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As pickleball continues to take off, especially among older Americans, ophthalmologists are warning that the sport can wreak havoc on the eye despite appearing about as low-impact as a Ping-Pong game in the basement.

In a , Andrew G. Lee, MD, of Baylor College of Medicine and Houston Methodist Hospital, and colleagues warned of potential ocular risks from pickleball, especially in people over age 65 who are "particularly vulnerable to eye injuries."

While pickleballs are lightweight and don't move very fast, their small size allows them to cause significant optical injuries because they can bypass the protective eye socket, Lee told MedPage Today. "The smaller a ball is, the more it can fit into the eye socket without hitting the bone. That's why smaller balls like racquetballs and squash balls are actually more likely to cause direct eye injury than tennis balls, footballs, or baseballs, which are bigger."

"Obviously, the incidence is going to increase with the increasing number of pickleball players," he added.

Pickleball, a paddle sport that's similar to tennis, badminton, and Ping-Pong, and surged in popularity over the past 5 years. Pickleballs are perforated and hollow, similar to Wiffle balls.

Last year, the Sports and Fitness Industry Association that it was the nation's fastest-growing sport, with participation up 159% from 2019-2022. The game is especially popular among seniors, with more than 80% of players over the age of 60. According , the investment bank UBS estimated in 2023 that pickleball injuries in the U.S. could cost $500 million a year, with strains, sprains, and fractures most commonly affecting the wrist, lower leg, and head.

CBS News last year that "the number of pickleball-related injuries has nearly doubled, from just under 9,000 in 2020, to just over 17,000 in 2022, according to the Consumer Product Safety Commission's National Electronic Injury Surveillance System," and about 75% of injuries since 2018 were among those ages 55-75.

Lee said Houston Methodist Hospital sees an outpatient case about once every 3 to 4 months, and more serious cases about once a year.

Ophthalmologist Albert Li, MD, of the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, told MedPage Today that he's treated several pickleball injuries.

"I have seen dislocated intraocular lenses and traumatic macular holes after direct impact of pickleball to the eye," he said. "Thankfully, we know how to fix these issues. However, all of these surgeries require a period of visual recovery during which the vision is impaired in that eye for several weeks."

"The major issue is when the energy of the moving pickleball is transmitted to the eye," he explained. "There are structures that can be injured or bleed. Patients could develop bleeding in the front of the eye, such as a hyphema, that would increase the eye pressure and could cause glaucoma and visual field loss. Even if this bleeding were not to occur, we know that the structures that help with the drainage of fluid from the eye can be damaged after trauma and cause glaucoma in the future."

The current report highlights case reports of optical pickleball injuries including corneal abrasion, retinal tears, vitreous hemorrhage, retinal detachment, posterior vitreous detachment, and traumatic lens subluxation.

In December 2023, 65-year-old actress Michelle Pfeiffer she suffered while playing pickleball.

Overall, "most of the injuries that we see with pickleball are minor or mild and self-resolving," Lee said. "But some are more dangerous, especially when you have a fracture or open globe [injury] with retinal detachment. Those require surgery."

He added that the risk of injury is also higher in those with pre-existing eye conditions. The , for example, occurred in a 39-year-old man who was injured when a pickleball bounced off his paddle into his eye. He'd previously suffered from dry eye disease, lattice degeneration, and meibomian gland dysfunction. His cornea healed after debridement and therapy with steroids.

Protective eyewear is mandatory in tournament racquetball and squash, but not tennis or pickleball. The American Academy of Ophthalmology that protective, shatterproof lenses "should be worn for sports such as basketball, racquet sports, soccer, and field hockey."

Lee suggested using wrap-around protective glasses designed to stay on the head. Prescription glasses or sunglasses may provide some protection, he added, but they can shatter or get knocked off the face.

People with high levels of nearsightedness -- more than 6 diopters of myopia -- are at special risk because their retinas are thinner and more likely to tear, Lee noted. "They probably should be wearing safety goggles for any ball, racket, or contact sports."

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