Photo by Josh Hedges/Zuffa LLC/Zuffa LLC via Getty Images

Some call the eyes the windows to the soul. The sage Christopher Walken once called them “the windows of your face.” Add this to the list: The eyes are easy targets for fighters’ open-gloved paws. Since the early days of sanctioned MMA, fighters, fans, and officials have forbid contact between fingers and the ocular cavities. But whether the light heavyweight champion’s name was Jon Jones or Chuck Liddell, the eye poke—accidental or otherwise—has been a perennial concern causing point deductions, technical decisions, tide-turning moments, and blurry visions.

We’ve all been poked in the eye at one point or another, and we all agree that it sucks. But for a more informed view of what’s involved, Fightland spoke with Dr. Michael Kelly—a sports-medicine specialist, part-time ringside doctor, and the author of the book Fight Medicine—about the most-likely and worst-case eye-poke-related injuries, the less-than-ideal circumstances facing a physician examining a fighter’s eyes at ringside, why new glove designs might not be an eye-poke panacea, and how herpes (along with causing that burning sensation) can impair your vision.

In terms of anatomy, the outermost layer of the eye is the cornea, a thin, clear layer of epithelial cells. Beneath that, you have the anterior chamber, which is filled with a very clear, thick fluid. As you go further back, you get into the globe of the eye. When there’s an eye poke, most injuries occur in either the cornea or the iris.

The epithelial layer of the eye can grow a new layer of cells in 24 to 48 hours—in that way, the eye is very resilient. Unfortunately, when you get into the more structural parts of the eye, you don’t have that resiliency.

An eye poke can lead to a scratch on the cornea, and those can be tough to deal with, depending on how big the scratch is. Sometimes it’s a gash. Sometimes it’s an abrasion where you have a bunch of little scratches going across. In particular, if they catch a part of the glove instead of the finger, the material can have an abrasion effect in multiple areas across the cornea.

Lysosomes, or enzymes, in our tears will kill a lot of bacteria and viruses. If it’s a young, healthy athlete, they usually do very well if it’s only a corneal abrasion. We routinely give them antibiotic drops, though most of the time the infection doesn’t occur. But if you get a corneal abrasion and it doesn’t heal or it gets infected, that can cause permanent visual impairment.

This ties into a different subject, but it’s very important: you worry about when fighters have herpes infections and they aren’t disclosed. If someone has a herpetic virus, they get a corneal abrasion, and the virus gets into the part of the cornea that’s damaged, that’s going to cause a distinct white line right across the cornea that’s generally permanent. As far as the health of the eye goes, that’s a deadly combination.

Traumatic iritis is something that we worry about. We’ll sometimes see a tear in the iris, which is controlled by the ciliary muscles. The muscles get damaged and cause a very distinct spasm of the iris, so that pupil looks like it’s closed, like a pinpoint—it’s what we call a miotic pupil. The other injury that’s significant is called hyphema. If you get a small tear in the soft tissues of the eye, you’ll see bleeding in the anterior chamber, where a layer of fluid in that anterior chamber obstructs your vision.

With traumatic iritis, if it’s microscopic and there’s no distinct change in the anatomy, treatment usually involves cycloplegic drugs, which relax that spasm of the ciliary muscle and allow the pupil to dilate again. With hyphema, if there’s blood in more than 30 percent of the anterior chamber, the athlete needs to see an eye surgeon and have that blood drained out. And it’s really important in the immediate, post-fight period not to do anything that’s going to increase the bleeding: you want to make sure the athlete is kept sitting upright and not applying pressure on the eye. I’ve seen an athlete with hyphema and a well-intentioned but not well-informed individual who said, “There’s blood. We’ve got to put direct pressure on it.” That’s not what you want to do in that setting.

Retinal damage is one of the main reasons why most of the larger commissions require repeated dilated eye exams: they’re looking for early signs of repetitive damage to the retina, so you can catch it before the athlete’s at risk of going blind. In the fight world, we see repetitive injuries from blunt, compressive forces transmitting through the anterior chamber, then through the globe, then reverberating off of the retina, which causes eventual retinal detachment. You see that condition in some older boxers. But with an eye poke, it’s not as much of a concern because we don’t see too many of those compressive forces.

Rarely, we see a fingernail get caught in the corners of the eye on the canthus—the pink tissue between the eyelid and the eyeball. Tears come out of the eyelid by the lateral side of the eye, they go across, and they drain in the medial side of the eye. If you have any tearing of either corner of the eye, that can be a problem: it can disrupt the flow of tears across the eye and into the drainage system. Down the road, that can result in glaucoma and stuff like that.

I’ve never seen it in a fight, but it could occur: If there’s enough force—say it’s a toe from a kick—you can conceivably rupture the globe of the eye. You get a tear between all three layers: the vitreous part, the anterior chamber, and the lens in between. The volume of the eye goes down, and you’ll see a clear, almost petroleum jelly substance oozing out of the pupil. It’s pretty nasty, and it’s catastrophic—you may lose the eye. Fortunately, most of the time, because the eye has springiness to it, you don’t get that force directed into the globe.

Eye pokes are tough things to deal with as a ringside doctor. You have limited time to make a diagnosis and see if a fighter is okay, and you don’t have a lot of leeway when it comes to ocular injuries because they can be permanent. And it can be very challenging depending on what the fighter is saying and doing. We all know that sometimes fighters may use an injury to get a little bit of a break, but sometimes they’re really injured and they’re trying to hide it because they don’t want the fight stopped.

When we examine the eye in the office, we’ll use some anesthetic drops called Tetracaine. The eye goes numb, we can shine line lights and see the anatomy very well, and we can use a scope to look deeper. But ringside, you really can’t anesthetize the eye, and it’s so sensitive to light. Everybody’s experienced this: you get poked in the eye, your eyes are tearing, and it’s tough to shine a light and figure out what’s actually going on without making it feel worse for a fighter than it really is.

My first fight I was covering—literally, the first bout of the night—a guy got knocked out, he got up, I’m looking at him and talking to him, and I see that one pupil is a pinpoint, and the other is dilated. In medical school, we’re taught that a dilated pupil with head trauma usually indicates brainstem herniation and impending death, but the person is usually in a coma. I’m looking at this guy’s eyes and I’m thinking, how could he be talking to me if he has a blown pupil?

I was very alarmed, very scared. One of the senior guys comes up and I said, “Look, he’s got a blown pupil but he’s talking!” He says, “Nah kid, he’s got what’s called traumatic iritis. The pupil’s not blown, it’s just that this one is so constricted.” It’s funny to think about now because it was sort of embarrassing on my part.

In New Jersey, there’s a five-minute rule for an eye poke, and a lot of people don’t know where that came from. Back in the 1970s, there was a boxing match that went down on television, a fighter had an eye injury and the ring doctors were crowded around and looking at the eye. The clock kept going, and it wound up being 20-something minutes before they made a determination. And with television, everybody who’s there paid for their tickets and is getting annoyed. After that, the sanctioning body started saying we have to have a time limit, and if they can’t go on, it has to be stopped and we go to the next bout. So the five-minute rule doesn’t necessarily relate to the amount of time it will take for it to get better or worse.

In MMA, we see more eye pokes than in boxing, but they’re usually not often permanent injuries. With boxing gloves, you never really get poked in the eye, but we see more retinal injuries because you have a larger surface area of blunt trauma. I don’t know if [changing the design of MMA gloves] to try to decrease the incidence of eye pokes will unintentionally wind up increasing the incidence of another type of injury.

Learn more from the Fight Doctor:

Fight Doctor - The Groin Strike

Fight Doctor – Cauliflower Ear

Fight Doctor – Bigfoot's Big Testosterone Problem

Fight Doctor – The Liver Kick

Fight Doctor – The Weight Cut