Contact Lenses

Doctor’s Play Book: 
The X’s and O’s of Fitting Athletes

Athletes have special contact lens needs. Here’s what they are and how you can meet them. 
By JOHN J. GARDNER, O.D.

By the time I crossed the suspension bridge in Nepal, my heart was pounding, my breathing was rapid, and the muscles in my legs felt spent. Yet I can barely think of a more exhilarating feeling than being as high up in the world as when I ran that marathon at Mount Everest 12 years ago. 

As a long-time sports enthusiast, I’m grateful for this and other experiences and for the fond memories of summers spent playing baseball and basketball (during my youth I must have logged 6,000 at bats). Today, these memories inspire me in my everyday practice, as I fit my athletic patients in contact lenses. 

Contact lenses that can meet the special visual demands of athletes are a growing need among our patients. Whether your patients run marathons in Asia, compete in professional sports or just play ball at the local field on weekends, you can help meet their special needs. This starts with understanding what influences our choices of lens material and design, solutions and lens replacement schedule. Here’s a page out of my playbook. 
Vision Requirements
When fitting athletes in contact lenses for specific sports, you must consider the specific vision requirements of whatever sport the patient plays. These include visual acuity (both static and dynamic), line of sight, overall field of gaze, speed of eye movements (saccades and pursuits), depth perception and contrast sensitivity. 

In most sports, the body moves forward with the eyes in slight or exaggerated upgaze, so the final lens choice must be very stable in this position. This is especially important with toric lens designs. Establish this during in-office bio- microscopy by having the patient look in upgaze.

Realize there are variations according to sport. For example, a baseball player requires different fields of gaze; a right-handed batter looks in left gaze, while a left-handed batter looks in right gaze. By contrast, soccer and tennis require rapid eye movements in all fields of gaze, and basketball players have upgaze and downgaze demands. 

Positional stability is especially important in sports that require rapid eye movements in various fields of gaze. Any delay in contact lens reorientation can adversely affect vision and visual performance.
Length of Competition
Another important consideration: overall duration of the event. Most events last 2-3 hours, but when you include pre- and post-performance activities, the total time for most sporting events is 3-5 hours. And, given the drive of many athletes, their training may last much longer. 

Ideally, we try to keep all our contact lens patients in their lenses during waking hours, but some patients can only wear them for limited periods. So, a patient might comfortably wear lenses during a two-hour tennis match, but could have great difficulty if he needed them for mountain climbing, a triathlon, a bike race or some other event that lasts much longer. 

The length of physiological confrontation of the eye and the potential for tissue insult (hypoxia) can cause corneal edema. If the cornea sustains this for long periods of time, tissue breakdown can occur. There’s greater potential for this with larger, tighter lens designs, including scleral lenses, intended only for competition. Still, I’ll try to work with patients to fit them appropriately for the sport of their choice. 

Environment

In some instances you might try fitting the patient with a thicker lens, which won’t dry out as quickly. However, lid position and lid tension may affect how well the lens centers.

The ambient, or external, environment involves wind, dirt, humidity, altitude, temperature and exposure to ultraviolet radiation. Large diameter soft lenses are necessary to prevent debris from getting underneath the lens. Water content and Dk values may play more of a role in lens choice when altitude and low humidity are key considerations since these result in lens dehydration and increased potential for corneal insult.

Replacement Possibilities

I often have patients wear their lenses four or five hours before follow-up exams so I can assess corneal physiology and observe how much debris builds up on the lens. This timing gives me an idea of how that lens will probably look at the end of a game or practice. Depending on the amount of debris, I may instill a lubricating drop to see if that cleans the lens and improves the patient’s acuity. If that doesn’t work, I’ll have the patient remove and rinse the lens or use a new lens.

When training patients to wear contact lenses, be sure to stress the importance of hygiene. This is one of the biggest problems we encounter with our athletic patients. For example, baseball players usually have dirt on their hands. Football and soccer players often get covered in dirt. Not exactly ideal conditions for handling contact lenses.

Instruct patients to use alcohol-based hand cleaners and then wait 15-20 seconds before repositioning or changing a contact lens. Also instruct swimmers to remove their contacts immediately when they leave the water and wait at least 30 minutes to insert new lenses. This wait allows the cornea to recover from potential hypoxia and from the hostile chlorine environment.

You might want to work with team trainers. Instruct them how to insert, re-center and remove contact lenses for their players. The trainers should have spare lenses on hand.

Special Needs

Though rarely used, scleral lenses may be necessary to offer these patients superior optics and positional stability. During water sports (water polo and water skiing), for example, conventional lenses could float out or fall out, while a scleral lens is likely to remain stable in the eye. 

These lenses will stay in place better but may create more physiological insult on the cornea after a few hours of wear. Patients should only wear them for 2-4 hours.

Likelihood of Compliance

Athletic patients who wear contact lenses have more issues than your regular contact lens patients. But if you can address those issues and meet those needs, you can offer them clear, comfortable vision whether they’re running a marathon in Nepal or just playing softball at the neighborhood field.

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Contact Lens Requirements of Specific Sports Baseball/Softball Visual demands. Sharp visual acuity and contrast sensitivity, especially for hitting. Requirements vary depending on whether the player is pitching, fielding or hitting. Line of sight is also critical while hitting. Right-handed hitters look in left gaze; left-handed hitters look in right gaze. Contact lenses, especially torics, must be very stable immediately after blinking. Correction. Soft lenses with appropriate line of sight stability are ideal at bat. RGPs offer sharp acuity, but players risk getting dust or dirt under the lens. My choice: large soft lenses, preferably disposables with UV protection. Avoid opaque lenses; these may introduce distorted perception through the pupil edge.  Duration. 3-5 hours. There’s adequate time between innings to remove and rinse or replace lenses. Hygienic conditions usually are acceptable.  Basketball Visual demands. Accurate rapid eye movements in upgaze. Some players tip their heads back on free throws and fade away jump shots so that line of sight is in slight downgaze. Positional stability is very important, due to upgaze demands. Correction. Soft lenses, especially larger diameter lenses (14.8mm and higher) are preferable.  Duration. 2-5 hours, with adequate time to reposition or replace lenses and adequate hygienic conditions. Football Visual demands. Acuity is important to the “skilled” position players. Line of sight varies, but is predominantly straightforward to upgaze. Correction. Soft lenses are ideal. My choices: Same as for baseball players. Also consider daily disposables to account for adverse hygienic conditions.  Duration. 3-5 hours. Hygienic conditions are poor, so players should replace lenses on the field as a last resort. Ice Hockey Visual demands. Visual acuity (dynamic), contrast sensitivity and rapid eye movements in all fields of gaze are important. Eye protection is essential. Correction. Soft lenses that are very stable on the eye provide excellent correction. Also consider the on-ice environment. Lenses dehydrate due to convection drying of the anterior contact lens surface and low humidity, which can affect comfort and vision. Consider thick, low water content (38-43%) lenses that offer sharp vision and good contrast sensitivity. I’ve also used Proclear Compatibles (62%, Biocompatibles) and Extreme H2O (59%, Benz) with impressive results. Duration. 3-5 hours. Players can use rewetting agents between shifts on the ice and replace lenses between periods if dehydration is significant. Soccer Visual demands. Rapid eye movements in all fields of gaze. This is a rapid moving sport, so lens stability is important. Correction. Soft lenses are ideal. Disposables with UV protection are my particular lenses of choice. Duration. 3-5 hours. Hygienic conditions are like football; players should replace lenses on-field only as a last resort. Tennis Visual demands. Visual acuity (dynamic) and rapid eye movements in all fields of gaze. Line of sight varies from downgaze (ground strokes) to upgaze (overhead shots). Positional stability is important. Correction. Soft disposable lenses are ideal. UV protection is very important. I’ve had success with Prosoft Sport Lens (CIBA Vision), which enhances the ability to see the optic yellow of tennis balls. Lenses are only for wear while playing tennis.  Duration. 1-3 hours. There’s time to instill rewetting drops as needed. The ambient environment is usually very clean.

Dr. Gardner is in private practice in Chicago and Hickory Hills, Ill. He frequently lectures on sports vision and is vice chair of the AOA’s Sports Vision Section.

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© Review of Optometry OnLine 
June 15, 2001