Give Athletes Better Vision Shot a at Better Vision
Whether they shoot foul shots or target rifles, your athletic patients require the best vision to stay at the top of their game.
Release Date: May 2012
Expiration Date: May 1, 2015
Optometrists can provide targeted visual
assessment, unique refractive options and even sports vision
training to help athlete patients achieve peak performance. This
article examines the visual skills that are most pertinent to your
athletic patients, as well as reviews the best vision-correction
options for athletes who participate in a variety of different sports.
Graham B. Erickson, O.D.
This course is COPE-approved for 1 hour of CE credit. COPE ID is 34635-GO. Please check your state licensing board to see if this approval counts toward your CE requirement for relicensure.
This continuing education course is joint-sponsored by the Pennsylvania College of Optometry.
Dr. Erickson is a paid consultant to Nike, Inc.
Good vision is a critical factor in sports performance,
because visual information
is the dominant sensory system when performing practically
any perceptual-motor task.1-4 Some researchers contend that
athletes possess superior visual
systems that allow them to see and
process critical visual information
more effectively than "non-athletes" and novice athletes.4-7 Others, however, argue that athletes do
not possess superior visual system
physiology, but that elite athletes
are able to use available visual
information more efficiently than
novices in a competitive sports
In either case, optometrists can
provide targeted visual assessment,
unique refractive options and even
sports vision training to help these
patients achieve peak performance.
Here, we'll examine the visual
skills that are most pertinent to
your athletic patients, as well as
discuss the best vision-correction
options for athletes who participate in a variety of different sports.
What is Sports Vision?
The term "sports vision" has
been used to describe a host of eye
care services that are provided to
athletes. Practitioners working in
this area usually are involved with
one or more of the following
- Prevention and management of
sports-related eye injuries.
- Assessment and remediation of
functional vision deficiencies that
may negatively impact competitive
- Specialized contact lens services with emphasis on environmental
factors in sports, position of gaze
factors, emergency care and attainment of maximum visual acuity.
- Performance-based ophthalmic
eyewear services that address visual
and environmental demands.
- Assessment of specific sports-related visual abilities.
- Enhancement training of
specific visual abilities that are considered to be essential for competitive consistency in a specific
- Consultation with athletes,
coaches, trainers and teams regarding visual factors and strategies
related to consistent peak athletic
Most of our patients are active
participants in sports or recreational activities, and many of
these individuals are dedicated to
the pursuit of athletic excellence. A critical, but often neglected,
aspect of peak human performance
is optimal visual function. So, all
optometrists must consider visual
performance factors when providing one or more of the aforementioned services to athletic patients.
Evaluation of Visual
The vision and visual perceptual
skills identified as important for
sports performance include: static
and dynamic acuities, contrast
sensitivity, distance stereopsis,
span of perception, central eye-hand reaction and response speeds,
and peripheral eye-hand response
speed.11,12 Two extensive review
articles concluded that athletes
have demonstrated better visual
abilities than non-athletes, and that
top-tier athletes--those who are
most successful--often have visual
abilities that are superior to lower-level or less successful athletes.5,6 Some aspects of these skills commonly are assessed as part of a routine vision exam, but many vision
skills are not evaluated for various
reasons (e.g., there is little or no
standardization of assessment procedures and/or limited or outdated
To effectively provide specialized vision care to an athlete, you
should first identify which vision
factors are essential to successful
performance in the individual's
sport(s) of choice.12,13 For example,
a dynamic and reactive sport, such
as basketball, has very different
visual demands than the static
precision requirements of target
shooting. The vision assessment
should then include methods to
evaluate the quality of those skills
in the most appropriate, accurate
and reproducible manner. The
following visual skills have been
frequently identified as important
across many sports disciplines:
*Static visual acuity (SVA). Assessment of visual performance
skills routinely begins with a measurement of SVA. Compromised
SVA can negatively affect other
areas of visual performance.11 Previous research has found mixed
results regarding SVA in athlete
For example, when SVA is
assessed using chart systems (with
20/20 as the best acuity measureable), there is no statistically significant difference in the visual
ability of athletes compared to
non-athletes.14-16 Even when a
best acuity demand of 20/15 is
presented, one study found that
81% of professional baseball players could achieve that level.17 The
researchers subsequently modified
their assessment method to achieve
acuity demands down to 20/7.5,
reporting overall mean SVAs of
approximately 20/13, with several
athletes exhibiting SVAs of 20/9.2
*Dynamic visual acuity (DVA). DVA generally is defined as the
ability of the visual system to
resolve detail when there is relative movement between the target
and the observer.6,11 Many sports
involve extensive object movement,
including balls, pucks, competitors, teammates, etc. Often, at elite
levels of sport, the velocity of
movement between the athlete and
the target is tremendously high, so
athletes need to accurately perceive
and identify critical target features
during dynamic situations.
One literature review indicated
that athletes demonstrate superior
DVA abilities compared to non-athletes, and that elite athletes have
better DVA than amateur or non-elite athletes do.5 This suggests that
there is an important link between
elite athletes and DVA ability.
On the other hand, a separate
report documented no significant differences in performance
on a DVA test between elite and
sub-elite youth soccer players.18 (However, their use of a predictable rotator device to measure
this function may not have been
environmentally appropriate to
simulate the visual task demands of
a dynamic, large-field sport such as
soccer.) Although many researchers agree about the importance
of DVA in sports, this visual skill
often is not assessed in clinical
practice due to limitations in available commercial instruments.6
*Contrast sensitivity (CS). CS
measures the visual system's ability to process spatial or temporal
information about objects and
their backgrounds under various
lighting conditions. Measuring an
athlete's CS is important because
most sports involve interpreting
visual information at contrast levels below what is measured with a
typical visual acuity chart.11 Performance of athletes on CS testing
is significantly better than non-athletes across all spatial frequencies evaluated.11,19,20 CS may be
improved or degraded with contact
lens wear or refractive surgery.
Many commercial systems are
available to measure CS.16 Several
devices use linear grating patterns
that vary in spatial frequency, contrast level and, possibly, orientation. Others use letters or numbers of different contrast levels and/
or sizes. CS measurements usually
involve determination of a threshold contrast level at specific spatial
frequencies, and reduced sensitivity
may relate to performance inconsistency in some sports.
* Stereopsis. Determining distance and spatial localization of
an object is a necessity for athletes
in many sports. While these judgments can be made using monocular depth cues, superior binocular
depth perception is more advantageous for an athlete.21
Research on the assessment of
stereopsis has produced mixed
results; some studies found no difference between athlete and non-athlete populations; whereas, other
studies found better performance
in athletes.11,17,21 The difference in
these findings may be due to the
lack of standardized testing procedures, the use of simulated depth
targets, and the limitations of the
instruments to measure threshold
Previous studies employed near
stereo tests or testing at far with
vectographic projection slides or
a Howard-Dolman apparatus.11 Considering that many sports are
dynamic, athletes would likely perform better with a dynamic stereop-sis assessment, because static testing
may not reveal much difference
between athletes and non-athletes.
facility. Competitive sports rarely
occur at one distance. Most athletes need to look between far,
intermediate and near distances
extremely quickly, requiring rapid
accommodative-vergence responses. This visual skill can be assessed
using "distance rock testing." A
study using this test presented
normative data for a population of
elite athletes, but did not compare
performance with that of non-athletes.11
* Perception span. Perception
span, or central visual recognition
accuracy, uses tachistoscopic presentation to measure the speed and
span of recognition. Several studies
have investigated speed of recognition abilities in athletes who play
baseball, cricket, volleyball, tennis
and other "fast ball" sports.22-25 Most studies have found that experienced athletes can evaluate sport-relevant information more rapidly
than inexperienced observers.22-25
Other studies have investigated
both the speed and span of recognition by evaluating the ability
to recall a sequence of numbers
presented tachistoscopically for
1/50 of a second and found no difference in athletes compared with
However, one particular report
found significant differences in performance for both span and speed
of recognition, which were also
present when distraction factors
were added to simulate competition conditions.26 When considering these differences in research
results, it indicates that the use of
numerical stimuli may confound
the assessment of recognition speed
Thus, the use of target parameters that more closely simulate
the visual information processed
in sport situations can yield better
discrimination of perception span
abilities that correlate with sports
* Central eye-hand reaction
and response time. Visual-motor
reaction and response speeds are
critical to performance. Reaction
time is the elapsed time between
the onset of a visual stimulus and
the initiation of a motor response.
Response time is the total time
required by the visual system to
process a stimulus plus the time
needed to complete the motor
Several studies report that athletes in various sports have faster
reaction times compared to non-athletes, and that reaction time is
a discriminator between expertise
levels.27-30 However, other studies
have not reproduced this difference.31,32 A gender bias also has
been reported, with males achieving faster times than females on
Interestingly, eye-hand reaction
time can be improved with brief
training regimens, making this a
potentially valuable assessment
and/or goal for the athlete.11
* Peripheral eye-hand response. Overall ability to process and
respond to visual stimuli strongly
enhances an athlete's eye-hand
coordination.6 The typical instrumentation used for evaluating
eye-hand coordination has been
a two-dimensional panel with an
array of lights mounted on a wall,
such as the Wayne Saccadic Fixator (Wayne Engineering).
When using this device, the athlete
is required to press a randomly lit
button as rapidly as possible with
one hand. Then, another button
is lit in a random position on the
instrument and the reaction time
reflex cycle is repeated for the
selected test time period. The panel
is set at the athlete's arm length
and is larger than the central visual
field, thus assessing a peripheral
The Wayne Saccadic Fixator is
typically programmed to test in
two primary modes: visual proaction time (a self-paced mode for
a set time period in which each
light remains lit until the button is
pressed, then the next random light
is lit); and visual reaction time (an
instrument-paced stimulus presentation in which each light stays lit
for a preset amount of time [0.75
seconds] before automatically
switching to another light, whether
or not the button is pressed).
One study found better visual
proaction times in youth athletes
than non-athletes, while another
study found no such difference
between adult athletes and non-athletes.14,34 Visual reaction time
has been compared in both athletes
and non-athletes in only one study,
in which athletes performed better
Nike SPARQ Testing
The Nike SPARQ Sensory Training Station is designed to test
vision skills that previously have
been identified as important for
sports, including SVA, DVA, CS,
distance stereopsis, accommoda-tive-vergence facility, span of perception, central eye-hand reaction
and response speeds, and peripheral eye-hand response speed. It is
designed to provide a customized
"sensory performance profile" that
graphically represents the athlete's
visual strengths and weaknesses
by comparing performance to a
database of peers. Each profile
presents the top four opportunities
for intervention and/or enhancement based on performance. For
example, if measurements of
visual acuity and CS are reduced, a
comprehensive eye exam is recommended.
The results of one study indicated that many of the Nike
SPARQ Sensory Training Station
assessments demonstrate repeatability as well as no learning effect
over time.35 The measures that did
improve across sessions (including
accommodative-vergence facility, central eye-hand reaction and
response speeds, and peripheral
eye-hand response speed) demonstrated an expected learning effect
due to the motor response characteristics being assessed.
Athletes who currently use vision
correction require an evaluation to
determine if the prescription is providing optimal visual performance
for the specific sport demands. A
task analysis of the sport will assist
in determining the specific visual
demands, and a careful refractive analysis can establish the best
refractive compensation for use in
that sport. For example, a myopic
baseball player may benefit from
an additional 0.25D of minus to
improve contrast judgment or
when playing in twilight conditions. Such prescriptions are sport-specific, and are not intended for
Ultimately, you should continue
the subjective refraction until the
best visual acuity is reached. Do
not stop the refraction at 20/20,
because the athlete may be capable
of seeing 20/10 or better. In some
sports, such as major league base
ball, 20/20 visual acuity is below
average.13,17 For many athletes, we
need to raise the bar above 20/20
in order to provide optimal vision.
Guidelines have been published to assist the practitioner in
determining when refractive compensation should be considered
(see "Guidelines for Refractive
Compensation in Athletes,").12,36 Any patient with myopia
of -0.25D or greater should be
counseled on the possible benefits of refractive compensation
(although correction of less than
-0.50D is not available with contact lenses).
|Guidelines for Refractive Compensation in Athletes
| Refractive Status
||Consider Prescribing at:
||-0.25D or more
||+1.00D or more
||0.50D or more*
||0.50D or more†
|* Against-the-rule astigmatism and oblique astigmatism are more detrimental than with-the-rule astigmatism.
† Consider meridional effects with asymmetric astigmatism.
Astigmatism has a similar effect
on visual resolution, especially
against-the-rule and oblique astigmatism. Refractive compensation
should be considered with -0.50D
or more astigmatism, although
with-the-rule astigmatism compensation may not yield as much
improvement on clinical evaluation.
Low amounts of hyperopia are
often well tolerated without correction; however, hyperopia of
+1.00D or greater may require
a significant amount of effort
from the athlete to achieve and
maintain clarity. Judicious refractive compensation may reduce
the accommodative effort needed
for the athlete to achieve optimal
image clarity. Low amounts of
anisometropia are not always compensated for, especially when the
refractive errors are low. Aniso-metropia of 0.50D or more can
have a detrimental impact on depth
perception, and some athletes may
be sensitive to that effect.5,6 Additionally, the effects of meridional
anisometropia should be considered in athletes with asymmetric
Balancing the image quality
through refractive compensation
will enhance sensory fusion and
improve the quality of spatial localization judgments. These
guidelines are useful for the practitioner to trigger the discussion of
the potential benefits of a refractive
prescription. Ultimately, however,
the athlete makes the decision
whether to experiment with a prescription.
Contact Lenses vs.
Spectacles are not commonly
recommended for use in sports.
The main concern is that most
eyewear does not offer the impact
resistance necessary to protect the
wearer from the possible hazards
encountered in many such activities. The American National Standards Institute (ANSI) performance
standards for dress and industrial-strength (safety) eyewear are not
applicable in most sports.
Instead, the American Society for
Testing of Materials (ASTM) has
developed performance standards
for eye and head protection in
many sports. ASTM performance
standards are established for protective eyewear in each sport individually, and the forces potentially
encountered in a sport are used
to determine appropriate testing
Nike Ignites a SPARQ
The Nike SPARQ Sensory Training Station consists of a single computer and two high-resolution LCD monitors (both 0.28mm dot pitch)--one 22-inch diagonal display and one
42-inch diagonal touch-sensitive display. A hand-held Apple iPod Touch is used in several
assessments to measure responses. A liquid crystal shutter system creates simulated depth
through a wireless link to the computer for stereopsis testing at far. Custom software controls
the displays, input acquisition and test procedures, based on subject responses. Pre-recorded
instructions are automatically played at the start of each assessment to maintain consistency
for each evaluation.
Even if the athlete selects appropriate protective eyewear, consider
the potential effects from optical
aberrations of the lenses. Monochromatic lens aberrations can
degrade the optical image transmitted through the off-center portions
of the lens, and distortion can
decrease the useful field of view
through a lens. The reduction in
the useful field of view can have
a detrimental impact on performance in sports. For example, a
right-handed tennis player viewing
the ball toss during a serve looks
through the left field portions of
his or her spectacle lenses, and the
image can be significantly altered
by large refractive errors secondary
to these aberrations.
On the other hand, field-of-view
aberrations, visual field restriction,
optical distortion, frame comfort,
frame stability, surface reflections,
lens fogging and precipitation
issues with spectacle lenses largely
can be avoided by moving the
optics onto the cornea. Contact
lenses eliminate the induced prismatic effects that are evident with
most spectacle lenses. The potential
visual field impediment created by
eyewear frames also is eliminated
with contact use, as are the issues
of lens reflection and fogging that
compromise visual performance
In comparison to spectacle
use, the peripheral visual field is
increased by approximately 15%
with contact lens wear.2 Contacts
are an excellent vision-correction
option for highly dynamic sports
(see "Dynamic Reactive Sports,"), because no frame can be
dislodged and no lenses can fog over. Although contact lens comfort is an obvious issue to contend
with, frames pose significantly
greater limitations for the majority
Dynamic Reactive Sports
Skeet and trap shooting
Track and field events
Take note, however, that both
target shooters and archers may
actually prefer spectacles to contact
lenses. The main advantage is the
stability of clear vision obtained
with spectacle lenses. Because
peripheral vision is not a significant factor in most aiming sports,
the enhanced visual field does not
offer a significant benefit. The
shooter or archer typically is not
bothered by lens aberrations off
the optical center. However, in athletes with strong prescriptions, the
lenses may need to be fit with the
optical centers set at the particular
eye position used when aiming.
Hydrogel Lens Applications
Due to better comfort and stability, soft contact lenses typically are
preferred to gas-permeable lenses
for use in sports. The main considerations for hydrogel lenses are
the material composition, water
content, diameter and thickness. In
general, lenses with a higher water
content tend to dehydrate faster
than low to medium water content
lenses.36 Therefore, thicker, low to
medium water content lenses or
silicone hydrogel lenses should be
used for athletes who have dehydration problems.36
Additionally, it has been suggested that the significantly increased
oxygen permeability with silicone
hydrogel lenses contributes to
improved comfort and decreased
symptoms of dryness. High water
content lens materials or silicone
hydrogel lenses may be needed for
prolonged lens wear situations,
in which oxygen transmission is
a crucial factor. Larger-diameter
lenses also are recommended for
better stability and hydration.
These lens recommendations
apply to sports in which considerable wind or airflow hits the athlete's face. Some endurance sports
require a lens modality for extended use. In sports such as high-altitude mountaineering, long-distance
sailing or long-distance motor racing, the athlete experiences extreme
environmental conditions over an
extended period of time, requiring excellent visual performance
throughout the event while maintaining good ocular health.
Contact lenses for athletic use
should fit more tightly than traditional fitting practices dictate.
The lens should exhibit minimal
movement after a blink as well as
maintain a good centering position
in extreme gaze directions.
Any athlete can benefit from
single-use lenses--from the weekend athlete, who seeks the comfort
of a disposable lens, to the professional athlete who prefers immaculately clean and fresh lenses before
starting a competition and a quick
replacement of lenses at any time
Single-use contact lenses can be a
particularly useful for water sports.
They offer an advantage over prescription masks or goggles, because
peripheral vision is not as restricted. Nonetheless, you cannot overlook the main concerns regarding
contact lens wear in the water--
namely lens loss and increased risk
for microbial infection.
Orthokeratology is another
option to reduce myopia and astigmatism with specially designed
rigid lenses. What could potentially
put an athlete at a disadvantage is
the increased presence of higher-order aberrations and spherical
aberration that may occur after initiating orthokeratology.37,38
The increase of higher-order
aberrations may cause a reduction
in low-contrast visual acuity during the daytime, and this reduction
is more significant in patients with
larger pupil sizes.38
remains an attractive option for
athletes, especially young, myopic
or astigmatic athletes who are not
yet eligible for refractive surgery.
Visual Performance Training
Literature reviews have indicated
that there is sufficient scientific support for the efficacy of vision therapy in modifying and improving
visual system disorders.4,12 The athlete who possesses average, or even
above average, vision skills presents
a compelling and controversial
challenge. Can the vision skills of
this athlete be enhanced above the
current level, and would this result
in demonstrable improvements in
Several studies have reported
positive effects of vision training programs on sports-specific
tasks, while other studies have not
identified improvement in performance.39-43 The differences in study
results are speculated to be caused
by differing athletic skill levels
(novice vs. expert subjects) and the use of general vs. specific vision
Additionally, research design
factors in all these studies weakened
the results and conclusions, indicating the need for further study in this
area of sports vision.
All the visual performance skills
described here have been shown to
be amenable to training.4 There are
eye care professionals who provide
this service. And, more recently,
optometrists have collaborated with
sports trainers to provide this service as part of personalized sports
training. The sports trainers are
taught the vision skill performance
procedures similar to vision therapists, and are instructed to integrate
these practices into the physical
training program under the direction of the optometrist.
In this model, the athlete receives
pre- and post-training assessments
with the optometrist, making the
O.D. part of the training team for
the athlete. The Nike SPARQ Sensory Testing and Training Stations
have digitized training programs for
some aspects of visual performance,
providing athletes the opportunity
to train in eye care practices or at a
sports training facility.
There is a vast array of refractive correction options available
for athletic patients, and eye care
professionals now have many
new technologies to choose from
in order to help meet the special
demands encountered in athletic
and recreational activities. We are
uniquely suited to assist in the selection of the best eyewear designs,
performance tints, contact lens
parameters and protection for our
Additional vision training services to remediate and enhance
critical visual performance factors
should be discussed with the athlete
as a management option. Most of
the patients that we examine are
routinely active in some sports and
recreational pursuits. Not only
do elite athletes reap performance
advantages from our services, but
patients from all walks of life can
benefit from improvement in visual
function across all aspects of daily
Once your reputation is established as an eye doctor who fulfills
the visual needs of athletes, word-of-mouth marketing will bring a
wealth of new athletic patients with
vision care needs to your practice.
Dr. Erickson is a professor
at Pacific University College of
Optometry. He has served as past-chair of the American Optometric
Association Sports Vision Section
and the Binocular Vision, Perception and Pediatric Optometry
Section of the American Academy
of Optometry. He lectures both
nationally and internationally on
the topics of sports vision, pediatrics
and binocular vision. Dr. Erickson
is a paid consultant to Nike, Inc.
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