual disturbances (ICD-9-CM code 64
Female
38
to the ED with sports-related ocular trauma; for 85 961 of 37
these individuals, ocular trauma was the primary diagnosis. 36
35
These 85 961 patients with primary sports-related ocular 34
trauma accounted for approximately 3.3% of all 2 636 037 33
32
patients with primary ocular trauma presenting to the ED 31
during the study period, and the 60 027 patients with iso- 30
29
lated sports-related ocular trauma represented 2.8% of all
28
2 156 962 patients with isolated ocular trauma (no other inju- 27
ries reported). Patients with primary sports-related ocular 26
25
trauma were most commonly male (69 849 [81.3%]; 95% CI, 24
80.6%-81.9%). Mean patient ages were 20.1 years (95% CI, 23
22
19.7-20.5) and 19 years (95% CI, 18.4-19.7) for males and 21
females, respectively (P < .001). Age-specific rates of injury 20
19
increased for every successive year from age 7 until age 15
18
years (among females) or age 17 years (among males), after 17
which they were markedly reduced (Figure 1). More than 16
15
half of the males (41 775 [59.8%]) and females (10 814 14
[67.1%]) who sustained sports-related primary ocular inju- 13
12
ries were 18 years or younger. 11
Basketball was the leading cause of injury among male pa- 10
9
tients (25.7%; 95% CI, 24.7%-26.7%), followed by baseball or
8
softball (13.2%; 95% CI, 12.5%-13.8%) and shooting an air gun 7
(12.7%; 95% CI, 11.7%-13.8%) (Table 1). Baseball or softball was 6
5
the most common cause of injury among female patients 4
(19.2%; 95% CI, 17.8%-20.7%), followed by cycling (10.8%; 95% 3
2
CI, 9.7%-12.1%) and soccer (10.3%; 95% CI, 9.2%-11.5%). Al- 1
though cycling accounted for the second-highest total num- 0
ber of eye injuries (n = 21 227), less than half of these injuries 0 10 20 30 40 50
(8319 [39.2%]) included a primary diagnosis of ocular trauma; ED Presentations per 100 000 Population
the same was true for ocular injuries associated with eques-
Population-based rate of presentation to the emergency department (ED) for
trian sports (310 [46.4%]) and off-road power sports (1873 primary diagnosis of sports-related ocular injury by sex and age, from January 1,
[35.4%]). The sport-specific proportion of ocular injuries iden- 2010, to December 31, 2013.
tified as primary vs secondary varied by sport, with soccer
Table 1. Injury Mechanism and Diagnosis Among Individuals With a Primary Diagnosis of Sports-Related Ocular Trauma,
From January 1, 2010, to December 31, 2013
Foreign body (930.x) 2068 (3) [2.7-3.3] 525 (3.3) [2.7-4] 2593 (3) [2.7-3.3]
Burn (940.x) 114 (0.2) [0.1-0.2] 73 (0.5) [0.3-0.8] 187 (0.2) [0.2-0.3]
Eye-related cranial nerves 125 (0.2) [0.1-0.3] 47 (0.3) [0.2-0.5] 172 (0.2) [0.1-0.3]
(950.x, 951.0, 951.1, 951.3)
(5688 [92.3%]), shooting an air gun (10 101 [91.1%]), and shoot- 30.7%); for baseball-related incidents, contusions (6331
ing a paintball gun (763 [89.7%]) demonstrating the largest pro- [51.5%]; 95% CI, 49.4%-53.7%) were most common, fol-
portions of patients presenting with sport-specific ocular in- lowed by orbital fractures (2568 [20.9%]; 95% CI, 19.2%-
juries identified as primary (Figure 2). 22.7%). Injuries sustained from shooting an air gun were
Overall, open wounds of the adnexa (ICD-9-CM code most commonly contusions (4818 [47.7%]; 95% CI, 44.9%-
870.x) were the most common type of injury (33.5%; 95% CI, 50.5%), followed by superficial wounds of the eye and
32.4%-34.5%), followed by contusions of the eye and adnexa adnexa (2946 [29.2%]; 95% CI, 26.9%-31.5%).
(ICD-9-CM code 921.x; 30.1%; 95% CI, 29.1%-31.1%) and Although only 3760 (3.1%) of all individuals who pre-
superficial injuries of the eye and adnexa (ICD-9-CM code sented to the ED with a diagnosis of ocular trauma had
918.x; 21.1%; 95% CI, 20.4%-21.8%) (Table 1). Among impaired vision, rates of visual symptoms varied widely by
basketball-related injuries, open wounds of the adnexa were sports-related activity, injury type, and age. The proportion
most common (9062 [46.6%]; 95% CI, 44.7%-48.4%), fol- of injuries resulting in impaired vision was highest for those
lowed by superficial wounds (5672 [29.1%]; 95% CI, 27.6%- injuries associated with paintball (10.2%), shooting an air
Table 2. Sports-Related Ocular Injuries, by Vision Impairment Status, From January 1, 2010, to December 31, 2013a
(continued)
Table 2. Sports-Related Ocular Injuries, by Vision Impairment Status, From January 1, 2010, to December 31, 2013a (continued)
Table 3. Odds of Impaired Vision Among Individuals Presenting to the Emergency Department With a Diagnosis
of Sports-Related Ocular Trauma, From January 1, 2010, to December 31, 2013
OR (95% CI)
Variable Adjusted P Value Unadjusted P Value
Activity
Football 1 [Reference] 1 [Reference]
Rugby 1.43 (0.48-4.23) 1.51 (0.51-4.50)
Baseball or softball 1.18 (0.74-1.88) 1.17 (0.75-1.85)
Lacrosse and field 1.06 (0.36-3.12) 1.05 (0.36-3.13)
hockey
Soccer 2.42 (1.5-3.91) 2.49 (1.55-3.98)
Basketball 0.95 (0.57-1.57) 0.99 (0.60-1.63)
Volleyball 1.51 (0.60-3.79) 1.64 (0.66-4.10)
Hockey 2.32 (0.82-6.52) 2.31 (0.81-6.64)
Paintball 4.75 (2.21-10.19) 5.03 (2.34-10.81)
Air gun 3.71 (2.34-5.88) 3.43 (2.16-5.45)
Racquet sports 2.29 (1.08-4.88) 2.53 (1.22-5.24)
<.001 <.001
Golf 1.44 (0.59-3.51) 1.59 (0.64-3.98)
Equestrian 1.76 (0.59-5.23) 2.00 (0.67-5.96)
Bowling NR NR
Jump rope NR NR
Track and field NR NR
Other individual 1.58 (0.76-3.29) 1.61 (0.78-3.36)
sports
Combat sports 0.77 (0.39-1.52) 0.80 (0.40-1.57)
Water sports 1.28 (0.64-2.54) 1.15 (0.58-2.27)
Cycling 0.66 (0.40-1.10) 0.69 (0.43-1.13)
Off-road sports 0.86 (0.45-1.64) 0.92 (0.49-1.73)
Other 0.59 (0.32-1.09) 0.40 (0.22-0.72)
(continued)
Table 3. Odds of Impaired Vision Among Individuals Presenting to the Emergency Department With a Diagnosis
of Sports-Related Ocular Trauma, From January 1, 2010, to December 31, 2013 (continued)
OR (95% CI)
Variable Adjusted P Value Unadjusted P Value
Age, y
0-9 1 [Reference] 1 [Reference]
10-19 2.76 (1.95-3.91) 3.70 (2.65-5.18)
20-29 2.67 (1.83-3.90) 2.92 (1.99-4.27)
30-39 3.12 (2.00-4.88) 3.29 (2.11-5.11)
.42 <.001
40-49 3.31 (2.10-5.22) 3.12 (2.00-4.87)
50-59 3.29 (1.96-5.54) 2.79 (1.70-4.58)
60-69 4.85 (2.70-8.70) 4.33 (2.46-7.63)
≥70 0.91 (0.21-3.95) 0.74 (0.17-3.19)
Sex
Male 1 [Reference] 1 [Reference]
.07 .65
Female 1.02 (0.82-1.27) 0.95 (0.77-1.18)
Income quartile, $
≤38 900 1 [Reference] 1 [Reference]
39 000-47 999 1.22 (0.93-1.61) 1.24 (0.95-1.62)
.046 .11
48 000-63 999 1.33 (1.01-1.76) 1.33 (1.01-1.75)
≥64 000 1.07 (0.78-1.46) 1.06 (0.77-1.46)
Month
January-March 1 [Reference] 1 [Reference]
April-June 1.09 (0.85-1.40) 1.00 (0.79-1.27)
.25 .77
July-September 1.12 (0.87-1.43) 1.01 (0.79-1.29)
Abbreviation: NR, not reported owing
October-December 1.14 (0.86-1.50) 1.12 (0.86-1.46)
to low values.
Although such approaches may be appropriate for orga- viduals engaging in these activities, along with individual
nized team sports, they are not likely to affect the burden of sports with high levels of injuries, such as cycling, will likely
sports-related ocular trauma due to nonorganized recre- require a coordinated approach from policy makers, indus-
ational sporting activities, including those most correlated try, and public health professionals. Further research is war-
with visual impairment, such as shooting paintball and air ranted to identify opportunities for intervention among
guns. Reducing sports-related ocular trauma among indi- sports participants.
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