Athletic Training and Sports Health Care

Case Review 

Changes in Vision, Retinal Ischemia, and Edema Indicative of Cardiovascular Disorders

Robert Charles-Liscombe, EdD, ATC; Brandon James Polking, PT, DPT, ATC; Richard Eurillo, MHA, LAT, ATC

Abstract

This case series describes the presentation, examination, and treatment of vision loss in two young adult athletes. Atraumatic changes in vision occur more frequently than eye injuries and are often early indicators of neurological, cardiovascular, hematological, endocrine, and autoimmune diseases. Potential causes of non-contact visual disturbances and the athletic trainer's role in detecting, referring, and managing eye conditions are presented.

[Athletic Training & Sports Health Care. 2019;11(3):136–142.]

Abstract

This case series describes the presentation, examination, and treatment of vision loss in two young adult athletes. Atraumatic changes in vision occur more frequently than eye injuries and are often early indicators of neurological, cardiovascular, hematological, endocrine, and autoimmune diseases. Potential causes of non-contact visual disturbances and the athletic trainer's role in detecting, referring, and managing eye conditions are presented.

[Athletic Training & Sports Health Care. 2019;11(3):136–142.]

Vision loss, including visual disturbances and blindness, has significant effects on quality of life and the ability to engage in physical activity. In 2015, approximately 7% of children younger than 18 years in the United States had diagnosed vision loss. Nearly 23 million American adults reported experiencing vision loss, whereas an additional 61 million adults in the United States were at high risk for vision loss.1 Regrettably, less than half of those at risk for vision loss had visited a vision specialist in the past 12 months.2 Although most of the conditions that cause vision loss are atraumatic, eye injuries also pose a significant risk. Approximately 600,000 documented sports-related eye injuries occur each year in the United States, more than 42,000 of which require emergency department attention and an estimated 13,500 of which result in a permanent loss of sight.3,4 Prevention, identification, and the management of eye disorders and injuries are essential skills for athletic trainers and others providing health care to physically active patients.5–7

Atraumatic changes in vision are more common than eye injuries and can be an early indicator of other disease processes and concerns. Refractive errors, acute infections, inflammatory conditions, cataracts, diabetic retinopathy, glaucoma, and age-related macular degeneration are more common than sports-related eye injuries among adults.4 Addressing vision loss as a public health concern requires the coordinated efforts of all health care providers in promoting eye and vision health, identifying social and environmental factors affecting visual impairment, improving early detection of eye disorders, and enabling access to high quality treatment.8 A thorough clinical examination is warranted when patients report changes in vision. Athletic trainers must recognize their responsibilities in prevention and early detection of eye disorders. Athletic trainers can expedite the diagnostic and treatment process, which can save an athlete's eye and visual field, especially in the case of trauma or a neurological or vascular incident. Prompt referral to an ophthalmologist or an optometrist ensures a comprehensive assessment of visual acuity, visualization of the anterior and posterior chambers of the eye with particular focus on the retinal structures, and inspection of the orbit to identify underlying systemic disease and development of a plan of care.7,9 We present two cases of National Collegiate Athletic Association (NCAA) Division III athletes with atraumatic vision loss and their diagnoses of previously asymptomatic cardiovascular and hematological conditions. The most common causes of atraumatic visual disturbances and the coordinated care necessary for treating patients with vision loss are discussed.

Case Reviews

Case 1

A 20-year-old NCAA Division III baseball player and athletic training student (height: 1.98 m; mass: 86 kg) presented to his supervising athletic trainer during clinical education with a complaint of spontaneous vision loss in his right eye. While lifting a 10-gallon cooler (approximate weight of 38 kg), the patient noted his vision becoming blurry and cloudy. He massaged his right eye in an attempt to relieve symptoms. Within 10 seconds, he noted complete blindness in his right eye without pain or other symptoms. The patient reported no family or personal history of eye injuries/illnesses, no use of corrective glasses or contact lenses, unremarkable medical history, no prior trauma to the head or face, and did not smoke or drink alcohol. The patient was in good physical condition. He reported no history of allergies or taking medications. His preparticipation physical examination 3 months prior revealed a visual acuity score of 20/20 on both eyes.

The athletic trainer began assessing the patient by asking if he could read letters at a distance, which he could not. If a patient has a visual acuity better than 20/400, significant vision impairment can be described as an ability to count fingers, perceive hand motion, light perception, and no light perception. The assessment indicated no light perception in the right eye and normal vision in the left eye. Pupillary reflex tests, oculomotor function, and cranial nerve (II to XII) examinations were normal. A basic screening for stroke-related symptoms (Balance disorder, Eyes – visual impairment, Facial muscle dysfunction, inability to raise Arms bilaterally and leg weakness, Speech disturbances and Time [BE-FAST]) was notable for visual impairment and sudden onset. Due to the immediate and unknown origin of vision loss, dilated fundus examination of the patient was not performed in the athletic training clinic by the supervising physician. He was immediately referred to the emergency department for follow-up examination. The differential diagnoses at the time included adult optic neuritis, anterior ischemic optic neuropathy (AION), spontaneous retinal detachment, sudden anterior uveitis, amaurosis fugax-transient retinal ischemia, branch or central retinal arterial occlusion (BRAO/CRAO), branch or central retinal vein occlusion (BRVO/CRVO), prodromal symptom of migraine headache, and benign/malignant tumor.

Examination in the emergency department occurred approximately 25 to 30 minutes after onset of visual symptoms. After near and far field screening, orbital examination, and undilated funduscopic examination using a standard ophthalmoscope by an attending family practice physician, the patient was immediately referred to a retinal specialist for complete ophthalmologic work-up. Vision testing confirmed minimal ability to recognize hand movements with confrontation visual testing. Intraocular pressure measured 11 mm Hg (normal: 12 to 21 mm Hg). Slit-lamp examination showed no significant findings in the conjunctiva, cornea, iris, and anterior chamber. Dilated fundus examination revealed a pale optic disc with a red fovea (cherry-red spot), suggestive of central retinal artery occlusion (CRAO).10Figure 1 shows the anatomy of the retina and associated vessels. For a representative image of this condition, visit the Retina Image Bank web site ( http://imagebank.asrs.org; file number 958).

Anatomy of the retina and associated vessels. Reprinted with permission from iStock.com.

Figure 1.

Anatomy of the retina and associated vessels. Reprinted with permission from iStock.com.

In an effort to reduce intraocular pressure and reper-fuse the retinal artery, latanoprost (1.5 mcg per drop, a prostaglandin F2 alpha agonist) and 2 mg/mL brimonidine tartrate and 5 mg/mL timolol per drop (a combined preparation of an alpha-2 agonist and a noncardioselective beta-blocker) were administered within 90 minutes of vision loss. Due to the significant risk of ischemic stroke and coronary and carotid artery blockage associated with CRAO,10 laboratory examinations for thrombophilic and inflammatory diseases, a Doppler ultrasound of the carotid arteries, a transthoracic echocardiogram, an electrocardiogram, and carotid and cranial magnetic resonance imaging with contrast were administered. Same-day test results were inconclusive. The patient was prescribed daily low-dose aspirin (81 mg) and anti-coagulant therapy, and discharged from the emergency department with recommendations for follow-up for idiopathic non-arteritic CRAO and permanent right eye blindness.

Following consultation with his primary care physician at 1 week, the patient was referred to a pediatric cardiology unit for further evaluation for possible causes of the CRAO. A second transthoracic echocardiogram with agitated saline 2 weeks after onset of blindness indicated the presence of a patent foramen ovale (PFO), a narrow opening of the atrial septum that shunts blood between the right and left atria. PFO are present in 25% of the general population and have been implicated in the onset of migraines, acute stroke, transient ischemic attack, heart attack, and CRAO.11 Seven weeks after acute onset of right eye vision loss, a transesophageal echocardiogram under general anesthesia confirmed the presence of the PFO. During the same procedure, a cribiform septal occluder device was inserted via catheterization from the femoral vein to close the PFO.

The patient was discharged from the hospital after 24 hours with instructions restricting vigorous activities for 1 to 2 weeks, gradual return to normal activities as tolerated, and a requirement to wear protective goggles during recreation, sports, and related high-risk activities to minimize likelihood of trauma to his functioning left eye.4,7 The athlete progressively increased exercise intensity and duration returning to full baseball-related conditioning and training 8 weeks after catheterization and PFO closure. As a result of left only monocular vision, the patient had to address changes in depth perception and peripheral right field vision loss during activities of daily living (driving and turning to the right) and baseball-related activities (pitching, fielding, and throwing). He successfully completed two baseball seasons following his injury without complications despite the permanent vision loss in his right eye.

Case 2

A 20-year-old female NCAA Division III lacrosse player (height: 1.68 m, mass: 58.18 kg) presented to the supervising athletic trainer with initial complaints of non-painful intermittent blurriness in her right eye. She reported experiencing increased blurriness in vision over the past 3 to 4 days. Initial assessment of vision revealed visual acuity of 20/400 in her right eye and 20/30 in her left eye. This was a significant change from her preparticipation examination (20/20 in the right eye and 20/30 in the left eye). Her orbit and adenexa were normal and her pupils were equal and reactive to light. She had a history of periodic psoriasis on her elbows and knees. Based on the loss of vision and presentation, she was referred to an ophthalmologist for evaluation. The differential diagnoses again included adult optic neuritis, AION, spontaneous retinal detachment and necrosis, sudden uveitis, amaurosis fugax-transient retinal ischemia, spontaneous retinal detachment, BRAO/CRAO, BRVO/CRVO, and benign/malignant tumor. Prodromal symptom of migraine headache was not included in the list of differential diagnoses as in the earlier case because changes in vision were over several days rather than sudden onset.

The ophthalmologist's slit-lamp examination revealed no abnormalities within the lens, sclera, conjunctiva, iris, or cornea. Fluorescein angiography and ocular coherence tomography revealed diminished outflow of the central retinal vein, retinal hemorrhaging, macular edema, and increased intraocular pressure. For a representative image of this condition, visit the Retina Image Bank web site ( http://imagebank.asrs.org; file number 1869).

The patient was initially prescribed anti-inflammatory (prednisone, 20 mg daily) and immunosuppressive (methotrexate, 7.5 mg once weekly and cyclosporine 75 mg twice a day) medications to reduce macular edema. Two weeks after the initial evaluation, an intravitreal injection of 0.05 mL of bevacizumab, a vascular endothelial growth factor antagonist (anti-VEGF), was administered to the right eye. Commonly employed in cancer management, bevacizumab slows the production of VEGF and diminishes neovascularization of the retina. The intended goal of treatment was to reduce the size of the branching veins in the retina and reduce the magnitude of macular edema present. Given the patient's age and history, a thorough work-up of vascular, immunologic, and hematologic causes were explored. Blood tests indicated that the patient was heterozygous for Factor V Leiden, a known mutation for thrombophilia. Anti-coagulant therapy (81 mg daily dose of aspirin) was added to her treatment regimen. At 1 month, her visual acuity had improved to 20/60 in the right eye. The patient was treated with intravitreal injections at 4 and 8 weeks followed by a gradual discontinuation of anti-inflammatory and immunosuppressive medications secondary to gastrointestinal side effects.

The patient missed the 12-week appointment and returned to the physician at 14 weeks with 20/200 visual acuity in the right eye. After resuming anti-VEGF treatments on a 4-week interval, the patient's visual acuity improved to 20/40 and stabilized. She was cleared to participate fully in the lacrosse season with required protective eyewear and intravitreal injections on a 4-week interval. She was further advised to minimize the likelihood of recurrent thrombi by avoiding oral contraceptives, prolonged limb immobility while flying and following surgery, and tobacco use. She completed the following lacrosse season with consistent anti-VEGF therapy and regular monitoring for macular edema and vision changes.

Discussion

Abrupt changes in visual acuity without trauma are rare and should be treated with high suspicion for systemic disease.9 The greatest risk to vision, and retinal health specifically, is advancing age. Vision changes in children and young adults are most often associated with refractive errors (myopia, hyperopia, and astigmatism), amblyopia, and strabismus. In adults, gradual changes in vision and loss of vision are most often associated with the loss of near field vision (presbyopia), followed by retinopathy (notably diabetic retinopathy), cataracts, glaucoma, and age-related macular degeneration.12 For a representative image of diabetic retinopathy, visit the Retina Image Bank web site ( http://imagebank.asrs.org; file number 24897). Most patients presenting with retinopathy and retinal occlusion are older than 60 years. With age, there is also a significant risk to the retinal circulation associated with metabolic syndrome (hypertension, diabetes mellitus, hyperlipidemia, and obesity).13

The incidence of CRAO is 2 in 100,000 whites per year and is extremely rare in young people. The incidence of CRVO is less than 3% of the population in the United States and it predominantly affects patients older than 60 years. Most patients with CRAO and CRVO have a prior history of cardiovascular disease, including hypertension and hyperlipidemia. Two previous case reports linked the development of CRAO with the presence of PFO14,15 in adults. Similarly, 2 case reports reported CRVO in patients who were carriers for the Factor V Leiden mutation.16,17 Although extremely rare, retinal artery and vein occlusions have been reported in young adults with sickle cell trait18,19 and sickle cell disease,20 following chiropractic cervical manipulation,21 ischemic cardiomyopathy,22 long distance running and intense physical activity,23-27 and in association with anabolic steroid use.28 Blood flow to the retinal and choroidal vessels increases by 16% to 40% from baseline during exercise based on intensity of effort.29 Studies have also demonstrated an acute reduction in intraocular pressure during sustained aerobic exercise and isometric exercise.30 Dehydration and increased blood viscosity have been hypothesized as a mechanism associated with increasing the risk of CRVO. The patient experiencing CRAO in this case report was engaged in an isotonic strength effort, and it can be hypothesized that a small thrombus was dislodged into the ocular circulation. The patient with CRVO in this case was encouraged to minimize the likelihood of thrombus formation by increasing hydration, avoiding long periods of immobilization and tobacco use, and using alternative contraception.

In contrast to the relatively low incidence rate of retinal artery occlusions, diabetic retinopathy is the most prevalent and leading cause of blindness in the United States and has similar clinical characteristics. From 2010 to 2050, the number of Americans with diabetic retinopathy is expected to nearly double, from 7.7 to 14.6 million. Hispanic Americans are expected to see the greatest increase in cases, rising more than three-fold from 1.2 to 5.3 million.1 With the increasing prevalence of diabetes mellitus worldwide, primary health care providers play a significant role in monitoring for potential development of retinopathy and enabling early detection and treatment. Initially asymptomatic, the distinguishing features of diabetic retinopathy are increasing frequency of floaters, blurred vision, distortion, and progressive visual acuity loss. Clinically, when examined by ophthalmoscope, early non-proliferative diabetic retinopathy will include evidence of microhemorrhages, blot hemorrhages, hard exudates and scarring, macular edema, and cotton wool spots. The optic disc appears normal and mild venous dilation may be present. Outreach photographic screening by trained medical personnel has been advocated as an effective alternative to an on-site specialist examination by an ophthalmologist for the presence of diabetic retinopathy in rural and resource poor settings.31

Implications for Clinical Practice

Given the association between systemic disease, ocular and vision changes, and the high economic and quality of life costs associated with vision loss and blindness, periodic evaluation of both vision and the visual system are recommended (Table 1). The athletic trainer should be prepared to examine the patient in the clinic and on the sideline when necessary. It is recommended that the sports medicine team have vision screening and eye care equipment readily available for use in the athletic training clinic and when traveling. Instruments for assessing vision would include near and far visual acuity charts (Snellen and Rosenbaum Pocket Vision Screener), white and cobalt blue penlights, fluorescein eye stain strips, cotton tip applicators for everting the eyelid, contact lens cases, an adjustable ophthalmoscope, and eye wash/saline.7 The athletic training clinical examination should take place in a room that can be darkened easily and includes taking a brief individual history of previous injuries, visual complaints, and a family history of eye disorders. The ocular examination consists of the external examination of the orbit, lacrimal system, and eyelids, pupil examination, red reflex testing, ocular alignment and motility assessment, an assessment of visual function and a visual examination of the cornea, iris, pupil, sclera, optic disc, and retina using a handheld ophthalmoscope.32 Based on the findings, referral for a comprehensive eye evaluation by an ophthalmologist or optometrist would also include a slit-lamp examination of the anterior chamber (cornea, iris, pupil, sclera), intraocular pressure testing, and dilated examination of the posterior chamber (vitreous humor, retina, optic disc, retinal artery and veins, and macula).

Recommended Frequency of Vision Screening and Eye Examinations by Age and Conditiona

Table 1:

Recommended Frequency of Vision Screening and Eye Examinations by Age and Condition

During infancy and childhood, scheduled well visits with a qualified health care professional provides an opportunity to screen patients for vision and eye alignment disorders and appropriately refer for comprehensive follow-up examination and treatment as needed.33 School-based screening and an annual preparticipation examination for those engaged in athletics can serve as opportunities to identify eye malalignment and risk factors for vision disorders.7 However, there is some disagreement on the recommended frequency of comprehensive eye examinations in asymptomatic adults with low risk. The American Academy of Ophthalmology recommends that a comprehensive dilated eye examination is not necessary for asymptomatic and low relative risk adults from 18 to 40 years of age when establishing a baseline for age-related changes is necessary.34 The American Optometry Association, in contrast, recommends that patients 18 to 39 years old receive vision screening and comprehensive eye examinations at least every 2 years and more frequently based on their age and risk profile.35 Annual examinations are recommended for patients with diabetes mellitus, hypertension, or a family history of ocular disease (eg, glaucoma or macular degeneration), those working in occupations that are highly demanding visually or hazardous to eyes, patients taking prescription or non-prescription drugs with ocular side effects, contact lens users, those who have had eye surgery, or individuals with other systemic health concerns or conditions.

Athletic trainers can assist in meeting the HealthyPeople 2020 vision goals to improve the “visual health of the nation through prevention, early detection, timely treatment, and rehabilitation.”36 The athletic trainer is often the first health care professional in the sports, recreation, and industrial setting to evaluate a patient complaining of changes in vision or eye pain. Following an initial assessment, athletic trainers can expedite the diagnostic and treatment process, which can save an athlete's vision. The athletic trainer should be able to examine the eye and visual systems and determine whether findings warrant referral to an ophthalmologist or optometrist for appropriate work-up and diagnosis. To enhance detection of systemic diseases such as diabetes mellitus, hypertension, hyperlipidemia, and other vascular occlusive disorders that can go undiagnosed, adults should receive a comprehensive baseline eye examination at age 40 years by an ophthalmologist or optometrist with frequency of follow-up examinations based on their individual risk profile. Athletic trainers are well positioned to reduce recreational and work-related eye injuries and increase the use of protective eyewear among children and adults. Protective eyewear and corrective lenses prescribed by an optometrist or ophthalmologist familiar with the patient's functional demands can provide a high quality visual acuity for sport and recreation. Following diagnosis of vision loss, the athletic trainer working with the sports medicine team should assist patients in engaging in appropriate rehabilitation strategies, managing their treatment plan, and resuming physical activity to their highest level of function.

References

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Recommended Frequency of Vision Screening and Eye Examinations by Age and Conditiona

Age/ConditionFrequencyExceptions and Referral Criteria
Newborn to 12 monthsAt each well visitConditions related to retinopathy of prematurity, family history of retinoblastoma, childhood cataracts, glaucoma, or metabolic and genetic disease; those who do not track well after 3 months; abnormal red reflex
12 to 36 monthsAnnuallyStrabismus, chronic tearing or discharge, those failing photoscreening
36 months to 5 yearsAnnually36 to 47 months = must identify majority of optotypes on 20/50 line to pass; 48 to 59 months = must identify majority of optotypes on 20/40 line to pass; those that fail photoscreening
5 to 18 yearsEvery 1 to 2 yearsMust identify majority of optotypes on 20/32 line to pass; children not reading on grade level
18 to 64 yearsAnnuallyIndividuals with family history of ocular disease; working in occupations that are demanding visually or eye hazardous; taking prescription or non-prescription drugs with ocular side effects; wearing contact lenses or glasses; who have had eye surgery; who experience changes in vision, pain, or impaired motion
18 to 40 yearsOncebIndividuals without risk factors
41 to 54 yearsEvery 2 to 4 yearsIndividuals without risk factors
55 to 64 yearsEvery 1 to 3 yearsIndividuals without risk factors
65 years and olderEvery 1 to 2 yearsIncidence of unrecognized ocular disease increases with age
Diabetes mellitus type I5 years after onset and annuallyWomen with type I should receive an eye examination before conception and then in the first trimester of pregnancy
Diabetes mellitus type IIAt the time of diagnosis and annuallyDue to prolonged period of insulin resistance and pre-diabetes, patients are recommend to have comprehensive eye exam when diagnosed
HypertensionEvery 1 to 2 years18 to 60 years = every 2 years; 61+ years = annually
Authors

From the School of Health Sciences, Mount St. Joseph University, Cincinnati, Ohio (RC-L); Select Medical NovaCare Rehabilitation, Cincinnati, Ohio (BJP); and Greensboro Orthopaedics, Greensboro, North Carolina (RE).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Robert Charles-Liscombe, EdD, ATC, School of Health Sciences, Mount St. Joseph University, 5701 Delhi Road, Cincinnati, OH 45233. E-mail: bc.charles-liscombe@msj.edu

Received: July 18, 2017
Accepted: February 21, 2018
Posted Online: June 25, 2018

10.3928/19425864-20180502-02

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