By Alexander Dagi, MD candidate, Columbia University Medical Center in New York City
Over the past decade, surfers have taken advantage of options available to protect their bodies while pushing the limits of the sport. Helmets are seen more frequently among those paddling into pitching reef breaks. Quick-release technologies have made surf leashes less likely to cause underwater traps. Inflatable vests have improved to meet the demands of big wave surfers.
I recently encountered a surfer in the hospital with a “blowout” fracture of the eye caused by a ricocheting surfboard. The patient had been surfing in Portugal when his board swung upward towards his face following a wipeout. He temporarily lost consciousness after the blow. However, he felt that only the survival instinct enabled him to swim to shore. Unfortunately, the injury required surgical repair.
SURFING-RELATED EYE INJURIES
Surfing-related eye injuries are a historical aspect of the sport. Jack O’Neill, founder of O’Neill wetsuits, might be the most iconic victim of a surfing-related eye injury. In 1971, Jack’s son Pat developed the first commercial surf leash. The leash came about to give surfers sufficient time to recover their surfboards after a fall and provide some measure of increased safety – use of the leash might reduce the risk of being at sea without a nearby board.
Jack was an early adopter of his son’s technology. However, initial leash designs used surgical tubing for support, which unfortunately allowed the leash to overstretch and snap towards the surfer. On one occasion, Jack’s surfboard flew back towards his left eye. As a result, he permanently lost sight and wore an eye patch for the remainder of his life.
THE GOOD NEWS
Surfing-related eye injuries are uncommon. However, in 2014, Dr Juliette Howden and her colleagues in New South Wales, Australia, found ten surfing-related eye injuries in a year when surveying sixteen coastal and teaching hospitals.
 If we estimated that 100,000 people surf annually in New South Whales, this would represent an incidence of 0.01% for surfing-related eye injuries in the local population.
The risk for any individual would vary depending on the frequency with which one surfed. It is also likely that minor injuries to the eye occur more frequently and are likely “under-reported” as surfers manage them without medical attention. All surfers sustain occasional injuries. It is the major surfing-related eye injuries that are worthy of attention.
THE LESS GOOD NEWS
The risk for surfing-related eye injuries does not seem to diminish with experience. As in the case that inspired this article, surfers who confront more advanced waves with angular, high-performance shortboards may be typical. . With faster, heavier waves come less predictable wipeouts. When surfed with the pointed, fibre-glassed tails, fins, and noses of modern shortboards, such conditions may lead to collisions that are difficult to control and, on occasion, tragic for the eye.
A 1998 study reviewing 11 cases of surfing-related eye injuries from California, Florida, and Hawaii, found that only 2 out of the 11 patients recovered their eyesight after surfing-related eye injuries.  The authors concluded that surfboard-related trauma could be “potentially devastating,” in part because the nose of the contemporary surfboard can injure the globe (the actual eyeball) and also the orbit (the bony region of the face containing the eyeball).
Several patterns of eye injury can occur with surfing. The mildest injury is a laceration of the eyelids. This type of injury can alter appearance but not typically vision.
Fractures of the orbit, the bones that surround and protect the eye, are called “blowout fractures.” This more significant trauma may lead to disfigurement when the eye gets displaced from the centre of the orbital opening. More critically, blowout fractures lead to the development of double vision. This phenomenon occurs because muscles responsible for normal movement of the eye can get caught in adjacent broken bones. Double vision occurs when the movement of one eye is restricted, whereas that of the second eye is not. In addition, the eyeball itself can suffer blunt trauma causing bleeding within the eye and other severe injuries like retinal detachment. Lastly, injuries to the eyeball can be forceful enough to rupture the eyeball itself.
Occasionally, fibreglass pieces can lodge themselves within the eye or the adjacent skin or bones, which may pose risks for infection, nerve injury, and chronic pain.
WHAT TO DO ABOUT SURFING-RELATED EYE INJURIES?
Fortunately, surfing-related eye injuries are uncommon. Nevertheless, seeking medical attention as quickly as possible may help preserve sight.
The development of some innovative solutions has helped reduce the risk of eye injury. For example, several companies have created rubber tips for surfboards noses. These may provide some protection, particularly from the lodging of fibreglass beneath the skin. There are, additionally, some helmets with visors, which may protect the eye more directly. As with all safety-related gear, there is always a payoff. This happens between the protection afforded and the perceived loss of freedom. On the other hand, surfing with only one sighted eye or double vision is not ideal. As it becomes available, trying protective gear might be the way to go.
 Zoumalan CI, Blumenkranz MS, McCulley TJ, Moshfeghi DM. Severe surfing-related ocular injuries: the Stanford Northern Californian experience. Br J Sports Med. 2008;42(10):855-857. doi:10.1136/bjsm.2007.041657
Alexander Dagi completed his undergraduate degree at Harvard, and spent some time working in France and Mexico prior to starting medical school at Columbia University.