An 18-year-old male high school student presented to our clinic with bilateral blunt ocular trauma caused by an exercise resistance band (ERB) during a muscle-building exercise. Best-corrected decimal visual acuities (BCVAs) for right and left eyes were light perception and 0.15, respectively. The right eye was operated 10 days after injury for persistent vitreous hemorrhage, and the left eye 5 months later because of macular hole onset. After 36 months, the right eye showed extensive retinal degeneration (BCVA 0.04), and the left eye macular hole closure (BCVA 1.2). ERBs should be used cautiously as they can cause serious ocular trauma

Ariyasu, Kanazu

Doi, Shinichiro

Kanzaki, Yuki

Kimura, Shuhei

Matoba, Ryo

Morizane Hosokawa, Mio

Morizane, Yuki

Shiode, Yusuke

English

Okayama University Scientific Achievement Repository

S ports-related ocular trauma is often caused by ball games and combat sports [1-3].  In recent years,  ocular injury due to exercise resistance band (ERB) use for muscle-building exercises has been reported [4-11].  This form of trauma has been reported to show several ocular findings such as corneal erosion,  hyphema,  trau-matic iritis,  vitreous hemorrhage,  and commotio retinae.  Most cases are cured by simple observation or medica-tion,  and do not require surgery [4-7,9].  Here,  we report a case involving an 18-year-old male with severe bilat-eral blunt ocular trauma sustained during an ERB mus-cle-building exercise for swimming.  The trauma resulted in multiple retinal tears,  retinal detachment,  extensive retinal degeneration,  and a macular hole.Case ReportAn 18-year-old male high school student,  who took up swimming as an extracurricular activity,  presented at our clinic with severe bilateral blunt ocular trauma caused by ERB accident while performing a mus-cle-building exercise at the pool.  The central part of a 1-m-long ERB was fixed to a poolside pipe with a hook-and-loop fastener.  The patient held both ends of the ERB and pulled with full force while maintaining an approximate distance of 2 m from the fixed part of ERB.  Suddenly,  the hook-and-loop fastener released,  and the ERB hit him in both eyes.  He immediately experienced binocular visual distur-bances,  and so came to our clinic.  He had not been wearing protective eyewear during the exercise.  The best-corrected decimal visual acuities (BCVAs) at the first visit were light perception for the right eye and 0.15 for the left eye,  while the intraocular pressure (IOP) was 26 and 16 mmHg,  respectively.  The right eye showed corneal erosion,  hyphema,  an iris defect,  vitreous hemorrhage,  no lens in the anterior segment,  and the Acta Med.  Okayama,  2022Vol.  76,  No.  3,  pp.  349-354CopyrightⒸ 2022 by Okayama University Medical School.http ://escholarship.lib.okayama-u.ac.jp/amo/Case ReportBilateral Blunt Ocular Trauma Caused by an Exercise Resistance Band during Muscle Building Exercise for SwimmingKanazu Ariyasu,  Shuhei Kimura＊,  Ryo Matoba,  Mio Morizane Hosokawa,   Yusuke Shiode,  Shinichiro Doi,  Yuki Kanzaki,  and Yuki MorizaneDepartment of Ophthalmology,  Okayama University Graduate School of Medicine,  Dentistry and Pharmaceutical Sciences,   Okayama 700-8558,  JapanAn 18-year-old male high school student presented to our clinic with bilateral blunt ocular trauma caused by an exercise resistance band (ERB) during a muscle-building exercise.  Best-corrected decimal visual acuities (BCVAs) for right and left eyes were light perception and 0.15,  respectively.  The right eye was operated 10 days after injury for persistent vitreous hemorrhage,  and the left eye 5 months later because of macular hole onset.  After 36 months,  the right eye showed extensive retinal degeneration (BCVA 0.04),  and the left eye macular hole closure (BCVA 1.2).  ERBs should be used cautiously as they can cause serious ocular trauma.Key words:  exercise resistance band,  traumatic macular hole,  traumatic retinal degeneration,  bilateral blunt ocu-lar trauma Received September 16, 2021 ; accepted January 25, 2022.＊Corresponding author. Phone : +81-86-235-7297; Fax : +81-86-222-5059E-mail : shuheik@cc.okayama-u.ac.jp (S. Kimura)Conflict of Interest Disclosures: No potential conflict of interest relevant to this article was reported.fundus was invisible (Fig. 1A).  B-mode echography showed vitreous hemorrhage; the location of the lens could not be identified and retinal detachment was not suspected.  In the left eye,  the cornea,  anterior chamber,  and lens were normal,  and posterior vitreous detachment and vitreous hemorrhage were observed.  There was a shallow serous retinal detachment at the posterior pole of the fundus,  commotio retinae at the temporal and nasal sides,  and several retinal tears without retinal detachment in the peripheral retina (Fig. 1B, D).  Head computed tomography did not show any orbital floor fracture.  Ten days after the trauma,  retinal photocoag-ulation of the peripheral retinal tears in the left eye was performed.  In the right eye,  vitreous hemorrhage persisted,  and pars plana vitrectomy was performed under general anesthesia 10 days after the injury.  The lens had dropped into the vitreous cavity,  and was aspirated with a vitre-ous cutter.  When the vitreous hemorrhage was evacu-ated,  more than 10 retinal tears and retinal detachment were observed.  The vitreous was removed to the extent possible,  and retinal photocoagulation was performed after fluid-air exchange.  At the end of the surgery,  the vitreous cavity was replaced with silicone oil (SO),  which was removed two months later.  Following the initial surgery,  gonioscopy revealed angle closure,  and IOP remained at 25-30 mmHg.  The patient was diag-nosed with secondary glaucoma,  and treated with dor-zolamide hydrochloride/timolol maleate,  travoprost,  and brimonidine tartrate.  Fundus examination after the initial surgery revealed retinal hemorrhage and retinal atrophy in the inferior half of the retina,  including the macula,  which gradually degenerated into a fibrous scar (Fig. 2C , E).The serous retinal detachment in the left eye gradually 350 Ariyasu et al. Acta Med.  Okayama　Vol.  76,  No.  3A BC DFig. 1　 Anterior segment,  B-mode echography,  and wide-angle color fundus photographs obtained at initial examination of an 18-year-old male with bilateral blunt ocular trauma caused by an exercise resistance band (ERB).  The right eye shows corneal erosion (A,  arrowhead),  hyphema (A,  arrow),  and an iris defect.  The fundus of the right eye is not visible.  A B-mode echography (inferior horizontal section) image of the right eye shows hyphema (C, ＊) and vitreous hemorrhage (C,  arrow) with nonrecognition of the location of the lens.  There is no suspicion of retinal detachment.  The left eye shows no significant findings in the anterior ocular segment (B).  A fundus photograph of the left eye shows commotio retinae (D,  arrow),  vitreous hemorrhage (D,  arrowhead),  and several retinal tears without retinal detachment in the peripheral retina.disappeared.  At four months after the trauma,  a sec-ondary epiretinal membrane was found on the temporal side of the macula,  and BCVA was 0.8 (Fig. 3A-D).  However,  at five months after injury,  a macular hole with a diameter of 142 μm was observed,  and BCVA decreased to 0.7 (Fig. 3E , F).  The maximum depth of June 2022 Bilateral Ocular Trauma by Exercise Band 351A BC DE FG HFig. 2　 Anterior segment and wide-angle color fundus photographs,  optical coherence tomography (OCT) images,  and Goldmann visual fields obtained at 36 months (last visit) after bilateral blunt ocular trauma due to an exercise resistance band.  The anterior segment of the right eye shows complete loss of the iris,  which has resulted in aphakia (A).  The anterior segment of the left eye shows no significant findings and no secondary cataract (B).  Wide-angle color fundus photographs of the right (C) and left (D) eyes show atrophic degeneration of the retina in the inferior half (arrowheads).  In the right eye,  OCT (vertical section) shows atrophy in all layers of the retina,  including the macula (E).  In the left eye,  the macular hole remains closed,  and the inferior retina shows thinning (F,  arrowheads).  The Goldmann visual field test shows visual field defects consistent with the extent of retinal degeneration in the right (G) and left (H) eyes.the retinal folds (MDRF) [12 , 13] was 31.4 μm.  We per-formed pars plana vitrectomy,  epiretinal membrane peeling,  the inverted internal limiting membrane flap technique,  and 20% sulfur hexafluoride gas tamponade.  The lens was preserved,  and the macular hole appeared closed on an optical coherence tomography (OCT) image obtained on postoperative day 10 (Fig. 3G , H).  The retina in the inferior half of the eye,  not including the macula,  gradually degenerated after surgery,  resulting in a fibrous scar (Fig. 2D and F).352 Ariyasu et al. Acta Med.  Okayama　Vol.  76,  No.  3A BC DE FG HFig. 3　 Optical coherence tomography (OCT) images of the left eye of an 18-year-old male with bilateral blunt ocular trauma caused by an exercise resistance band (ERB).  Horizontal B-scan images (A ,C ,E ,G) are shown in the left column,  while en face OCT images (B ,D ,F ,H) flattened by the inner limiting membrane (ILM) are shown in the right column.  A B-scan image shows retinal detachment involving the macula (A,  arrowheads),  while an en face OCT image shows no abnormal findings (B).  Four months after the trauma,  B-scan (C) and en face OCT (D) images show an epiretinal membrane (C ,D,  arrowheads) and a pseudomacular hole in the central fovea (C,  arrow).  The en face OCT image clearly visualizes the localization of an epiretinal membrane (D,  arrowheads) and shows retinal folds caused by epiretinal membrane traction (D,  arrows).  Five months after the trauma,  a macular hole with a diameter of 142 μm can be observed (E ,F,  white arrow).  Although the extent of the epiretinal membrane has not changed significantly (E ,F,  arrowheads),  there are fewer retinal folds (F,  black arrow).  One month after surgery,  the macular hole has closed (G,  arrow).  Both epiretinal membrane and the retinal folds disappeared (H).  There were no postoperative complications requiring reoperation in either eye at the last visit (36 months after the trauma).  BCVA at the last visit was 0.04 in the right eye and 1.2 in the left eye,  while IOP was 15 and 12 mmHg,  respectively.  The Goldmann visual field test showed visual field defects consistent with the extent of retinal degeneration in both eyes (Fig. 2G , H).The case patient gave written,  informed consent prior to undergoing surgery and for publication of the report.DiscussionIn this report,  we describe a case involving a young adult with severe bilateral blunt ocular trauma caused by an ERB during a muscle-building exercise for swim-ming.  The left eye showed a macular hole five months after the injury.  The macular hole was surgically closed,  and visual acuity improved.  However,  there was fibrous scarring of the retina,  including the posterior pole,  and visual acuity was poor in the right eye.  Previous reports have shown that ocular trauma due to ERB can cause corneal erosion,  hyphema,  lens dislocation,  macular hole,  and commotio retinae,  among other complica-tions [4-11].  However,  to the best of our knowledge,  there are no reports of severe cases or several patholo-gies in a single case,  or reports of macular hole onset five months after ocular trauma [4-11].  There are three possible causes of ocular trauma by ERB: (i) the ERB breaks due to deterioration; (ii) the ERB is inadequately fixed; and (iii) injury prevention measures are insufficient.  Countermeasures for ERB breakage include storage in an appropriate environment (i.e.,  a cool,  dark,  and dry place),  and thorough checking for damage before use [9].  Moreover,  the manufacturer should set an expiration date for its use [9].  Prevention for inadequate fixation of ERB include careful evaluation to determine adequate fixation before use [9].  Remedies for inadequate protection of the user include the use of protective glasses [6 , 9 ,10].  In the present case,  the ERB was not damaged,  and the latter two causes were con-firmed.Currently,  there is no consensus on the indications and timing of vitrectomy for traumatic macular hole.  According to previous reports,  the characteristics of traumatic macular hole that result in spontaneous clo-sure include a small diameter (244.9 ± 114.4 in the closed group vs.  523.9 ± 320.0 μm in the unclosed group) [14 , 15],  relatively young age (12.0-14.6 years in the closed group vs.  27.0 years in the unclosed group) [15-17],  and absence of preoperative posterior vitreous detachment [16 , 17].  The timing of spontaneous clo-sure is estimated to be within one week to four months after the trauma [17].In the present case,  although the macular hole diam-eter (142 μm) was small enough to allow spontaneous closure,  the patient was 18 years old and had preopera-tive posterior vitreous detachment.  In addition,  it was thought that the inferior retina had already degenerated,  and retinal plasticity had decreased.  Furthermore,  OCT images showed secondary epiretinal membrane with retinal folds,  which indicated the presence of reti-nal traction by epiretinal membrane (Fig. 3D, F) [13].  Accordingly,  we judged that the macular hole was unlikely to close spontaneously,  and decided to perform immediate vitrectomy.  Considering the presence of retinal degeneration and traction,  we chose the inverted internal limiting membrane flap technique [18] to ensure complete macular hole closure.  In conclusion,  our findings suggest that both users and manufacturers need to be aware that ERB can cause serious ocular trauma and accordingly,  implement ade-quate safety measures.  Further follow-up is needed to examine the long-term visual function in this case.References 1. Filipe JA,  Barros H and Castro-Correia J: Sports-related Ocular Injuries: A Three-year Follow-up Study.  Ophthalmology (1997) 104:  313-318. 2. Youn J,  Sallis RE,  Smith G and Jones K: Ocular injury rates in college sports.  Med Sci Sports Exerc (2008) 40: 428-432. 3. Mishra A and Verma AK: Sports related ocular injuries.  Med J Armed Forces India (2012) 68: 260-266. 4. Ducharme J and To KW: Exercise Band-Induced Hyphema.  Arch Ophthalmol (1995) 113: 142. 5. Joondeph SA and Joondeph BC: Retinal Detachment due to CrossFit Training Injury.  Case Rep Ophthalmol Med (2013) 2013: 189837. 6. Wangsathaporn K and Tsui I: Commotio retinae resulting from rub-ber band injury in two girls.  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Bilateral Blunt Ocular Trauma Caused by an Exercise Resistance Band during Muscle Building Exercise for Swimming

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Bilateral Blunt Ocular Trauma Caused by an Exercise Resistance Band during Muscle Building Exercise for Swimming

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