Eye injuries in badminton – players’ perspective toward the usage of personal protective equipment

ABSTRACT Objective We conducted a survey between April to September 2021 to understand the perspective of badminton players on the usage of personal protective equipment to avoid eye injuries. Methods The survey was conducted online. It was disseminated through various social media platforms and via e-mail. The survey was initially shared with university-level badminton players. Both recreational and professional players were included. They were further encouraged to circulate the survey questionnaire among their colleagues. Results In total, the survey received 372 responses. After removing possible duplicates and incomplete responses (n = 28), 92.5% (n = 344) of the responses were included in the final analysis. Among the 344 included responses, recreational and professional players accounted for 77.6% (n = 267) and 22.4% (n = 77), respectively. The mean age ± SD of the recreational and professional players were 24.1 ± 6.3 years (range 14–60 years) and 25.7 ± 6.0 years (range 14–61 years), respectively. A significant difference was noted for self-reported eye injuries between recreational and professional players while playing badminton (χ2 value = 5.321, p = 0.02). Among the recreational and professional players, 93.6% (n = 250) and 88.3% (n = 68) did not use protective eyewear while playing badminton. Professional players were at higher risk of eye injuries than recreational players (OR = 2.9, 95% CI = 1.1–7.8). Conclusion The majority of badminton players in both groups agreed that PPE usage would lower the risk of sustaining eye injuries; however, they are ambiguous about the usage of protective eyewear. In contrast, players with self-reported eye injuries were aware of its impacts and encouraged the usage of PPEs associated with badminton. Further studies are warranted to understand and educate badminton players about the causes and impacts of eye injuries in badminton.


Introduction
Badminton has gained enormous popularity as a recreational and professional sport with the active participation of players from different age groups, both in India and globally [1,2].Participating in sports has always involved an inherent risk of injuries [3], and badminton is no exception [4].The increase in the level of participation is correlated to the occurrence of eye injuries [5].Badminton is classified as a high-risk, hazardous sport prone to accidental eye injuries [6][7][8].It is played with a small dense projectile, called a shuttlecock, moving at high speeds very close to the players [7].Various studies have reported eye injuries in badminton with common ocular signs such as hyphema, lens subluxation, vitreous hemorrhage, choroidal rupture, and retinal detachment [6,[9][10][11][12].The majority of accidental eye injuries in badminton are caused by the shuttlecock [10,13,14].Most of these eye injuries could be treated on an outpatient basis; however, a few require in-patient admissions [15,16].Vision loss is rare in eye injuries associated with badminton, and treatment outcomes often have a good visual prognosis [12].Studies conducted on badminton and eye injuries are mostly retrospective, reporting the common causes and emphasizing the importance of personal protective equipment (PPE) [9,10,12,17].Standardized bodies such as the American Society for Testing and Materials -ASTM F3164 (Standard Specification for Eye Protectors for Racket Sports (Racquetball, Squash, Tennis) (astm.org)),Standards of Australia, (AS/NZS 18527.2:2022| Standards Australia), and Standards of New Zealand (AS/NZS 18527.2:2022::Standards New Zealand) have now adopted and modified the guidelines of ISO 18527 2:2021 (ISO -ISO 18527-2:2021 -Eye and face protection for sports use -Part 2: Requirements for eye protectors for squash and eye protectors for racquetball and squash 57).These standardized bodies provide the specific requirements for all eye protectors intended for eye protection against ocular hazards in sports such as squash, and racquetball, as well as sports with similar hazards (for example-badminton) [7,18,19].Wearing proper eye protection could potentially decrease the rate of eye injuries in several sports, including badminton.Despite this, very few badminton players wear protective eyewear while playing.
The badminton racquet is more or less comparable to the squash racquet except for weight, while the badminton racquet is naturally lighter [6].A prospective hospital-based study conducted by Nicholas Jones to assess the overall pattern of sports injuries found that nearly half of the eye injuries were caused in racquet sports, with a similar frequency in badminton and squash -a similar sport to badminton [20].Numerous studies also explored the usage of PPE through questionnairebased surveys in squash [15,[21][22][23].However, no such studies were conducted on recreational and professional badminton players [24] to understand players' perspectives toward the usage of PPE and eye injuries associated with badminton.Therefore, in this context, we aimed to understand the badminton players' (recreational and professional) perspectives toward the usage of PPE in the sport using a questionnairebased survey [22,23].

Study design
A cross-sectional, prospective, and self-administered survey was conducted from April to September 2021.The survey was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee (UH/IEC/2021/43).

Survey
A validated questionnaire was adopted from published literature [23] to accomplish the primary objective of the present study.The survey questions were designed on Google forms and administered through social media platforms.The survey consisted of 20 questions, which were divided into four sections: i) Demographic information that included age, gender, and level of participation; ii) badminton-related questions such as hours spent playing in a week, playing experience, and level of participation; iii) history of eye injuries and associated questions; iv) questions related to the knowledge and attitudes toward the use of protective eyewear in badminton.The outline of the survey is shown in Figure 1.All badminton players from India who could comprehend English and played badminton either for recreation or professionally were eligible to participate in the online survey with no age limit.Initially, the survey was shared with university-level recreational and professional badminton players.These players were encouraged to forward the survey link to their colleagues who played badminton (sampling technique snowball or chain referral).
All participants were given an overview of the survey before proceeding to the first section.They were informed about the purpose and time required to complete the survey.They were also informed about the confidentiality of their participation in the study.Those who consented to participate in the study were automatically redirected to the survey form.Players who did not provide online consent and those with missing data were excluded from the analysis.In the online survey, players could not alter their responses after submission.The survey questions are available in the supplementary file.

Statistical analysis
Data sorting and analysis were done using Microsoft Office Excel (version 2007) and Statistical Package for the Social Sciences software version 22.0 (SPSS, Inc., Chicago, IL, USA).Data was segregated into recreational and professional players and analyzed separately.Descriptive statistics, like frequency and percentages, were calculated for categorical variables, and the continuous variables were expressed as mean ± SD.The Shapiro-Wilk test indicated that the data was not normally distributed (p < 0.05).Cross tabulation with a chi-square (χ2) test was used to determine the association between knowledge, attitude, and practices with injury prevention variables.Statistical significance was set at p < 0.05.

Results
A total of 372 responses were received for the survey.After removing the duplicates and incomplete responses (n = 28), 92.5% (n = 344) of the responses were included in the final analysis.Among the 344 included responses, recreational and professional players accounted for 77.6% (n = 267) and 22.4% (n = 77), respectively.The mean age of the recreational and professional badminton players were 24.2 ± 6.0 years (mean ± SD, range: 14-60 years) and 25.7 ± 8.7 years (range: 14-61 years), respectively.The number of males participating in badminton either recreationally (62.9%, n = 168) or professionally (75.3%, n = 58) was significantly higher (χ 2 value = 4.080, p = 0.04) compared to females.Most of the recreational players (30%, n = 80) played badminton for less than an hour per week.In contrast, professional players (35.1%, n = 27) played for more than 10 h per week, as shown in Figure 2.
The responses showed that approximately 65% of both recreational and professional players had less than 10 years of experience playing badminton.There was a significant difference (χ 2 value = 5.321, p = 0.02) between the selfreported eye injuries of recreational players (3.7%, n = 10/ 267) and professional players (10.4%, n = 8/77) in the 12 months prior to the administration of the survey.Data on the frequency, causation, and medical attention for eye injuries self-reported by recreational and professional players in the 12 months prior to the survey are summarized in Table 1 and Table 2 Only a few recreational players required medical attention for their eye injuries.In contrast, most professional players required medical attention for their eye injuries.Risk analysis revealed that professional players were at a higher risk of sustaining eye injuries compared to recreational players (Odds ratio = 2.9, 95% CI = 1.1-7.8).Injuries with shuttlecock were the most common cause of eye injuries in both groups (66.6%), followed by collision with the opponent (16.6%) and fall (5.5%).
When badminton players were asked about the frequency of PPE use, 93.6% of recreational players and 88.3% of professional players reported that they did not wear protective eyewear while playing badminton.Moreover, 63.7% of recreational players and 68.8% of professional players were unaware of the type of protective eyewear that should be worn while playing badminton.

Overall players' attitudes toward protective eyewear
Most badminton players (~30% -40%) from both groups were uncertain regarding various questions related to eye injuries and PPE use in badminton.Table 3 summarizes the responses of the recreational and professional players.Most recreational (62.9%) players and approximately half of the professional players (49.4%) either agreed or strongly agreed that PPE usage would significantly reduce the risk of eye injuries while playing badminton.

Attitudes toward protective eyewear by players who reported eye injuries (recreational and professional)
The overall responses from badminton players toward PPE usage were uncertain.However, the responses of the players who reported eye injuries were concerned about various aspects of badminton and PPE usage.Approximately 70% of players from both groups who suffered eye injuries thought PPE wear would significantly reduce the risk of sustaining eye injuries.Similarly, around 75% of professional players believed the risk of eye injury in badminton is high and that they are a particular problem for badminton players.Table 1 and 2 provide a detailed history of eye injuries.The behavioural responses of the players are reported separately in Table 4.It also details the responses of recreational and professional players who had injuries in the 12 months prior to the survey.

Discussion
it is important to understand the level of knowledge and perspectives of badminton players regarding eye injuries and the usage of PPE.Overall, most players were uncertain regarding the usage of protective eyewear.However, players who have sustained eye injuries from both groups were in favor of PPE usage.Several studies related to badminton described the nature of this sport, associated eye injuries, and the role of PPE in prevention [10,13,14,25,26].
The majority of the recreational players and a few professional players either agreed or strongly agreed that PPE wear should be made compulsory for all junior players.A few racquet sports associations have made standard protective eyewear of ASTM F3164 mandatory for all badminton players under the age of 19 years [26][27][28].
Based on the self-reported eye injuries by the players from both groups, it was observed that shuttlecock was the most common cause of eye injury, which is evident from previous studies as well [10,13,16,17].Approximately 90% of players from both groups did not use protective eyewear while playing badminton, which is similar to squash [21,23].Though the reasons behind not wearing protective eyewear were not investigated in the current study, we speculate that the reasons might be similar to those mentioned by Eime et al. in a questionnairebased study conducted on squash players [21].Approximately 65% of players from both groups were unaware of the type of protective eyewear that should be used while playing badminton.For players who are wearing spectacles while playing badminton, it is recommended by ASTM that lenses made with materials of polycarbonate or trivex which could be more suitable, as they have high impact resistance [7,21,29].
This study has a few limitations.collecting data in-person or through investigator-administered surveys was not possible because of the COVID-19 pandemic-mandated lockdowns and players being away from badminton academies.Data collection was planned over a phone call interview.However, the contact details of professional players were not available.We believe the responses would have been better if we had conducted the present study in person with detailed interviews.Such interviews might have provided better insights into eye injuries associated with this sport.
Consistent with the previous literature, it is evident that eye injuries happen in badminton.Professional badminton players with more hours of participation should be more cautious while playing as they are at a higher risk of sustaining eye injuries compared to recreational players.Most players in both recreational and professional categories were unaware of the type of eyewear that should be used while playing.We speculate that spreading awareness among badminton players about eye injuries and their causation is more important than recommending PPE wear.This, in turn, might lead to adequate knowledge of PPE wear.Conducting awareness campaigns on eye injuries could be beneficial to raise awareness regarding potential eye injuries among badminton players.It would also serve to lower their risk of injuries while playing badminton.Since implementing the usage of PPE in sports might reduce the rate of injuries [30][31][32], future studies with in-depth interviews with badminton players might provide further insights into eyewear usage in this sport.

Figure 1 .
Figure 1.Flow chart of the survey.

Figure 2 .
Figure 2. Box plot depicting the trends of badminton participation among the two groups.

Table 1 .
Details of self-reported eye injuries in recreational players (n = 10).

Table 2 .
Details of self-reported eye injuries in professional players (n = 8).

Table 3 .
Summary of behavioral responses from recreational and professional players toward PPE use in badminton.