Article, Ophthalmology

Ocular trauma secondary to exercise resistance bands during the COVID-19 pandemic

a b s t r a c t

Objective: To characterize injuries caused by exercise resistance bands.

Method: Single-site retrospective case series of patients presenting to the Bascom Palmer Eye Institute emergency room with ocular injuries secondary to exercise resistance bands from March through September 2020.

Results: Eleven patients (9 males, 2 females, 14 eyes) were reviewed. Eight patients had a unilateral injury (3 right eyes, 5 left eyes) while 3 had bilateral injuries. Iritis was the most common presentation, seen in all 11 pa- tients, followed by hyphema (9 patients, 82%), and vitreous hemorrhage (4 patients, 36%). Among affected eyes, the mean presenting visual acuity was approximately 20/100, improving to 20/40 on the last follow up (p = 0.06). However, 4 eyes (33%) had vision <=20/60 at last follow up.

Conclusions: Exercise resistance bands can cause a wide spectrum of ocular injuries, some leading to long-term Vision loss. As such, we recommend that patients strongly consider using eye protection goggles or glasses while using resistance bands for exercise.

(C) 2020

  1. Introduction

The Covid19 pandemic led to extended lockdowns across the United States, during which Americans were required to stay at home except to perform essential functions [1-3]. Even after lockdown orders were lifted, many businesses, including gyms, remained closed due to social distancing requirements [4,5]. Since the start of the COVID19 pan- demic, we noted an increase in resistance exercise band-induced Ocular trauma to the Bascom Palmer Eye Institute emergency department.

Resistance exercise bands were originally used for rehabilitation therapy but have grown in popularity in strength training [6,7]. If not se- cured properly, the elastic bands can recoil and cause ocular trauma. Single reports and small case series of ocular trauma secondary to exer- cise bands have previously been reported and include lens dislocation, retinal detachment, macular holes, and ruptured globe injuries [8-10].

Herein, we present the largest case series of ocular trauma second- ary to exercise resistance bands, all of which presented during the COVID19 pandemic.

? Bascom Palmer Eye Institute received funding from the NIH Core Grant P30EY014801, Department of Defense Grant #W81XWH-13-1-0048, and a Research to Prevent blindness Unrestricted Grant. The sponsors or funding organizations had no role in the design or conduct of this research.

* Corresponding author at: Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136, United States of America.

E-mail address: [email protected] (H. Al-khersan).

  1. Methods

The present retrospective consecutive case series received approval from the Institutional Review Board at the University of Miami and ad- hered to the Health Insurance Portability and Accountability Act and the Declaration of Helsinki. Charts were reviewed for all patients presenting to the Bascom Palmer Eye Institute emergency room with a docu- mented resistance band injury from March 2020, the start of the COVID19 lockdown in Miami-Dade county, through September 2020.

Included in the study were patients who presented with an ocular injury associated with the use of an exercise-specific resistance band. Patients with injuries due to industrial bungee cords or other non- exercise related bands were excluded. Patient information collected in- cluded demographics, presenting visual acuity and Intraocular pressure (IOP), clinical exam findings, follow up, and treatment information. Sta- tistical analysis was performed using StataIC 15.1 (StataCorp, LLC, Col- lege Station, TX). A p-value <0.05 was considered statistically significant.

  1. Results

In total, 14 charts of patients with documented resistance band- related injuries were identified. Of these, 3 patients were excluded after chart review revealed non-exercise related resistance band or bungee cord injuries. The remaining 11 patients (14 eyes) consisted of 9 males and 2 females. Eight patients had a unilateral injury (3 right

https://doi.org/10.1016/j.ajem.2020.11.054

0735-6757/(C) 2020

Presenting demographics, visual acuities, and intraocular pressures of patients with exercise resistance band ocular injuries

Patient

Sex

Age

Affected Eye

Presenting Vision

Presenting IOP

Follow- up Duration

Patient 1

Male

26

Right

20/20

13

None

Patient 2

Male

48

Bilateral

20/100 and 20/25

10 and 12

4 months

Patient 3

Male

50

Left

Counting fingers

12

3 weeks

Patient 4

Male

62

Left

20/25

39

3 months

Patient 5

Female

33

Left

20/25

19

2 weeks

Patient 6

Male

27

Bilateral

20/150 and 20/150

19 and 18

1 week

Patient 7

Male

41

Right

Hand motions

19

2 weeks

Patient 8

Male

49

Left

Hand motions

25

3 months

Patient 9

Female

47

Right

20/25

17

1 week

Patient 10

Male

80

Left

20/50

15

None

Patient 11

Male

37

Bilateral

20/25 and 20/25

10 and 10

3 weeks

Fig. 1. A-C: Slit lamp photography demonstrates blood diffusely distributed in the anterior chamber causing a red hue (A), which consolidated into a hyphema on follow-up (B, blue box, magnified in C).

eyes, 5 left eyes) while 3 had bilateral injuries. The mean age of patients was 45.5 years (range 26-80 years). Patient demographics, presenting acuities, and IOPs are listed in Table 1.

The most common presenting ocular finding was iritis, which was seen in all 11 patients, followed by hyphema (9 patients, 82%) (Fig. 1), and vitreous hemorrhage (4 patients, 36%) (Fig. 2, Table 2). One patient presented with a macular hole (Fig. 3).

Fig. 2. Fundus photography demonstrates vitreous hemorrhage appearing as opaque media opacities (white arrows) as well as intraRetinal hemorrhage (yellow arrowheads).

Among affected eyes, the mean presenting visual acuity was 0.71 logMAR (Snellen equivalent 20/100), which improved to 0.28 logMAR (Snellen equivalen 20/40) on the last follow up (p = 0.06). However, among eyes with follow-up beyond the initial emergency room visit (12 of 14 eyes), 4 eyes (33%) had vision <=20/60.

The mean presenting IOP among affected eyes was 17 mmHg. Two eyes demonstrated Elevated intraocular pressures on initial presenta- tion (39 and 25 mmHg). At final follow up, one eye had an IOP above normal (26 mmHg).

Nine patients (82%) presented for at least one scheduled follow-up visit, but ultimately seven patients (64%) were lost to follow-up before completing treatment or observation. The mean follow-up duration for patients presenting for at least one visit after their initial emergency room visit was 4.7 weeks.

All patients required at least topical therapy, which included a com- bination regimen of cyclopentolate, a cycloplegic, and prednisolone, a topical corticosteroid. Patients with corneal epithelial defects also re- ceived topical antibiotic drops. Lastly, one patient who presented with an elevated IOP was placed on topical IOP-lowering therapy. The patient who presented with a traumatic macular hole required Surgical repair with a pars plana vitrectomy and membrane peel.

  1. Discussion

With the increase of home exercise in the setting of quarantines and social distancing policies during the COVID19 pandemic, we have seen a rise in recreational exercise resistance band-related ocular injuries. The present series of 11 patients, all who presented after the start of the COVID19 pandemic, represents the largest in the literature.

Similar to ocular injuries due to bungee cords, resistance bands can cause a spectrum of ocular injuries involving all ocular structures. Com- mon anterior segment injuries include corneal epithelial defects, iris de- fects, traumatic iritis, and hyphema. Posterior segment injuries include

Table 2

Types of ocular injuries induced by exercise resistance band ocular injuries. KED: Corneal epithelial defect.

Patient

KED

Iritis

Hyphema

Iris Defect

Angle Recession

Cataract

Vitreous Hemorrhage

Macular Hole

Retinal Tear

Retinal Hemorrhage

Commotio Retinae

Patient 1

X

Patient 2

X

X

X

X

X

X

Patient 3

X

X

X

X

X

Patient 4

X

X

X

Patient 5

X

X

X

Patient 6

X

X

X

X

X

Patient 7

X

X

X

Patient 8

X

X

X

Patient 9

X

X

X

Patient 10

X

X

Patient 11

X

Total Patients

2

11

9 (82%)

1 (9%)

2 (18%)

1 (9%)

4 (36%)

1 (9%)

1 (9%)

1 (9%)

2 (18%)

(%)

(18%)

(100%)

vitreous hemorrhage, retinal tear or detachment, macular hole, and commotio retinae (retinal edema). As is seen generally with ocular trauma, most of the patients were male [11-13].

While many of these injuries can be treated with observation or top- ical therapies, surgical intervention is sometimes required for certain conditions such as macular holes. Additionally, long-term visual deficits may be seen; four eyes maintained vision worse than 20/60 as of their last follow-up visit in the present study.

While the patients in the current study presented to an ocular emer- gency room, most will present to a general emergency room or urgent care clinic. As such, emergency room physicians should be comfortable triaging such patients. While ophthalmic examinations can be limited in the emergency room, a baseline vision and IOP should be taken. Addi- tionally, fluorescein staining to identify a corneal epithelial defect should be performed. If there is suspicion of a ruptured globe, IOP mea- surements should be deferred, the globe should not be excessively ma- nipulated, a protective shield should be placed over the eye, and the patient should be seen emergently by the ophthalmology service [14,15].

All patients who present with an ocular injury from an exercise re- sistance band should receive a baseline examination in the emergency department. Based on the severity of the injury, there should be a low threshold for referring the patient to an ophthalmologist for follow-up care if needed. Some manifestations of traumatic ocular injuries can be chronic. For example, vision-threatening complications such as angle-recession, which can cause elevated IOP and insidious loss of vi- sion, and traumatic cataracts may not be present on initial examination [16-18]. Therefore, follow-up may be needed to determine the risk of

Fig. 3. A,B: optical coherence tomography demonstrates a full thickness macular hole before (A) and after (B) surgical repair with pars plana vitrectomy and membrane peeling.

long-term vision loss as well as to perform advanced ophthalmic exam- inations such as gonioscopy.

Ultimately, exercise resistance bands can cause a wide spectrum of ocular injuries, many leading to long-term vision loss. As such, we rec- ommend that patients strongly consider using eye protection such as goggles or glasses while using resistance bands for exercise. Ocular inju- ries resulting from exercise resistance bands should receive follow-up care with an ophthalmologist.

Declaration of Conflicting Interest

None of the authors report any financial interests related to the present work.

CRediT authorship contribution statement

Hasenin Al-khersan: Conceptualization, Methodology, Formal analysis, Writing and revision. Thomas A. Lazzarini: Conceptualiza- tion, Methodology, Writing and revision. Anne L. Kunkler: Concep- tualization, Methodology, Writing and revision. Diana M. Laura: Conceptualization, Methodology, Writing and revision. Kenneth C. Fan: Conceptualization, Methodology, Writing and revision. Lily Zhang: Conceptualization, Methodology, Writing and revision. David W. Redick: Conceptualization, Methodology, Writing and revision. Humberto Salazar: Conceptualization, Methodology, Writing and revision. Charles M. Medert: Conceptualization, Methodology, Writing and revision. Nimesh A. Patel: Conceptualiza- tion, Methodology, Writing and revision, Supervision, Project administration.

Acknowledgments

This study was supported by the NIH Center Core Grant P30EY014801 and Department of Defense Grant #W81XWH-13-1- 0048 to the Bascom Palmer Eye Institute.

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