Research

JAMA Ophthalmology | Original Investigation

Epidemiology of Sports-Related Eye Injuries in the United States

R. Sterling Haring, DO, MPH; Isaac D. Sheffield, BS; Joseph K. Canner, MHS; Eric B. Schneider, PhD

Supplemental content
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.

OBJECTIVE To examine the emergency department (ED) burden of sports-related ocular

trauma in the United States.

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).

CONCLUSIONS AND RELEVANCE In our study, approximately 30 000 individuals presented

annually to EDs in the United States with sports-related eye injuries; in more than 70% of
these cases, eye injuries were the primary diagnosis. Activities involving projectiles pose the
greatest risk for visual impairment in the short term, although long-term outcomes were
unavailable.
Author Affiliations: Center for
Healthcare Quality and Patient
Safety, University of Lugano, Lugano,
Switzerland (Haring); Center for
Surgery and Public Health, Harvard
Medical School, Boston,
Massachusetts (Haring, Sheffield,
Schneider); Department of Health
Policy and Management, Johns
Hopkins Bloomberg School of Public
Health, Baltimore, Maryland (Haring,
Schneider); Johns Hopkins Surgery
Center for Outcomes Research, Johns
Hopkins School of Medicine,
Baltimore, Maryland (Haring, Canner,
Schneider); Carver College of
Medicine, University of Iowa, Iowa
City (Sheffield).
Corresponding Author: R. Sterling
Haring, DO, MPH, Center for
Healthcare Quality and Patient
Safety, University of Lugano, Via G.
JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2016.4253 Buffi 13, 6900 Lugano, Switzerland
Published online November 3, 2016. (sterling.haring@jhmi.edu).

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 Research Original Investigation
O
cular injuries are a significant cause of morbidity and
disability in the US population.1,2 The Centers for Dis-
ease Control and Prevention estimates that the an-
nual rate of presentation to the emergency department (ED)
for all-cause ocular injury is approximately 37.6 per 10 000
population.3 Eye injuries can have long-term sequelae that
affect quality of life for years and can predispose the indi-
vidual to further injury, depression, and systemic disease.4-15
Visual impairment also poses substantial economic chal-
lenges to patients, health systems, and payers, which may fur-
ther affect the patient’s access to quality care and follow-up.16-18
Sports-related activities contribute to a substantial pro-
portion of injuries in the ED, particularly among young
people.19-22 Although many of these injuries are musculosk-
eletal in nature, sports-related injuries to the central nervous
system and eyes are not uncommon in EDs.21,23-30 Eye inju-
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-
tencies in how these injuries have been defined; for
example, narrow definitions of the word sport, possibly
influenced by regional and cultural differences, have exag-
gerated interstudy variability.5,34-37 Unclear definitions of
delineations between organized sporting activities and rec-
reational sporting activities contribute to this variability.
A 2013 article by Selassie et al38 expanded the accepted defi-
nition of sports-related injuries; using external cause of
injury codes from the International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM), the authors
were able to include injuries sustained during recreational
activities, such as swimming, running, and off-road power
and equestrian sports. Modifications to the ICD-9-CM imple-
mented in 2009 further expanded researchers’ ability to
characterize sports-related injury by differentiating between
specific team sports (eg, football, baseball, or basketball).39
In light of these developments, we sought to estimate and
characterize the burden of sports-related ocular trauma in EDs
in the United States from 2010 to 2013.
Methods
The Nationwide Emergency Department Sample (NEDS),
part of the Healthcare Cost and Utilization Project, is the
nation’s largest all-payer ED database; as such, it includes
data on all patients, regardless of insurance status. When
weighted to the level of the US population, the NEDS con-
tains administrative discharge data on approximately 30 mil-
lion ED visits annually from more than 900 hospitals
nationwide. 40 The NEDS and other Healthcare Cost and
Utilization Project data sets are often used by the National
Center for Injury Prevention and Control for the purpose of
epidemiologic statistics and surveillance, and compare
favorably with other well-established national samples, such
as the National Hospital Ambulatory Medical Care Survey
and the National Hospital Discharge Survey.41,42
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Epidemiology of Sports-Related Eye Injuries in the United States
Key Points
Question What activities led to the highest number of
sports-related eye injuries between 2010 and 2013 in the United
States?
Findings In a cross-sectional analysis of a nationally
representative emergency department database, 120 847
individuals presented to emergency departments nationwide
between 2010 and 2013 with a diagnosis of sports-related ocular
injury, which was the primary diagnosis in 85 961 patients.
Basketball, baseball, and air guns were the most common causes
of injury, accounting for almost half of all primary sports-related
eye injuries.
Meaning These findings may help set priorities and develop
strategies to try to reduce sports-related eye injuries among
individuals presenting to emergency departments in the United
States each year.
Ocular trauma was defined as a diagnosis of either blow-
out fracture of the orbit, open wounds of the ocular adnexa
or eye, superficial injury or contusion to the eye or adnexa, for-
eign body on the external eye, burn confined to the eye and
adnexa, or injury to the optic nerve and pathways or cranial
nerves III, IV, or VI (ICD-9-CM codes 802.6, 802.7, 870.x, 871.x,
918.x, 921.x, 930.x, 940.x, 950.x, 951.0, 951.1, and 951.3). These
cases were further identified as either a primary or nonpri-
mary diagnosis of sports-related ocular trauma. Although the
acute and long-term effects of ocular injuries can be just as se-
vere or worse for patients for whom the eye-related injury is
not the primary diagnosis, including those associated with mo-
tor vehicle crashes, traumatic brain injury, and other polytrau-
matic injuries, we focused much of our analysis on patients
with primary diagnoses of ocular injury to more clearly elu-
cidate which activities contribute most specifically to eye in-
jury. Patients with sports-related ED presentation were iden-
tified using a list of ICD-9-CM external cause of injury codes
compiled from examination of the literature and ICD-9-CM
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
not required.
We queried the NEDS database using the above criteria to
identify all patients presenting to EDs in the United States be-
tween January 1, 2010, and December 31, 2013; before 2010,
details on injuries sustained while playing specific team sports
(eg, football, baseball, basketball) were either unavailable or
not widely used, which limited their utility for the purposes
of this study. Data examined included visit-level data, such as
information related to the injury, diagnosis, ED-specific
charges, geographic region, and expected primary insurer, as
well as patient-level data, such as age, sex, and zip code–
based estimated income quartile. χ2 Testing was performed on
these categorical variables to measure association, with P ≤ . 05
considered significant. Population-specific rates were calcu-
lated using data from the US Census Bureau.
jamaophthalmology.com
 Epidemiology of Sports-Related Eye Injuries in the United States Original Investigation Research

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

368.x) and blindness and low vision (ICD-9-CM code 369.x); 63

62
as with others, these diagnoses are only present in the medi-
61
cal record if they were made at the time of the ED visit, so lack 60
of a vision-related code may reflect either unimpaired vision 59
58
or that assessment of vision was not performed. As this model 57
was explanatory in nature, stepwise variable selection for par- 56
55
simony was not used. Wald tests were used to assess the ef- 54
fect of individual variables on the model, and P ≤ .05 was con- 53
52
sidered significant.
51
Standard descriptive statistical methods were used to ana- 50
lyze associations between patient, injury, and hospital char- 49
48
acteristics and presentation to the ED with sports-related ocu- 47
lar injuries. 46
45
44
43
42
Results 41
40
39
During the 4-year study period, 120 847 patients presented
Age at Presentation, y

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-
trian sports (310 [46.4%]) and off-road power sports (1873
[35.4%]). The sport-specific proportion of ocular injuries iden-
tified as primary vs secondary varied by sport, with soccer
Population-based rate of presentation to the emergency department (ED) for
primary diagnosis of sports-related ocular injury by sex and age, from January 1,
2010, to December 31, 2013.

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 Research Original Investigation Epidemiology of Sports-Related Eye Injuries in the United States

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

No. (%) [95% CI]

Male Female Total
Characteristic (n = 69 849) (n = 16 112) (N = 85 961) P Value
Activity
Football 4320 (6.2) [5.6-6.7] 273 (1.7) [1.3-2.2] 4593 (5.3) [5-5.7]
Rugby 491 (0.7) [0.6-0.9] 65 (0.4) [0.2-0.7] 556 (0.6) [0.5-0.8]
Baseball or softball 9191 (13.2) [12.5-13.8] 3096 (19.2) [17.8-20.7] 12 287 (14.3)[13.7-14.9]
Lacrosse 594 (0.9) [0.7-1.1] 280 (1.7) [1.3-2.3] 873 (1) [0.8-1.2]
Soccer 4027 (5.8) [5.4-6.2] 1662 (10.3) [9.2-11.5] 5688 (6.6) [6.2-7.1]
Basketball 17 935 (25.7)[24.7-26.7] 1527 (9.5) [8.5-10.6] 19 463 (22.6)[21.7-23.6]
Volleyball 380 (0.5) [0.4-0.7] 324 (2) [1.6-2.6] 705 (0.8) [0.7-1]
Hockey 668 (1) [0.8-1.2] 47 (0.3) [0.2-0.5] 715 (0.8) [0.7-1]
Paintball 700 (1) [0.8-1.3] 63 (0.4) [0.2-0.7] 763 (0.9) [0.7-1.1]
Air gun 8887 (12.7) [11.7-13.8] 1214 (7.5) [6.5-8.7] 10 101 (11.8)[10.8-12.8]
Racquet sports 1222 (1.7) [1.5-2.1] 364 (2.3) [1.8-2.8] 1586 (1.8) [1.6-2.1]
<.001
Golf 785 (1.1) [0.9-1.3] 184 (1.1) [0.8-1.6] 969 (1.1) [1-1.3]
Equestrian 116 (0.2) [0.1-0.3] 194 (1.2) [0.9-1.7] 310 (0.4) [0.3-0.5]
Bowling NR NR NR
Jump rope 26 (0) [0-0.1] 70 (0.4) [0.3-0.7] 96 (0.1) [0.1-0.2]
Track and field NR NR NR
Other individual sport 1001 (1.4) [1.2-1.7] 256 (1.6) [1.2-2.1] 1257 (1.5) [1.3-1.7]
Combat 3099 (4.4) [4.1-4.8] 282 (1.8) [1.3-2.3] 3381 (3.9) [3.6-4.3]
Water sports 1505 (2.2) [1.9-2.5] 909 (5.6) [4.8-6.6] 2414 (2.8) [2.5-3.1]
Cycling 6567 (9.4) [8.8-10] 1747 (10.8) [9.7-12.1] 8319 (9.7) [9.1-10.2]
Off-road sports 1410 (2) [1.8-2.3] 463 (2.9) [2.3-3.6] 1873 (2.2) [1.9-2.5]
Other 6857 (9.8) [9.2-10.5] 3065 (19) [17.5-20.6] 9922 (11.5) [10.9-12.3]
Injury typea
Orbital fracture (802.6-802.7) 6435 (9.2) [8.7-9.8] 1723 (10.7) [9.6-11.9] 8158 (9.5) [9-10]
Adnexa wound (870.x) 24406 (34.9) [33.8-36.1] 4358 (27) [25.3-28.9] 28765 (33.5) [32.4-34.5]
Open wound of eyeball (871.x) 1821 (2.6) [2.3-3] 278 (1.7) [1.3-2.3] 2099 (2.4) [2.2-2.8]
Superficial injury (918.x) 15 087 (21.6)[20.8-22.4] 3058 (19) [17.6-20.4] 18 145 (21.1)[20.4-21.8]
Contusion (921.x) 19 792 (28.3)[27.3-29.4] 6050 (37.5) [35.7-39.4] 25 842 (30.1)[29.1-31.1] <.001

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)

Abbreviation: NR, not reported owing to low values.

a
International Classification of Diseases, Ninth Revision, Clinical Modification codes in parentheses.

(5688 [92.3%]), shooting an air gun (10 101 [91.1%]), and shoot-
ing a paintball gun (763 [89.7%]) demonstrating the largest pro-
portions of patients presenting with sport-specific ocular in-
juries identified as primary (Figure 2).
Overall, open wounds of the adnexa (ICD-9-CM code
870.x) were the most common type of injury (33.5%; 95% CI,
32.4%-34.5%), followed by contusions of the eye and adnexa
(ICD-9-CM code 921.x; 30.1%; 95% CI, 29.1%-31.1%) and
superficial injuries of the eye and adnexa (ICD-9-CM code
918.x; 21.1%; 95% CI, 20.4%-21.8%) (Table 1). Among
basketball-related injuries, open wounds of the adnexa were
most common (9062 [46.6%]; 95% CI, 44.7%-48.4%), fol-
lowed by superficial wounds (5672 [29.1%]; 95% CI, 27.6%-
30.7%); for baseball-related incidents, contusions (6331
[51.5%]; 95% CI, 49.4%-53.7%) were most common, fol-
lowed by orbital fractures (2568 [20.9%]; 95% CI, 19.2%-
22.7%). Injuries sustained from shooting an air gun were
most commonly contusions (4818 [47.7%]; 95% CI, 44.9%-
50.5%), followed by superficial wounds of the eye and
adnexa (2946 [29.2%]; 95% CI, 26.9%-31.5%).
Although only 3760 (3.1%) of all individuals who pre-
sented to the ED with a diagnosis of ocular trauma had
impaired vision, rates of visual symptoms varied widely by
sports-related activity, injury type, and age. The proportion
of injuries resulting in impaired vision was highest for those
injuries associated with paintball (10.2%), shooting an air

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 Epidemiology of Sports-Related Eye Injuries in the United States Original Investigation Research

patients tended to be young, and incidence peaked during

Figure 2. Common Mechanisms of Sports-Related Ocular Injury
adolescent years for both male and female patients. This
Jump Rope differential burden on the young highlights the potential for
long-term loss of quality-adjusted life years.
Equestrian
Primary
Patients presenting with injuries resulting from basket-
Rugby Secondary
ball, cycling, and baseball or softball and air guns represented
Hockey the largest cohort of ED presentations for all primary and
Lacrosse nonprimary sports-related ocular injuries. Among only pa-
Paintball tients with primary ocular injuries, ED presentation was most
Volleyball
commonly owing to basketball, baseball or softball, and shoot-
ing an air gun. Combined, these 3 activities accounted for 48.7%
Golf
Other
of all primary injuries in this population. Although most inju-
Individual Sport ries resulting from sports-related activities were superficial,
Racquet more than one-fifth of baseball-related injuries were blowout
Sport

Water Sports fractures of the orbit.

Combat Sports
Off-road
Football
Soccer
Air Gun
Other
Baseball
Cycling
Basketball
0 5000 10 000 15 000 20 000 25 000
ED Presentations, No.
Aggregate number of presentations to the emergency department (ED) for
sports-related ocular injury by mechanism of injury and primary vs secondary
diagnosis, from January 1, 2010, to December 31, 2013.
gun (8.2%), racket sports (5.8%), and soccer (5.7%) (Table 2).
After adjustment for other variables, the odds of impaired
vision for sports-related ocular trauma were 4.75 times
higher for a paintball-related injury (95% CI, 2.21-10.19) and
3.71 times higher for an air gun–related injury (95% CI, 2.34-
5.88) than for football-related ocular injuries (P < .001)
(Table 3). Adjusted odds of visual impairment generally
increased by age, and did not vary by sex, income quartile,
or season.
Discussion
Traumatic ocular events and their sequelae predispose pa-
tients to long-term physical, psychosocial, and economic ef-
fects, and sports-related events have been reported as a promi-
nent contributor to the overall burden of ocular trauma.9,10,12,43
Sports-related ocular trauma has been identified as a substan-
tial risk factor for inpatient hospitalization, with some esti-
mates suggesting that 22% to 40% of hospitalizations for ocu-
lar trauma were the result of injuries sustained during
participation in sporting activities.25,26,44
We have found that these injuries represent a substan-
tial burden in EDs in the United States, accounting for
approximately 30 000 ED visits annually—an estimate sub-
stantially higher than previously reported. 5 Presenting
Impaired vision was rare but showed a strong affiliation
with recreational projectile-firing devices. Paintball and air
guns accounted for 991 of all 3760 cases resulting in
impaired vision (26.4%), despite accounting for only 11 937
of all 120 847 injuries (9.9%). Soccer-related injuries also
contributed a disproportionate share of visual impairment
(408 of all 3760 vision impairments [10.9%] and 7162 of all
120 847 injuries [5.9%]). Cycling-related injuries were rela-
tively less likely to lead to visual impairment (377 of all 3760
visual impairments [9.7%] and 21 227 of all 120 847 injuries
[17.6%]).
Logistic regression modeling underscored the elevated
risk associated with projectile-firing recreational devices, as
injuries from shooting paintball and air guns showed 4.75
and 3.71 times greater adjusted odds, respectively, of lead-
ing to visual impairment than injuries sustained during par-
ticipation in football. Patients with injuries from soccer and
hockey also showed substantially elevated risk of vision
impairment after adjustment, compared with patients pre-
senting to the ED with isolated ocular injuries sustained
playing football (odds ratio, 2.42 and 2.32, respectively;
P < .001) (Table 3).
Limitations
Use of an administrative database such as the NEDS carries
several limitations.45 The number of individuals sustaining
sports-related ocular injuries who present to non-ED
sources, such as primary care physicians, outpatient oph-
thalmologists, and urgent care facilities, or who choose not
to seek care, is unknown, and such individuals will not be
included in ED-specific data sets such as the NEDS; our
study is limited to those presenting to the ED for care. Simi-
larly, data after discharge from the ED, such as surgical inter-
vention and length of hospitalization, are unavailable in this
data set, as are data on long-term visual outcomes or
detailed assessments of visual acuity, all of which would
likely be of interest to both health care professionals and
policy makers. The NEDS contains administrative discharge
data as provided by participating hospitals to the Healthcare
Cost and Utilization Project via state agencies; while coding
practices at individual hospitals may vary to some extent, it
is anticipated that the treating health care professional
would generally be responsible for diagnoses.

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 Research Original Investigation Epidemiology of Sports-Related Eye Injuries in the United States

Table 2. Sports-Related Ocular Injuries, by Vision Impairment Status, From January 1, 2010, to December 31, 2013a

No. (%) [95% CI]

Characteristic Not Impaired Impaired No. of Patients P Value
Activity
Football 5739 (97.1) [96-97.9] 171 (2.9) [2-4] 5910
Rugby 730 (96.8) [91.9-98.8] 24 (3.2) [1.2-8.1] 754
Baseball or softball 16 359 (97)[96.2-97.6] 511 (3) [2.4-3.8] 16 871
Lacrosse 980 (97.4) [94-98.9] 27 (2.6) [1.1-6] 1007
Soccer 6754 (94.3) [92.9-95.4] 408 (5.7) [4.6-7.1] 7162
Basketball 21 612 (97.6)[97.1-98.1] 523 (2.4) [1.9-2.9] 22 135
Volleyball 862 (95.7) [91.5-97.9] 39 (4.3) [2.1-8.5] 901
Hockey 920 (94.7) [88.1-97.8] 50 (5.1) [2.2-11.9] 971
Paintball 765 (89.8) [83.6-93.9] 86 (10.2) [6.1-16.4] 851
Air gun 10 182 (91.8)[90.5-93] 905 (8.2) [7-9.5] 11 086
Racket sports 1702 (94.2) [90.7-96.4] 105 (5.8) [3.6-9.3] 1807
<.001
Golf 1167 (96.2) [92.6-98.2] 45 (3.7) [1.8-7.4] 1213
Equestrian 640 (95.9) [89.7-98.5] 27 (4.1) [1.5-10.3] 668
Bowling 84 (100) 0 84
Jump rope 96 (100) 0 96
Track and field NR NR 45
Other individual sport 1496 (95.7) [93-97.4] 67 (4.3) [2.6-7] 1563
Combat sports 4095 (97.8) [96.6-98.6] 92 (2.2) [1.4-3.4] 4187
Watersports 2938 (97.5) [96-98.5] 75 (2.5) [1.5-4.1] 3013
Cycling 20 861 (98.3)[97.8-98.6] 366 (1.7) [1.4-2.2] 21 227
Off-road sports (97.9) [96.8-98.6] (2.1) [1.4-3.2] 5287
Other 13 885 (99.1)[98.7-99.4] 3760 (0.9) [0.6-1.3] 14 012
Sex
Male 93 836 (96.9)[96.5-97.2] 3036 (3.1) [2.8-3.5] 96 872
.71
Female 23 239 (97)[96.6-97.2] 725 (3) [2.6-3.6] 23 964
Age category, y
0-9 20 832 (98.9)[98.6-99.1] 234 (1.1) [0.9-1.5] 21 066
10-19 47 116 (96.2)[95.7-96.6] 1875 (3.8) [3.4-4.3] 48 992
20-29 20 397 (96.5)[95.8-97.2] 730 (3.5) [2.8-4.2] 21 127
30-39 10 585 (96.5)[95.5-97.3] 380 (3.5) [2.7-4.5] 10 964
<.001
40-49 8275 (97) [95.9-97.8] 258 (3) [2.3-4.1] 8533
50-59 5919 (97.4) [96.3-98.2] 159 (2.6) [1.8-3.7] 6077
60-69 2585 (96) [93.9-97.4] 107 (4) [2.6-6.1] 2692
≥70 1378 (98.7) [96.9-99.5] 18 (1.3) [0.5-3.1] 1396
Income quartile, $
≤38 900 26 791 (97.2)[96.6-97.6] 785 (2.8) [2.4-3.4] 27 576
39 000-47 999 26 395 (96.8)[96.3-97.3] 868 (3.2) [2.7-3.7] 27 263
.14
48 000-63 999 28 185 (96.5)[95.9-97] 1025 (3.5) [3-4.1] 29 210
≥64 000 33 419 (97.2)[96.6-97.7] 946 (2.8) [2.3-3.4] 34 365
Region
Northeast 18 619 (97.1)[96.3-97.8] 552 (2.9) [2.2-3.7] 19 171
Midwest 28 178 (96.1)[95.2-96.9] 1136 (3.9) [3.1-4.8] 29 314
<.001
South 35 700 (96.4)[95.8-96.9] 1332 (3.6) [3.1-4.2] 37 032
West 34 588 (97.9)[97.5-98.2] 742 (2.1) [1.8-2.5] 35 330
Hospital setting
Urban 99 551 (97)[96.6-97.3] 3110 (3) [2.7-3.4] 102 661
.88
Rural 15 158 (96.9)[96.2-97.5] 483 (3.1) [2.5-3.8] 15 641

(continued)

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 Epidemiology of Sports-Related Eye Injuries in the United States Original Investigation Research

Table 2. Sports-Related Ocular Injuries, by Vision Impairment Status, From January 1, 2010, to December 31, 2013a (continued)

No. (%) [95% CI]

Characteristic Not Impaired Impaired No. of Patients P Value
Injury typeb
Orbital fracture (802.6-802.7) 7810 (97.3) [96.9-97.7] 349 (2.7) [2.3-3.1] 8158
Adnexa wound (870.x) 28 581 (99.4)[99.1-99.5] 184 (4.3) [3.3-5.5] 28765
Open wound of eyeball (871.x) 1956 (93.2) [90.4-95.2] 143 (6.8) [4.8-9.6] 2099
Superficial injury (918.x) 17 480 (96.3)[95.6-97] 666 (3.7) [3-4.4] 18 145
Contusion (921.x) 24 424 (94.5)[93.7-95.2] 1418 (5.5) [4.8-6.3] 25 842 <.001

Foreign body (930.x) 2541 (98) [96.1-99] 52 (2) [1.1-3.9] 2593

Burn (940.x) 187 (100) 0 187
Eye-related cranial nerves (950.x, 951.0, 157 (91.5) [76.6-97.3] 15 (8.5) [2.8-23.4]
172
951.1, 951.3)
b
Abbreviation: NR, not reported owing to low values. For injury type, only patients with primary ocular injuries were included
a
N = 120 847. Complete data were not available for every record; for sex, (N = 85 961). International Classification of Diseases, Ninth Revision, Clinical
N = 120 835; for annual income, N = 118 414; for hospital setting, N = 118 302. Modification (ICD-9-CM) codes in parentheses.

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)

the incidence of sports-related ocular trauma.37,46-51 Man-

Conclusions
These results suggest a path forward for efforts to prevent
sports-related ocular trauma. Research has repeatedly
shown that appropriate protective eyewear can reduce
dating the use of such protective gear has reduced rates
of injury across several sports, and recent research sug-
gests that when appropriate eyewear is available but not
mandatory, top-performing athletes frequently choose to
wear it.48

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 Research Original Investigation Epidemiology of Sports-Related Eye Injuries in the United States

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-
nized team sports, they are not likely to affect the burden of
sports-related ocular trauma due to nonorganized recre-
ational sporting activities, including those most correlated
with visual impairment, such as shooting paintball and air
guns. Reducing sports-related ocular trauma among indi-
viduals engaging in these activities, along with individual
sports with high levels of injuries, such as cycling, will likely
require a coordinated approach from policy makers, indus-
try, and public health professionals. Further research is war-
ranted to identify opportunities for intervention among
sports participants.

ARTICLE INFORMATION
Accepted for Publication: September 7, 2016.
Published Online: November 3, 2016.
doi:10.1001/jamaophthalmol.2016.4253
Author Contributions: Dr Haring had full access to
all the data in the study and takes responsibility for
the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Haring, Sheffield,
Schneider.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Haring.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Haring, Sheffield, Schneider.
Administrative, technical, or material support:
Haring, Canner, Schneider.
Study supervision: Schneider.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Previous Presentations: These findings were
presented at the Academic Surgical Congress of the
Association for Academic Surgery; February 2,
2016; Jacksonville, Florida.
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