Eyes on the Tries

It’s that time of year again – the Six Nations Championship is about to dominate the weekends of rugby lovers, right from the kick off on February 5, to the last whistle on March 19. For those of you not aware, the Six Nations Championship is a rugby tournament between the six most elite national teams in Europe – England, Wales, Ireland, Scotland, France, and Italy (in no particular order). Played in a group format, it’s a hotly contested competition and a matter of pride for players and fans alike.

We have managed to secure an interview with Dan Morris, specialist in cataract and oculoplastic surgery based in Cardiff, UK, who is the match day ophthalmologist for the Welsh Rugby Union team, the reigning champions. He has laid out how this ophthalmic extra-curricular job came about, what it entails, and even given advice on how to provide medical help for your favorite sports team.

How did you get into sports ophthalmology, and in particular, the Welsh rugby?
 

I suppose that I was just in the right place at the right time. I did a sports medicine degree during my training, which I’ve always been interested in and nearly ended up pursuing full time. My sporting experience would still open some of the right doors. As it transpired, when I arrived in Cardiff, UK, there had been a couple of high-profile injuries to elite rugby players that hadn’t been dealt with very well in the acute setting, and they wanted someone to be around for the matches – so I offered to help out! That was about 10 years ago. With my background in sports medicine, it was easier to slip into the role within the team.

The Welsh Rugby Union medical team is a lot like the multidisciplinary teams (MDTs) I’m part of at the University Hospital of Wales, where I’m a general ophthalmologist, but also an oculoplastic and orbital surgeon. The success of that Welsh Rugby Union medical team relies on good teamwork, good communication, good leadership – the whole is certainly much greater than the sum of the parts within that team.

Rugby isn’t the only sport which I’ve been able to offer ophthalmic help to – I also help out with the Welsh Football Association games, and the British Boxing Board of Control.

So how ingrained are you into the team? Is it just a match day arrangement, or more?

It’s a home arrangement, where I provide medical cover for the players of both teams when they’re in the Principality Stadium, the Welsh national stadium in Cardiff. I don’t travel with the squad; the team has its own team doctors and physiotherapists who will travel wherever the team goes, and they get in touch with me between matches if there are any eye or orbital problems. The whole medical team works together with the squad inside of matches and training, but also outside of those times. It’s also common for them to give me a phone call if they have an issue when they’re up in Scotland, or wherever they might be. If it’s needed, I might get one of my colleagues up there to see them. We’re only providing stadium cover for the for the teams, but not the crowd – we can’t do anything if they decide to pour beer in each other’s eyes!

Who is part of the medical team?
 

We’ve got emergency medicine doctors, anesthetists, a neurosurgeon, orthopedic surgeons, maxillofacial surgeons, a dentist, us – the eye care team, and then an awesome team of paramedics. It’s quite a big team, and we could deal with almost anything in the medical room. There have been high profile cardiac arrests of late, so we’ve got all the wherewithal for resuscitation and intubation.

So how does a match day with the medical team play out?
 

Everyone’s got a role to play in the medical room. There’s a briefing a couple of hours before the match, and a debrief afterwards to discuss the injuries and anything we could do to improve management and communication. We meet the visiting team doctors and physios to discuss who wants to do any stitching that arises, which is what I have to do sometimes. It’s also important that we discuss who is performing which role for the head injury protocols, because they’re obviously a big issue these days. Ultimately, we’re just making sure everyone’s reading from the same script so that we provide the best medical care that we can.

Do all teams have ophthalmologists, or is this quite rare?
 

That’s a good question and I’m not sure what the answer is. I think Professor Dame Carrie MacEwen – one of my mentors and an inspiration, has helped out the Scottish team in the past, but I’m not sure whether running the General Medical Council is compatible with matchday rugby! I haven’t spoken to anyone else who’s an ophthalmologist specifically for a stadium or a team before, but they may well be out there.

That makes sense to me, because you’re the only one I could find! So how common are eye injuries in rugby, and what are the biggest dangers?
 

Thankfully, they are not too common. During the game I might be called upon to examine an eye or stitch a laceration anywhere on the face; brows and foreheads are most common so I can put my oculoplastic skills to good use with occasional eyelid lacerations as well. I also help the maxillofacial team with other facial injuries – for example if any ears are hanging off or sliced lips. I’ve dealt with corneal abrasions, hyphemas, and then, of course, blowout fractures are pretty common. Between ourselves and the maxillofacial surgeon we have the majority of eye care covered for the game.

We also often help out between matches with the rehabilitation of players who might have eye problems, such as double vision. We also have follow ups with players that are local; we see them afterwards to follow them up. If they’ve come from abroad, or further afield, then we’ll try and set up a follow up with an ophthalmologist closer to home – unless they’re English, of course, when they get sent packing!

I’m always happy to lend a hand with anything else that needs to be done as part of the bigger team. If you’ve got someone with multiple injuries, or they are having significant problems with pain, for example, I can help out the anesthetists and the emergency medicine doctors, or show the orthopedic surgeons how stitching is done properly!

I get the impression you support the Welsh rugby team, too?
 

Yes, but I have English, Welsh, and Italian blood in me, and my wife is Scottish, so the Six Nations Tournament is an interesting time in our house. But, because we’re living in Wales, and I’m working with the Welsh team, I proudly support Wales.

One of the great things about the rugby and the Six Nations is that it’s always a good opportunity for a laugh and some banter between fans. The rivalries are usually quite happy ones – it’s great when the French come over, and we’re all singing together in the pub afterwards. And the Welsh are an easy team to support in the rugby, as it’s so ingrained into the Welsh culture from grassroots up – so it’s a great sport to be part of in Wales.

How have the injuries sustained in rugby changed over the years?
 

There used to be a lot of eye gouging – I have rugby players in my clinic in Cardiff who had career-ending injuries and lost an eye because of gouges during rugby matches, and they’re pretty horrendous injuries. Gouges can be devastating to the eye and the eye socket, which has led to them being outlawed now. So not only will you be sent off and banned for doing it, you might well face a criminal prosecution if you start gouging people in the eye these days.

The big game changer for such injuries was when Hawk-Eye (a computer vision and monitoring system) was introduced for international matches, bringing cameras everywhere and the technology and personnel to use it in real time; it is very difficult to get away with professional fouls nowadays. Hawk-Eye allows the referee to immediately ask the Hawk-Eye technicians to let them see all the views available and make an informed decision. We’ll often go in at halftime and review the footage with the Hawk-Eye cameras, and we catch these cheeky little gouges going on in rucks. Referees come down on them really hard, which is great for player welfare and less work for me to do! There are occasional gouges, often just by mistake, but the offending player will still get sent off even if it was an accident. This all means that players know they must keep their hands away from eyes now, which is fantastic news.

Concussion is an important topic at the moment, in rugby and across many sports. We’ve really got to stay ahead of the game to protect players – there have been some high-profile players getting dementia early, as with other sports. With eye symptoms being fairly common in concussion, we’re often involved when there’s blurred vision, double vision or even loss of vision. We had one Welsh player who went completely blind after a line-out concussion in a French game. That obviously caused a lot of stress to the player, his family, and the team doctors. But his scans were normal and thankfully his vision returned the next day. Visual symptoms are a sign of significant concussion.

Have you had any experience with the goggles that were approved for rugby player use?
 

I think they’re a good addition to the sport, because they protect the eyes. I don’t think it will catch on in general with rugby players, but for those who only have one eye or have a form of vision impairment, as with any other sport, I think you’ve really got to be careful and protect the eyes, so it’s a sensible idea. We use similar protective equipment when a player has had a blowout fracture, with a semi-mask apparatus that protects the cheek. It’s something that has been implemented in the military as well, with soldiers wearing eye protection to avoid injury from improvised explosive devices, which cause such devastating shrapnel eye injuries.

As with any protective devices, they can have a dual psychological effect on players – they can make players hit harder and fight harder, like when wearing a helmet or a scrum cap, or they can also be seen as a sign of weakness, which is a major reason that I can’t see them becoming completely mainstream. Many Welsh players wear contact lenses and they don’t have any problems. Sometimes you’ll see the doctor run on the field with a fresh contact lens for someone who’s lost one, but that’s as bad as it gets.

How has COVID-19 affected the rugby?
 

COVID-19 has been tough for all sports, but especially for rugby, because the crowds in the stadiums really make the games special and lift the players. You can see how the mental health of the players (and the fans) was really affected by COVID-19, as their normal routines were disrupted. The low point for me were the autumn internationals in 2020, when we had to move to Parc y Scarlets in Llanelli, because they were using the Principality Stadium as a field hospital. It was freezing cold, raining, windy, and we weren’t playing very well. The only people there were the players, the press, and us in the whole stadium, which was pretty miserable. I’m delighted to see crowds being allowed back in safely, which will make such a huge difference to the upcoming tournament.

What is the pressure like, when you’re treating a sportsperson on the international stage?
 

There’s a lot of time pressure when you’re stitching someone up during a match, as you’ve got that 10-minute blood window before they’re not allowed to come back on, so if they need a head injury assessment, you’ve really got to be a fairly swift technician and get those stitches in sharp – and the player is also raring to get back on the field. We had to stitch up the great New Zealand player Richie McCaw’s forehead in the World Cup actually, no pressure there... But you just chat away with the player, trying to keep their mind off the procedure and get them out back in the game as quickly as you can. It really is a privilege to be part of it – trying to deliver high-quality medical care to elite athletes during huge international matches. This work really brightens up my February, March, and the time with the rest of the games. The players are also great guys, truly professional, who work and train so hard, and are genuinely grateful for the help you’re giving them. I almost feel their pain when they suffer from career threatening injuries. It can be the end of their careers, so it’s gratifying to get their injuries sorted, and to see players like George North and Alan Wyn Jones come back from injury – they’re talismanic people!

It's all voluntary, so we’re not paid to do it, but we do get a few perks occasionally! We do it because we love the game of rugby and want to give the players the best possible care.

What advice would you give to readers who would like to be their favorite sports team’s ophthalmologist?
 

There are various courses you can do, not for just ophthalmology, but also for general sports medicine and pitch side medical care, but for me, it was serendipitous. It is about luck, and being in the right place at the right time, but you can create your own luck to a certain degree. I’ve always said that you’ve got to actually put yourself in the position to get the job, and work hard at it. These days, it is much more difficult as a trainee to get the time to get involved in extra activities like this, but you can still do it; you just have to be tenacious and beaver away. And you’re not going to become a “sporting ophthalmologist” as such; you have to offer a variety of skills. So doing either a part time Sports Medicine degree, or a similar course, would help. Also, just offering to help out at your local club with general medical issues can be a big step in the right direction. My kids play hockey, ski and do other sports, so if they have injuries, I’ve always got a bag in the back of my car and help out. You can also work at slowly making the right contacts, and offering to be helpful when people want you.

What would be your dream ophthalmology job?
 

To be the ophthalmologist for a British Lions Rugby tour of course, not that they’ve ever asked for one! But, otherwise, I’ve already got my dream sporting ophthalmology role with the Welsh Rugby Union.

Who do you think will win the 2022 Six Nations Championship?
 

Wales, of course! It’s going to be a thrilling Six Nations and it looks to be a pretty open competition. I’m sure there will be some surprises like last year, but I think Wales probably has a fairly uphill battle to retain the title. They are also a fairly resurgent Scotland, with France, Ireland, and England playing well, and Italy can’t be ignored either. But I think the good thing about Wales is they tend to rise to the occasion. Fingers crossed, anyway!

Is there anything else you’d like to mention?
 

As a result of my sporting ophthalmology work, I represent the Royal College of Ophthalmologists on the Council of the Faculty of Sport and Exercise Medicine (UK). This Faculty, which will hopefully be a Royal College in its own right one day soon, promotes and accredits sports physicians, but also promotes exercise for treatment and prevention of cardiovascular disease, and improving mental health. As medics and ophthalmologists, we should be having that discussion about exercise with our patients improve health as a whole, and reduce the risk of AMD, diabetes and cardiovascular eye problems, such as vein occlusions. Exercise is so important and it’s a cheap “prescription” to offer people.

I also do some charity work with the Welsh Rugby Charitable Trust who look after injured rugby players, especially those with spinal injuries – it’s good to be able give a little back to injured players for the sacrifices they have made.

Dan Morris is a specialist in cataract and oculoplastic surgery based in Cardiff, Wales, UK, and is the match ophthalmologist for the Welsh Rugby Union.