The recent explosion of the sport known as pickleball has been unescapable. Not only is this arguably the fastest growing sport in America, but also it seems to be embraced by any and every age demographic. At first, most of us thought the cute name and modest equipment were more of a fad, but as you visit your local community recreation centers, you will find previous playing fields, tennis courts, and even parking lots converted to full-time pickleball courts.
Certainly, much of the mass appeal of the sport is rooted in the simplicity and low cost of participation. Think tennis with many modifications. To start, it is played on a much smaller court: 20 feet by 44 feet compared to a standard tennis court, which is 60 feet by 120 feet. A smaller, simple, solid paddle is used to hit a modified Wiffle ball. In general, the ball moves much slower than in tennis, and the athletes do not have to cover nearly as much space. Reduced burden of movement and more generous reaction times have made it a very popular choice for senior athletes. If you have ever tried or remember learning to play tennis, you will surely recall barely working up a sweat, as the skill of hitting the ball well is a significant barrier to getting a lengthy volley going. Pickleball is much more forgiving and allows most first-time players to achieve some lengthy back and forth right away. But don’t go and brand pickleball a geriatric sport because, like any mass-played sport, pickleball can become incredibly competitive, and there are elite competitions with elite athletes. From personal experience, many of my friends who have recently retired from the NFL are now traveling for competitive tournaments.
The perforations in the plastic ball used in pickleball do provide some unique vision-related properties compared to more conventional balls. The ball is designed to catch air and stay aloft longer due to the holes. This property allows for more time to react and to travel to the ball. The wind resistance also causes the ball to rapidly decelerate when it is struck aggressively. The rapid deceleration of the ball requires the brain to recalculate the strike location constantly. When played at pace, the sport can be quite visually challenging and keep the participant continually entertained.
With the low barrier for entry, in terms of both cost and physical ability, it should be no surprise that presbyopes are the largest demographic in this fast-growing sport. In my clinic, it is easily the number one presbyopic sport, now far outnumbering golfers, runners, and cyclists. Being able to relate to your patients’ concerns and vision demands with the recreation of their choice goes a long way toward providing superior patient care. Here are some of my key concerns I address when I have a pickleball athlete in my exam chair.
Maximize Vision
This may seem trivial but correction should be maximized for sport. If correction is required, contacts are better than glasses. Although often used, progressive spectacle lenses are not a great choice. Their limited distance viewing and peripheral distortion can limit a player's performance. Because all of the vision-related tasks are happening at length, your presbyopes do not require correction while playing. These patients are spending a lot of time and money on this sport, don’t hesitate to recommend correction optimized for the sport. Athletes don’t wear dress shoes to go for a run, they should not wear progressive lenses on the court. With the same justification, successful multifocal contact lens wearers will often benefit from single vision contacts for sporting purposes.
Eye Protection
From a sports vision standpoint, we never like the idea of patients wearing fashion eyewear during sporting competitions. This type of eyewear poses a significant safety risk, and the frames are not specially designed to stay on the face with rapid movement. A high-speed ball, swinging solid paddle, and often the playing partner all pose risks to the athlete’s eyes. In a perfect world, all would wear ASTM F803-19 (American Society for Testing and Materials)-certified eyewear, but with limited availability and styles, this standard can be difficult to meet. A more realistic approach to eye protection consists of impact-resistant sunglasses and eyewear. Many of the sports-oriented sunglasses companies make frames with interchangeable lenses so the athlete can wear clear lenses indoors and tinted lenses outdoors. These options are more fashion forward and comfortable and an easier sell regarding the need to protect the eyes.
Eye Warm-up Drills
As we age, we lose contrast sensitivity, reaction time, and even dynamic visual acuity. Just like with skeletal muscle, these skills can be enhanced with warm-up drills. Although many sports vision doctors or coaches may have specific warm-up drills that they prefer, a recent publication (The Complete Book of Pickleball by Kurt Burghart) enlisted a group of the top sports vision doctors in the country to recommended specific eye warm-up drills for your pickleball players.
Vision Enhancement
There are a wealth of studies that show how good or bad diets can affect vision performance. They suggest that various vitamins and minerals could be used to at least preserve visual function as we age. The carotenoids are a specific group that has been shown to both increase visual function in norms (even elite athletes), as well as reducing the risk of disease in the aging. Lutein and zeaxanthin are the 2 best known, and they may have the dual effect of increasing visual performance and reducing risk of macular degeneration in the “at-risk” population. Lutein and zeaxanthin are among the few supplements that we universally recommend to athletes.
Another product that I have had some surprise success with is miotic drops used for presbyopia. I have tried using miotic drops with some pickleball players for increased distance vision and possible reductions in higher-order aberrations. I have some players who feel like they have a significant advantage with the induced miosis, but I have had others who did not detect any difference. As a side note, all were pleasantly surprised at their near vision when ordering food or drinks after the match.
Treat Dry Eye
Your presbyopes playing pickleball are also the largest demographic for dry eye and the resulting consequences. This group is already at a disadvantage with preexisting dry eye, and the environmental and sport-specific demands of pickleball can make dry eye significantly worse. Some will play outdoors in the wind; some will play indoors in dry, heavily ventilated sports complexes; and all will have increased concentration rates, leading to decreased blink rates. These factors all add up to stressing an already dry eye. A simple and obvious go-to is to tell your athletes to put some artificial tears in their playing bag. Think of the tears as Gatorade, and put a drop in 5 to 10 minutes before you play. The downside is that this approach is superficial symptom relief and does not address the underlying inflammation causing dry eye. A more effective solution often involves the use of immunomodulating eye drops to address the inflammation and increase natural tear production. These drops are safe and well tolerated and only need to be used in the morning and at night, but they do take up to several months to achieve an effect. I would guess that more than 90% of my presbyopic pickleball players are currently using an immunomodulating eye drop.
Just like pickleball is an easy and unthreatening sport for our patients, so is becoming a vision champion for them in your clinic. There are many things you can do to help these patients, but the most important may just be starting the conversation and showing interest.
Disclosure
Dr. Cunningham has a financial relationship with Orasis Pharmaceuticals.
