Chp14OcularInjuries.pdf

Ocular Injuries

Chapter 14

Ocular Injuries

Introduction

The preservation of the eyes and eyesight of service personnel

is an extremely important goal. Despite comprising as little as

0.1% of the total body surface area, injuries to the eye are found

in 5–10% of all combat casualties. In the Vietnam War almost

50% of casualties with penetrating eye wounds eventually lost

vision in the injured eye. Improvements in ophthalmic care in

the last 30 years offer hope that blindness in combat casualties

will be less common in future wars.

Tr iage of Patients With Eye Injuries

ABCs (airway, breathing, and circulation) and life-threatening

injuries have priority, then treat eyesight and limbs.

Soldiers with mild eye injuries may be treated and returned

to duty by nonspecialized personnel.

Soldiers with more severe injuries should be evacuated to

save vision.

Distinguishing major ocular injuries from minor ones may

be difficult.

At the FST level, due to time and equipment restraints,

surgeons will likely ‘patch and evacuate’.

Identifying Severe Eye Injuries

Associated injuries.

ο Shrapnel wounds of the face — think intraocular foreign

body (IOFB).

ο Lid laceration — check for underlying globe laceration.

Vision.

14.1

Emergency War Surgery

ο Use book print, medication labels, finger counting, and

the like, to evaluate vision.

ο Compare sight in the injured eye to the uninjured eye.

ο Severe vision loss is a strong indicator of serious injury.

Eyeball structure.

ο Obvious corneal or scleral lacerations.

ο Subconjunctival hemorrhage — may overlay an open

globe.

ο Dark uveal tissue presenting on the surface of the eye

indicates an open globe.

ο Foreign body — did it penetrate the eye?

ο Blood in the anterior chamber (hyphema) indicates severe

blunt trauma or penetrating trauma.

Proptosis — may indicate a retrobulbar hemorrhage.

Pupils.

ο Pupillary distortion — may be associated with an open

globe.

Motility.

ο Decreased motility on one side may be caused by an open

globe.

ο Other causes include muscle injury, orbital fracture, and

orbital hemorrhage.

Open Globe

May result from penetrating or blunt eye trauma.

May cause loss of vision from either disruption of ocular

structures or secondary infection (endophthalmitis).

Biplanar radiographs or a CT (computed tomagraphy) scan

of the head may help to identify a metallic intraocular

fragment in a casualty with severe vision loss, a traumatic

hyphema, a large subconjunctival hemorrhage, or other signs

suspicious for an open globe with an IOFB.

Immediate Treatment of an Open Globe

Tape a rigid eye shield (NOT a pressure patch) over the eye.

Do not apply pressure on or manipulate the eye.

Do not apply any topical medications.

Start quinolone antibiotic PO or IV (eg, ciprofloxacin 500 mg bid).

14.2

Ocular Injuries

Schedule an urgent (within 24–48 h) referral to an ophthal-

mologist.

Administer tetanus toxoid if indicated.

Prevent emesis (Phenergan 50 mg or Compazine 10 mg IM/IV).

Treatment of Other Anterior Segment Injuries

Subconjunctival Hemorrhage

Small subconjunctival hemorrhages (SCH) may occur

spontaneously or in association with blunt trauma. These

lesions require no treatment.

SCH may also occur in association with a rupture of the

underlying sclera.

Warning signs for an open globe include a large SCH with

chemosis (conjunctiva bulging away from globe) in the setting

of blunt trauma, or any SCH in the setting of penetrating

injury. Casualties with blast injury and normal vision do not

require special care.

Suspected open globe patients should be treated as described

above.

Treatment of Chemical Injuries of the Cornea

Immediate copious irrigation (for 30 minutes) with normal

saline (NS), lactated Ringer’s (LR), or balanced salt solution.

Nonsterile water may be used if it is the only liquid available.

Use topical anesthesia before irrigating, if available.

Measure the pH of tears to ensure that if there is either acid

or alkali in the eye, the irrigation continues until the pH

returns to normal. Do not use alkaline solutions to neutralize

acidity or vice versa.

Remove any retained particles.

Using fluorescein test, look for epithelial defect.

ο If none, then mild chemical injuries or foreign bodies may

be treated with artificial tears.

ο If an epithelial defect is present, use a broad-spectrum

antibiotic ophthalmic ointment (Polysporin, erythromycin,

or bacitracin) 4 times per day.

Noncaustic chemical injuries usually resolve without

sequelae.

14.3

Emergency War Surgery

More severe chemical injuries may also require treatment with

prednisolone 1% drops 4–9 times per day and scopolamine

0.25% drops 2–4 times per day.

Pressure patch between drops or ointment if a large epithelial

defect is present.

Monitor (daily topical fluorescein evaluation) for a corneal

ulcer until epithelial healing is complete.

Severe acid or alkali injuries of the eye (recognized by

pronounced chemosis, limbal blanching, and/or corneal

opacification) can lead to infection of the cornea, glaucoma,

and possible loss of the eye. Refer to an ophthalmologist

within 24–48 hours.

Treat mustard eye injuries with ophthalmic ointments, such

as 5% boric acid ointment, to provide lubrication and minimal

antibacterial effects. Apply sterile petrolatum jelly between

the eyelids to provide additional lubrication and prevent

sealing of the eyelids.

Treat nerve agent ocular symptoms with 1% atropine sulfate

ophthalmic ointment, repeat as needed at intervals of several

hours for 1–3 days.

Corneal Abrasions

Diagnosis.

ο Be alert for the possibility of an associated open globe.

ο The eye is usually very symptomatic with pain, tearing,

and photophobia.

ο Vision may be diminished from the abrasion itself or from

the profuse tearing.

ο Diagnose with topical fluorescein and cobalt blue light

(Wood’s lamp).

ο A topical anesthetic may be used for diagnosis, but should

NOT be used as an ongoing analgesic agent — this delays

healing and may cause other complications.

Treatment.

ο Apply broad spectrum antibiotic ointment (Polysporin,

erythromycin, or bacitracin) qid.

ο Options for pain relief.

♦ Pressure patch (usually sufficient for most abrasions).

♦ Diclofenac 0.1% drops qid.

14.4

Ocular Injuries

♦ Larger abrasions may require a mild cycloplegic agent

(1% Mydriacyl or Cyclogyl) and a pressure patch.

♦ More severe discomfort can be treated with 0.25%

scopolamine one drop bid, but this will result in pupil

dilation and blurred vision for 5–6 days.

ο Small abrasions usually heal well without patching.

ο If the eye is not patched

♦ Antibiotic drops (fluoroquinolone or aminoglycoside)

may be used qid in lieu of ointment.

♦ Sunglasses are helpful in reducing photophobia.

ο Casualties who wear contact lenses should have the lens

removed and should not be treated with a patch because

of the higher risk of developing a bacterial corneal ulcer.

ο Abrasions will normally heal in 1–4 days.

ο Initial treatment of thermal burns of the cornea is similar

to that for corneal abrasions.

All corneal abrasions need to be checked once a day until

healing is complete to ensure that the abrasion has not

been complicated by secondary infection (corneal ulcer,

bacterial keratitis).

Corneal Ulcer and Bacterial Keratitis

Diagnosis.

ο Corneal ulcer and bacteria keratitis are serious conditions

that may cause loss of vision or even loss of the eye!

ο A history of corneal abrasion or contact lens wear.

ο Increasing pain and redness.

ο Decreasing vision.

ο Persistent or increasing epithelial defect (positive

fluorescein test).

ο White or gray spot on the cornea seen on examination with

penlight or direct ophthalmoscope.

Treatment.

ο Quinolone drops (eg, Ocuflox), 1 drop every 5 minutes

for 5 doses initially, then 1 drop every 30 minutes for 6

hours, then 1 drop hourly around the clock thereafter.

ο Scopolamine 0.25%, one drop bid may help relieve

discomfort caused by ciliary spasm.

14.5

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