A Practical Guide for Sports Eye Protection

Paul F. Vinger, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 6 - JUNE 2000

In Brief: Sports eye injuries can be serious but are preventable. Any sport that involves a stick or racket, a ball or other projectile, or body contact presents a risk of serious eye injury. Physicians have an obligation to warn players of potential risk and to recommend appropriate eye protection. Sports eye protection should be designed specifically for the activity or sport. Eye protection that bears the seal of sanctioned organizations should be mandated for high-risk sports.

Eye injuries in sports and recreation are an international problem, widely recognized as preventable with appropriate protective equipment (1-20). The US Consumer Product Safety Commission (CPSC) estimate of almost 40,000 eye injuries from sports in the United States (table 1) (21) is only a fraction of the total, which also includes eye injuries seen in ophthalmologists' offices and specialty eye hospitals that are not sampled by the CPSC.

TABLE 1. 1998 Sports and Recreational Eye Injury Estimates by Age-Group and Percentage of Total

All Ages Under 5 Ages 5-14 Ages 15-24 Ages 25-64 65 and Older

Activity Est (%) Est (%) Est (%) Est (%) Est (%) Est (%)

Basketball 8,723 (22.2) 148 (0.4) 2,338 (5.9) 3,856 (9.8) 2,381 (6.1) 0 (0)

Water/pool sports 4,593 (11.7) 133 (0.3) 1,782 (4.5) 699 (1.8) 1,817 (4.6) 162 (0.4)

Baseball 4,029 (10.3) 182 (0.5) 2,195 (5.6) 823 (2.1) 829 2.1) 0 (0)

Racket sports* 2,767 (7.0) - (0) 1,000 (2.5) 926 (2.4) 822 (2.1) 19 (0)

Hockey** 1,614 (4.1) - (0) 515 (1.3) 628 (1.6) 471 (1.2) 0 (0)

Football 1,464 (3.7) - (0) 533 (1.4) 583 (1.5) 348 (0.9) 0 (0)

Soccer 1,325 (3.4) - (0) 741 (1.9) 378 (1.0) 206 0.5) 0 (0)

Ball sports*** 1,270 (3.2) 115 (0.3) 581 (1.5) 375 (1.0) 160 (1.0) 39 (0.1)

Golf 828 (2.1) 7 (0) 142 (0.4) 75 (0.2) 604 (1.5) 0 (0)

Combatives**** 448 (1.1) - (0) 56 (0.1) 82 (0.2) 310 (0.8) 0 (0)

Total selected sports 27,061 (68.9) 585 (1.5) 9,883 (25.1) 8,425 (21.4) 7,948 (20.2) 220 (0.6)

Other activities 12,236 (31.1) 596 (1.5) 4,273 (10.9) 2,932 (7.5) 4,190 (10.7) 245 (0.6)

Totals 39,297 (100.0) 1,181 (3.0) 14,156 (36.0) 11,357 (28.9) 12,138 (30.9) 465 (1.2)

*Includes racquetball, tennis, squash, paddleball, badminton, and handball
**Includes ice, field, street, and roller hockey
***Includes unspecified ball sports
****Includes boxing, martial arts, and wrestling
Compiled by Prevent Blindness America (21) from statistics provided by the US Consumer Product Safety Commission (CPSC) from the National Electronic Injury Surveillance system (NEISS). NEISS is the core of CPSC's Bureau of Epidemiology, and currently comprises 101 hospital emergency departments that constitute a stratified sample of all hospital emergency departments within the United States and its territories. NEISS data—categorized by body part, product, and activity system—are good for evaluating the total social cost of injuries that affect large segments of the population.

Although risk of eye injury exists for many sports, risk can be mitigated with proper eyewear and precautions. Physicians who follow guidelines and prescribe certified eyewear for active patients can help them remain injury-free during participation.

Sports and Risk of Eye Injuries

Sports with the potential of ball (puck, shuttlecock), stick (racket, crosse), or body contact frequently cause eye injuries, but the incidence is difficult to determine because there are few studies in which the actual number of participants at risk is known. Some data are available for selected activities, however.

Statistics. An estimated 5.5% of all college varsity athletes sustain some form of eye injury each season (22). The 25% probability that an unprotected squash player will suffer a significant eye injury after 25 years of playing 3 days a week in the Boston area (23) is comparable to an Australian survey of all squash players that showed an incidence of 17.5 eye injuries per 100,000 hours of play (24). In the latter study, 26% of all squash players surveyed reported that they had suffered at least one eye injury. Another racket sport, racquetball, has an incidence of one eye injury for each 1,764 hours of play and hospitalization for eye injury after each 11,760 participation hours (25,26).

Facial injury (including eye injury) to the unprotected ice hockey player is extremely high—7% in the first year of play, increasing to 66% after eight seasons, and up to 95% for professional players. The average professional hockey player in his career has had 1 facial bone fracture, 2 teeth lost, and 15 facial lacerations that required sutures (27).

Approximately 1 in 10 college basketball players sustains an eye injury each year (28). In Massachusetts annually, 1 of every 238 children 5 to 19 years old was treated at a hospital for a baseball-related injury (29). A 1-year prospective study of eye injuries among 800 major league players from 26 baseball teams showed that 30% of the 20 injured players (2.5%) missed games because of their eye injury (30). Women's lacrosse players have a 6.2% to 9.9% annual incidence of face, eye, and tooth injuries (31); 22% of the players had incurred head or face contact at least once per game (32). In another study, 6,229 college football players had an eye injury incidence of 0.03 for 1,000 practice or game sessions, and a player on an average college football team had a significant eye injury about once every 62 weeks of participation (33).

Consequences and risk reduction. Eye injuries can be devastating in terms of their total cost: pain, loss of function, and long-term disability. A person who lost one eye at age 16 and faces cataract surgery at age 70 on the remaining eye has far more reason to be anxious than does a person with two good eyes. Eye injuries also affect others besides the injured person. For example, of all the people who visit an eye hospital emergency department for an eye injury, 12.5% with severe injury and 5% with less severe injury sue someone (34). Are these litigations justified? Is anyone responsible, or are these injuries the "assumed risk" that one takes when playing a sport?

The risk of eye injury in a particular sport (table 2) is proportional to the chance of the eye being hit hard enough to cause injury; however, risk is not correlated with the classification into collision, contact, and noncontact categories. Available eye protectors can reduce the risk of eye injury by at least 90% (35-37), but a principal impediment to the more widespread use of protective eyewear is confusion of all concerned with sports—principals, athletic directors, coaches, umpires, referees, players, and medical personnel—as to which protectors are the most effective.

TABLE 2. Risk Categories for Sports-Related Eye Injury for the Unprotected Player

High Risk
Small, fast projectiles
   Air rifle/BB gun
   Paintball
Hard projectiles, fingers, "sticks," close contact
   Baseball/softball/cricket
   Basketball
   Fencing
   Field hockey
   Ice hockey
   Lacrosse, men's and women's
   Squash/racquetball
   Street hockey
Intentional injury
   Boxing
   Full-contact martial arts
Moderate Risk
Fishing
Football
Soccer/volleyball
Tennis/badminton
Water polo
Low Risk
Bicycling
Noncontact martial arts
Skiing
Swimming/diving/water skiing
Wrestling
Eye Safe
Gymnastics
Track and field*

*Javelin and discus have a small but definite potential for injury that is preventable with good field supervision.

Eyewear Safety Certification

Eye safety standards in the United States are primarily the responsibility of two organizations, the American Society for Testing and Materials (ASTM) (38) and the American National Standards Institute (ANSI) (39). The National Operating Committee on Standards for Athletic Equipment (NOCSAE) also writes standards for selected sports. Other countries have their own organizations that set standards and protocols.

Sports eyewear safety standards. The ASTM writes standards for sports eyewear in the United States; the NOCSAE has standards for football face shields and men's lacrosse face shields. Founded in 1898, the ASTM is a not-for-profit organization that provides a forum for users, producers, and those with a general interest (eg, representatives of government and academia) to meet on common ground and write standards for materials, products, systems, and services in many different fields. ASTM committees are balanced, which means that the number of voting producers (manufacturers) cannot exceed the combined number of voting nonproducers (users and those with general interest). The eye safety subcommittee, a part of committee F-8 on athletics and athletic equipment (one of 134 ASTM standards-writing committees), had its origin in the hockey face shield subcommittee that was formed in 1973.

At present, ASTM has completed the following standards for sports eye protectors:

ASTM F803: Eye protectors for selected sports (racket sports, women's lacrosse, field hockey, baseball, basketball);
ASTM F513: Eye and face protective equipment for hockey players;
ASTM F1776: Eye protectors for use by players of paintball sports;
ASTM F1587: Head and face protective equipment for ice hockey goaltenders;
ASTM F910: Face guards for youth baseball; and
ASTM F659: High-impact resistant eye protective devices for Alpine skiing.

Selected types of eye and face protection are shown in figures 1 through 3.

[Figure 1]

[Figure 2]

[Figure 3]

Nonsports eyewear standards. ANSI writes standards for protective eyewear in the United States with the exception of sports eyewear. It is the central body responsible for the identification of a single, consistent set of voluntary standards called American National Standards and is the US member of international standards organizations. ANSI follows the principles of openness, due process, and a consensus of those directly and materially affected by the standards.

ANSI standards for eyewear that is not for sports use are:

ANSI Z80.5: Requirements for ophthalmic frames;
ANSI Z80.1: Prescription ophthalmic lenses—recommendations;
ANSI Z80.3: Requirements for nonprescription sunglasses and fashion eyewear; and
ANSI Z87.1: Practice for occupational eye and face protection.

The ANSI Z80 series of standards are for dress eyewear, also called streetwear spectacles. The test requirements are minimal and geared to the desire for a diversity of styles in fashion eyewear. Streetwear spectacles are not appropriate for work or sports with impact potential. Polycarbonate lenses should be used for dress eyewear unless there is a specific reason for another lens material. Streetwear frames are often fragile and have poor lens-retention properties. Significant eye injuries have resulted from frame failure.

The ANSI Z87.1 industrial safety standard is being revised. In its present form, the standard allows for lenses that shatter with relatively little energy. The frame test for spectacles with removable lenses is not strict and allows the substitution of a weaker lens after the frame is tested with a polycarbonate lens. Industrial eye protectors are not satisfactory for sports unless tested to ASTM specifications (figure 4).

[Figure 4]

Testing. The NOCSAE has standards for baseball, football, and lacrosse helmets, baseballs and softballs, and face shields for football and men's lacrosse. To determine whether products pass the applicable standards, they are submitted to a testing laboratory. The testing laboratory must comply with the International Organization for Standardization (ISO) and Inter-European Commission (IEC) Guide 25-1990. The American Association for Laboratory Accreditation (A2LA) accredits all types of laboratories, except medical. A laboratory must be able to provide evidence of the successful completion of the A2LA evaluation process to perform the tests that are relevant to the standard test procedures. A2LA was approved under the Accrediting Body Evaluation Program of the National Institute of Standards and Technology. By the end of 1997, 987 laboratories were accredited and 330 laboratories were in the process of obtaining accreditation.

Eyewear certification. Eye protectors are often certified, providing the user with the assurance that the protector will afford reasonable protection. The Protective Eyewear Certification Council (PECC; Web site: http://www.protecteyes.org/) certifies protectors complying with ASTM standards (except for ice hockey). The Canadian Standards Association (CSA) certifies products complying with the Canadian racket sport and ice hockey standards, which are similar to the ASTM standards. The Hockey Equipment Certification Council (HECC) certifies ice hockey equipment, including helmets and face shields. NOCSAE does the same for football helmets and face guards, men's lacrosse helmets and face guards, and baseball helmets. The PECC, CSA, HECC, or NOCSAE seals (figure 5) assure users that each protector can be safely used. Categories of eyewear based on their suitability for sports eye protection are listed in table 3, and the status of eye protection availability for sports commonly played in the United States is shown in table 4.

[Figure 5]

TABLE 3. Satisfactory and Unsatisfactory Eyewear* for Eye-Risk Sports

Satisfactory for Eye-Risk Sports
Safety sports eyewear that conforms to the requirements of the American Society for Testing and Materials (ASTM) standard F803 for selected sports (racket sports, baseball fielders, basketball, women's lacrosse, and field hockey; see figures 1 and 2)
Sports eyewear that is attached to a helmet or is designed for sports for which ASTM F803 eyewear alone provides insufficient protection. Those for which there are standard specifications include youth baseball batters and base runners (ASTM F910), paintball (ASTM 1776), skiing (ASTM 659), and ice hockey (ASTM F513). Other protectors with NOCSAE standards are available for football and men's lacrosse (see figures 2 and 3).
Not Satisfactory for Eye-Risk Sports
Streetwear (fashion) spectacles that conform to the requirements of American National Standards Institute (ANSI) standard Z80.3
Safety eyewear that conforms to the requirements of ANSI Z87.1, mandated by OSHA for industrial and educational safety eyewear (see figure 4)

*There are several types of clear material (glass, allyl resin, high-index plastic, acrylic, polycarbonate) from which prescription or nonprescription (plano) lenses may be fabricated. Polycarbonate is the most shatter-resistant clear lens material and should be used for all safety eyewear.

TABLE 4. Recommended Eye Protectors for Selected Sports*

Sport Minimal Eye Protector Comment

Baseball/softball, youth batter or base runner ASTM F910 Face guard attached to helmet

Baseball/softball, fielder ASTM F803 for baseball ASTM specifies age ranges

Basketball ASTM F803 for basketball ASTM specifies age ranges

Bicycling Helmet plus streetwear ANSI Z80, industrial ANSI Z87.1, or sports ASTM F803 eyewear Use only polycarbonate lenses; excellent plano industrial spectacles are available that are inexpensive and give good protection from wind and particles

Boxing None available; not permitted in sport Sport contraindicated for functionally one-eyed

Fencing Protector with neck bib Test requirements of the International Federation of Fencing

Field hockey (both sexes) Goalie: full face mask; others: ASTM F803 for women's lacrosse Protectors that pass ASTM F803 for women's lacrosse also pass for field hockey; should have option to wear helmet with attached face mask

Football Polycarbonate eye shield attached to helmet-mounted wire face mask

Full-contact martial arts None available; not permitted in sport Contraindicated for functionally one-eyed

Ice hockey ASTM F513 face mask on helmet; goaltenders ASTM F1587 HECC or CSA certified full face shield

Lacrosse, men's NOCSAE face mask attached to lacrosse helmet

Lacrosse, women's ASTM F803 for women's lacrosse Should have option to wear helmet with attached face mask

Paintball ASTM F1776 for paintball

Racket sports (badminton, tennis, paddle tennis, handball, squash, and racquetball) ASTM F803 for specific sport

Soccer ASTM F803 for any selected sport No specific standard for soccer; currently, eye protectors that comply with ASTM F803 for any specified sport are recommended

Street hockey ASTM F513 face mask on helmet Must be HECC or CSA certified

Track and field Streetwear/fashion eyewear Use only polycarbonate lenses

Water polo/swimming Swim goggles with polycarbonate lenses

Wrestling No standard is available Custom protective eyewear can be fabricated

*For sports in which a face mask or helmet with eye protector is worn, functionally one-eyed athletes, and those who have had previous eye trauma or surgery, and for whom their ophthalmologists recommend eye protection, must also wear sports protective eyewear that conforms to ASTM F803 requirements.

Choosing Appropriate Eye Protection

The vast majority of sports officials, administrators, and physicians are genuinely concerned about making sports as safe as possible while still maintaining fun and appeal. Most want to protect athletes, but don't know how to proceed or what to buy. They want information on what to use for their athletes, whether they order, specify, or purchase.

The basic steps. The basic steps in choosing protective gear for an eye-safety program include (1) knowing the athlete's vision and eye history, (2) using only eye protectors that have been certified to national performance standards (see table 3), and (3) having professionals assist the athlete in selecting and fitting protective eyewear. The latter point is especially important because various kinds of eye protection and different brands of sports goggles vary significantly in their fit. An experienced ophthalmologist, optometrist, optician, or athletic trainer can help an athlete select appropriate protective gear that fits well. Sports programs should assist indigent athletes in evaluating and obtaining protective eyewear.

Functionally one-eyed athletes. It is important to identify athletes who have eye conditions that make them more susceptible to catastrophic injury. One such condition is being functionally one-eyed—having a best-corrected visual acuity of worse than 20/40 in the poorer-seeing eye (31). A severe injury to the better eye in this person can result in a major handicap, such as the inability to obtain a driver's license in many states (40). Athletes who are functionally one-eyed must wear appropriate eye protection during all sports and recreational activities, and athletes who have had eye surgery or trauma to the eye may have weakened eye tissue that is more susceptible to injury. Those who have had prior surgery are considered functionally one-eyed if the best corrected vision in either eye is less than 20/40. Athletes who have had surgery may need additional eye protection if the surgery makes them more prone to serious injury from trauma (see figure 1). Some may be restricted from participating in certain sports; however, with proper protection the functionally one-eyed and those with prior eye disease should be able to participate in most sports. The input of the treating ophthalmologist is essential in making the determination.

Additional recommendations. Several other recommendations also address eyewear choice and should be considered in fitting patients with eye protection:

Proper fit in children is essential. Because some children have narrow facial features, they may be unable to wear even the smallest sports goggles. A possible solution is to fit these children with impact-resistant 3-mm polycarbonate lenses in ANSI Z87.1 frames designed for children. However, the parents must be informed that this protection is not optimal, and the choice of eye-safe sports should be discussed.
Protectors with clear lenses (plano [nonprescription] or prescription) should have polycarbonate lenses, which is the strongest lens material available (41). In the extremely rare instance that a polycarbonate lens cannot be used (eg, the athlete can tolerate only the optics of a lens with a lower index of refraction than polycarbonate), the athlete who participates in an eye-risk sport should either (1) wear contact lenses plus an appropriate protector as listed in table 3, or (2) wear an over-the-glasses eyeguard that conforms to the specifications of ASTM F803 for sports for which an ASTM F803 protector is recommended (see figure 1).
For sports requiring a face mask or helmet with an eye protector or shield, functionally one-eyed athletes should also wear sports eye protectors that conform to the requirements of ASTM F803 (for any selected sport) to maintain some level of protection if the face guard is elevated or removed (as in ice hockey or football by some players on the bench). The helmet must fit properly and have a properly fastened chin strap for optimal protection.
Contact lenses offer no protection. Therefore, athletes who wear contact lenses must also wear appropriate eye protection (see tables 3 and 4).
Athletes must replace sports eye protectors that are damaged or yellowed with age, because they may have become weakened.
Functionally one-eyed athletes and those who have had an eye injury or surgery can participate in almost all sports if they use appropriate eye protection. The exceptions are boxing, for which eye protection is not practical, and full-contact martial arts, for which protection is not allowed. No standards exist for eye protectors in wrestling, but the incidence of eye injuries is low in this sport. Eye protectors that are firmly fixed to the head have been custom made for wrestling, but wrestlers need to know that such protectors may not be sufficient to prevent injury.

Parting Views

There are effective means of protecting the player from injury with products that conform to ASTM, CSA, or NOCSAE specifications. Products that bear a certification seal from PECC, HECC, CSA, or NOCSAE are easily identifiable and are preferred. During several million player-years of use, there have been no eye injuries to any player wearing a protector that conformed to ASTM F803 requirements. Similarly, there have been no reported significant eye injuries to any of the more than 1 million players wearing a full hockey face shield certified by HECC or CSA since the ASTM standard was first published in 1977 and HECC was founded in 1978.

Players of any sport assume some injury risk while participating, but players (and parents of minors) have the right to know the actual risk. The injury incidence should be documented by a prospective injury reporting system. The risk and the means of reducing it must be clearly articulated to players and players' parents. The vast majority of eye injuries can be prevented with existing protectors. The prudent school official will mandate eye protection for sports that use a stick or a ball or other projectile or that involve significant body contact. The team physician should insist that players of sports with an eye hazard wear certified protectors. Non-team physicians should include a sports history as part of the routine examination of all patients and recommend protective eyewear appropriate for the patient's activity.

References

Coroneo MT: An eye for cricket: ocular injuries in indoor cricketers. Med J Aust 1985;142(8):469-471
Jaison SG, Silas SE, Daniel R, et al: A review of childhood admission with perforating ocular injuries in a hospital in north-west India. Indian J Ophthalmol 1994;42(4):199-201
Pump-Schmidt C, Behrens-Baumann W: Changes in the epidemiology of ruptured globe eye injuries due to societal changes. Ophthalmologica 1999;213(6):380-386
Drolsum L: Eye injuries in sports. Scand J Med Sci Sports 1999;9(1):53-56
Lynch P, Rowan B: Eye injury and sport: sport-related eye injuries presenting to an eye casualty department throughout 1995. Ir Med J 1997;90(3):112-114
Pikkel J, Gelfand Y, Miller B: Incidence of sports-related eye injuries (in Hebrew). Harefuah 1995;129(7-8):249-250, 294-295
Lawson JS, Rotem T, Wilson SF: Catastrophic injuries to the eyes and testicles in footballers. Med J Aust 1995;163(5):242-244
Ghosh F, Bauer B: Sports-related eye injuries. Acta Ophthalmol Scand 1995;73(4):353-354
Biasca N, Simmen HP, Bartolozzi AR, et al: Review of typical ice hockey injuries: survey of the North American NHL and Hockey Canada versus European leagues. Unfallchirurg 1995;98(5):283-288
Pardhan S, Shacklock P, Weatherill J: Sport-related eye trauma: a survey of the presentation of eye injuries to a casualty clinic and the use of protective eye-wear. Eye 1995;9(pt 6 suppl):50-53
Fong LP: Sports-related eye injuries. Med J Aust 1994;160(12):743-747, 750
Capoferri C, Martorina M, Menga M, et al: Eye injuries from traditional sports in Aosta Valley. Ophthalmologica 1994;208(1):15-16
Jones NP: Eye injury in sport: incidence, biomechanics, clinical effects and prevention. J R Coll Surg Edinb 1993;38(3):127-133
ten Napel JA: Eye injuries in sports (in Polish). Klin Oczna 1990;92(3-4):48-49
Rapoport I, Romem M, Kinek M, et al: Eye injuries in children in Israel: a nationwide collaborative study. Arch Ophthalmol 1990;108(3):376-379
Macewen CJ: Eye injuries: a prospective survey of 5671 cases. Br J Ophthalmol 1989;73(11):888-894
Crowley PJ, Condon KC: Analysis of hurling and camogie injuries. Br J Sports Med 1989;23(3):183-185
Pashby T: Eye injuries in sports. J Ophthalmic Nurs Technol 1989;8(3):99-101
Jones NP: Eye injury in sport. Sports Med 1989;7(3):163-181
Kelly SP: Serious eye injury in badminton players. Br J Ophthalmol 1987;71(10):746-747
Prevent Blindness America (formerly National Society to Prevent Blindness): 1997 Sports and Recreational Eye Injuries. Schaumburg, IL, Prevent Blindness America, 1998
Powell JW: National Athletic Injury/Illness Reporting System: eye injuries in college wrestling. Int Ophthalmol Clin 1981;21(4):47-58
Reif AE, Vinger PF, Easterbrook M: New developments in protection against eye injuries. Squash News 1981;4(6):10-14
Genovese MT, Lenzo NP, Lim RK, et al: Eye injuries among pennant squash players and their attitudes towards protective eyewear. Med J of Aust 1990;153(11-12):655-658
Soderstrom CA, Doxanas MT: Racquetball: a game with preventable injuries. Am J Sports Med 1982;10(3):180-183
Rose CP, Morse JO: Racquetball injuries. Phys Sportsmed 1979;7(1):73-77
Wilson K, Cram B, Rontal E, et al: Facial injuries in hockey players. Minn Med 1977;60(1):13-16
Marton K, Wilson D, McKeag D: Ocular trauma in college varsity sports, abstracted. Med Sci Sports Exerc 1987;19(2 suppl):S53
Schuster M: Baseball-Related Injuries Among Children: Statewide Comprehensive Injury Prevention Program. Boston, Bureau of Parent, Child and Adolescent Health, Massachusetts Department of Public Health, 1991
Zagelbaum BM, Hersh PS, Donnenfeld ED, et al: Ocular trauma in major-league baseball players. N Engl J Med 1994;330(14):1021-1023
Vinger PF: The eye and sports medicine, in Tasman W, Jaeger EA (eds): Duane's Clinical Ophthalmology. Philadelphia, JB Lippincott, 1994, pp 1-103
Piltz W: Eye and facial injuries in women's lacrosse: a paper on women's lacrosse in Australia. Read before the Second International Symposium on Ocular Trauma. Geneva, Switzerland, April 2-5, 1992
Zemper ED: Injury rates in a national sample of college football teams: a 2-year prospective study. Phys Sportsmed 1989;17(11):100-105
Schein OD, Hibberd PL, Shingleton BJ, et al: The spectrum and burden of ocular injury. Ophthalmology 1988;95(3):300-305
Jeffers JB: An ongoing tragedy: pediatric sports-related eye injuries. Semin Ophthalmol 1990;5(4):216-223
Larrison WI, Hersh PS, Kunzweiler T, et al: Sport-related ocular trauma. Ophthalmology 1990;97(10):1265-1269
Strahlman E, Sommer A: The epidemiology of sports-related ocular trauma. Int Ophthalmol Clin 1988;28(3):199-202
American National Standards Institute: American National Standard Practice for Occupational and Educational Eye and Face Protection. Des Plaines, IL, American Society of Safety Engineers, 1998
American Society for Testing and Materials: 1999 Annual Book of ASTM Standards: General Products, Chemical Specialties, and End Use Products. West Conshocken, PA, American Society for Testing and Materials, 1999
Federal Highway Administration: Manual on Uniform Traffic Control Devices for Streets and Highways. Washington, DC, US Department of Transportation, 1988
Vinger PF, Parver L, Alfaro DV III, et al: Shatter resistance of spectacle lenses. JAMA 1997;277(2):142-144

Dr Vinger is a clinical professor of ophthalmology at Tufts University School of Medicine in Medford, Massachusetts. Address correspondence to Paul F. Vinger, MD, 297 Heath's Bridge Rd, Concord, MA 01742; e-mail to vingven@tiac.net.