Severe surfing-related ocular injuries: the Stanford Northern Californian experience
- 1Department of Ophthalmology, Stanford University Medical Center, Stanford, California, USA
- 2Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
- Dr D M Moshfeghi, Department of Ophthalmology, Stanford University Medical Center, Room W3002, 900 Blake Wilbur Drive, Stanford, California, USA;
- Received 8 August 2007
- Revised 15 October 2007
- Accepted 21 December 2007
- Published Online First 15 January 2008
There is a growing body of literature describing severe surfing-related ocular injuries that result in permanent vision loss. We describe three severe surfing-related ocular injuries that occurred on beaches in northern California. One particular case stresses the need to tailor treatment to the patient and injury because of the possibility of good outcomes despite severe injury. Attention should also be directed towards commercially available safety gear and providing additional safety measures to prevent other orbital and ocular injuries.
Sports-related ocular injuries compromise a significant percentage of ocular morbidity. Surfing has a high risk for severe ocular injuries.1–4 Surfing-related injuries have poor outcomes and surgeons may hesitate to reoperate after primary repair. We present three cases with severe ocular injury, one of which regained useful vision after reoperation.
A 39-year-old man sustained a surfboard injury to his left orbit (table 1). He presented with light perception (LP) vision and an afferent pupillary defect (APD). He had a dense hyphema, hypotony and misshapen globe. Computed tomography (CT) showed a disorganised vitreous cavity and a left inferior orbital fracture (fig 1). Intraoperative exploration revealed a 17 mm scleral perforation (fig 1). A significant amount of prolapsed uvea and vitreous was excised during primary repair. A left medial canthal laceration was repaired initially and the orbital fracture was repaired at a later date.
The patient underwent a retinal evaluation 4 days later. He was noted to have a 50% hyphema, proliferative vitreoretinopathy, rhegmatogenous retinal detachment, and a vitreous and suprachoroidal haemorrhage in the left eye. He elected for scleral buckle, pars plana vitrectomy, lensectomy, endolaser treatment, inferior retinotomy and silicone oil placement in the left eye.
Six months postoperatively, his best-corrected visual acuity (BCVA) was stable at 20/100 and the retina remained attached.
A 41-year-old man, who sustained extensive ocular and orbital injury while surfing (table 1), presented with no light perception (NLP) and a dense APD. The eye was grossly misshapen due to full-thickness nasal and temporal limbal–scleral lacerations. Portions of the iris, choroid and retina were prolapsed through the wound. He also had a displaced inferior orbital floor fracture and a partial-thickness right upper lid laceration. Following primary repair of the globe and eyelid laceration, he was NLP with an oedematous cornea. Ultrasound revealed intraocular disorganisation, haemorrhage and retinal detachment. The patient declined further surgery. Five months later the eye became phthisical.
A 28-year-old man sustained ocular and orbital injury while surfing (table 1). Presentation was NLP with amaurotic left pupil. The globe was intact with a normal anterior segment examination. Funduscopic evaluation found a haemorrhage extending from the optic disc. The nerve itself was cratered, consistent with optic nerve avulsion. Correspondingly, posterior tenting of the globe was seen on CT.
Additional injuries included a canalicular laceration with avulsion of the left eyelid. CT revealed orbital roof and floor fractures. The eyelid and canalicular laceration were repaired and the orbital fractures kept under observation. Postoperatively, vision remained NLP.
Surfing-related ocular injuries are serious and often lead to permanent visual deficits. Two reports have described the severity of surfing-related ocular injuries.3 4 We present three more cases occurring in northern California.
Of the 17 patients described in all three reports, 76.5% (13/17) had ruptured globes. Visual outcome is in most cases unfavourable, with 35.3% (6/17) of the patients presented having NLP and only 17.6% (3/17) recovering an acuity of 20/40 or better. Concomitant facial lacerations and orbital trauma were also common, with 64.7% (11/17) having eyelid lacerations.
The development of microsurgical techniques, the operating microscope and vitrectomy have enabled salvage of eyes and restoration of vision to eyes that would otherwise have been enucleated.5 We report success in salvaging the eye and vision in a patient who may have been considered having an irreparable injury because of its extent. This case stresses the need to tailor treatment to the patient and injury, because of the possibility of good outcomes despite severe injury.
All three injuries presented occurred during the winter months on beaches in northern California after the surfers “wiped out” while trying to ride a large wave or avoid an oncoming wave. The beaches in this area are internationally known for their powerful northwest swells, which generate large waves during the winter months. A large number of experienced surfers enjoy riding such waves on “shortboards,” usually 1.83–2.13 metres (6–7 feet) in length, which are lightweight and easily manoeuvreable in large wave conditions. Longboards, in contrast, are usually 2.44–3.04 metres (8–10 feet) in length and, because of their better stability, are often preferred by beginners in small-wave conditions (fig 2). However, this is only a trend with many exceptions; “longboarders” and “shortboarders” of all skill levels can be found in the majority of conditions. In our report, all three were very experienced surfers riding shortboards. Interestingly, each was hit by a different part of their board: the fin, nose or tail (fig 2). Such injuries can certainly occur with longboards as well. However, given that a higher proportion of experienced Northern Californian surfers ride shortboards during the winter months, some extent of self-selection bias may explain why all three of our reported injuries occurred while riding a shortboard.
A less obvious contributor to injury is the ankle leash. The ankle leash is an elastic rope that tethers the surfboard to the surfer through an ankle strap (fig 2). All three patients were using relatively short ankle leashes, 1.83–2.44 metres (6–8 feet). Shorter leashes offer the advantage of tethering the surfboard in close proximity to the surfer but for this same reason may place the surfer at greater risk of injury. Two of the three surfers had injuries occur immediately after rising to the surface and having the board snap back due to leash tension. Longer leashes (2.44–3.04 metres (8–10 feet) in length) may help reduce this risk.
What is already known about this topic
Sports-related ocular injuries compromise a significant percentage of ocular morbidity.
There is a growing body of evidence that surfing is associated with severe ocular injuries.
The development of microsurgical techniques has enabled salvage of eyes and restoration of vision to eyes that would otherwise have been enucleated.
What this study adds
Surfing ocular injuries can be caused by different parts of the surfboard.
There may be some greater risks to surfing in larger wave conditions and being strapped to a short ankle leash.
Various safety measures are available, such as helmets and protective eyewear, which may help prevent ocular injury.
There are several commercially available products for surfboards that provide some protection. Soft rubber tips (Diamond Tips; SurfCo Hawaii Inc, Pearl City, Hawaii, USA) can be attached onto the tip or tail of shortboards. Other products that are available include flexible fins made of softer material, such as urethane rubber (Pro Teck fins; SurfCo Hawaii Inc).
Incongruous with the preferred surfer image and therefore rarely used, helmets and protective eyewear designed for water sports are available and provide significant protection. For instance Gath (Margaret River, Australia) and Pro-Tec (Cypress, California, USA) helmets are available at many stores specialising in surfing-related gear. Gath helmets are unique in additionally providing a retractable, shatterproof visor for eye and face protection. Several different types of protective eyewear for water sports are also available, such as Seaspecs (Miami, Florida, USA) and Barz Optics (Queensland, Australia), which can help prevent ocular trauma in many instances.
In conclusion, surfing continues to be a sport enjoyed by millions around the world. There is a growing body of literature describing severe ocular injuries that result in permanent vision loss.3 4 Despite the availabilities of products that may prevent significant ocular and surrounding facial and head trauma, surfers seem to be hesitant to use such protective equipment. Attention should ultimately be directed in promoting such safety measures to the surfing community in order to help prevent orbital and ocular injury.