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Practical Considerations in the Treatment of Eye Casualties

Medical Science Publication No. 4, Volume 1

PRACTICAL CONSIDERATIONS IN THE TREATMENT OF EYE CASUALTIES*

MAJOR JOHN E. EDWARDS, MC

Injuries of the eye have always posed a difficult problem for the general medical officers who have to deal with them in forward echelons In this discussion I shall present what we have found in Korea to be the most satisfactory methods of handling these casualties, both from the medical and the military standpoints.

The seriousness of the problem is mainly due to the severity of the injuries and their likelihood to result in permanent and grave disabilities. The number of eye casualties has been only about 5 percent of the total injured in both World Wars and Korea, but in Korea alone, 1,071 soldiers suffered blindness in one and 149 in both eyes.

Tiny particles will cause little damage to other parts of the body, but their penetration into the eye is often enough to destroy its usefulness. The eyes of an infantry man have to be kept under protective cover much of the time, both in offense and in defense. The skull above them is protected against small missiles by the helmet, but the eyes'only protection is their location in the bony orbit and the winking reflex of the lids which is not effective against the high-speed particles of modern warfare.

The injuries of the eye principally encountered are: (1) burns, (2) contusions, (3) abrasions, (4) penetrating wounds.

1. Burns. First let us consider burns. They are (a) chemical or (b) thermal.

a. Chemical. In Korea the most frequent offenders were battery acids, lye used in cleaning solutions, and brake fluid (fig. 1). The damage done by chemical agents depends not only on the amount and concentration but also on the length of time in which they are able to act. This is particularly true of alkalis where the end product, in itself, is strongly alkaline. It is, therefore, imperative that all chemicals spilled in the eye be washed out immediately with whatever water may be available. It happens, unfortunately, all too often that patients are brought in to medical installations several minutes away without the eye having been washed out, and with dire results, al-


*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


469

FIGURE 1.

though local source of water was available. This indoctrination should be done in basic training and repeated as often as may be necessary. The pain which occurs with burns and with trauma in general is in a large part due to a reflex spasm of the ciliary bodies and the iris which can be relieved by the use of mydriatic drugs such as homatropine, scopolamine and atropine. These drugs should be used along with local antibiotic agents of which sulfacetamide and bacitracin ointments are the safest and most effective.

A special type of burn is due to phosphorus. In this, the treatment consists of thorough débridement of all phosphorus particles and neutralization of any remaining fragments with copper sulfate. Two percent copper sulfate is used, then washed out with saline. The hazards of copper sulfate are well recognized, yet the penalty for failure to remove all phosphorus is too great, and this justifies the rather heroic treatment. Again, as in any other type of burns, the use of mydriatics is advisable.

b. Thermal. Thermal burns of the eyeball itself are fortunately seldom serious because of the excellent protective mechanism provided by the closing of the lids. Third degree burns of the lids, however, are very disfiguring and disabling if not properly cared for. This is due to the contracting scars separating or everting the lids (fig. 2). This lack of protection to the eye may ultimately result in drying, then infection with loss of sight or even loss of the entire eye. Therefore, it is emphasized that even small third degree or questionable third de-


470

FIGURE 2.

gree burns of the eyelid be treated by prompt tarsorrhaphy. This should be accomplished as early as possible and certainly within the first 72 hours even at installations not giving definitive eye care. As a temporary measure, a simple suture connecting the marginal surfaces of the lids will suffice. This can be improved upon by making a shallow incision in each lid in the gray line which lies between the row of lashes and the openings of the Meibomian glands and suturing the marginal


471

surfaces together. The resulting scar tissue will yield a firm closure which can later be released with ease.

2. Contusions. Contusions encountered in Korea came from two sources: from accidental injuries such as those caused by fists, automobile accidents and rifle barrels, and from combat injuries such as those from mines, concussion grenades or other exploding missiles.

Contusions can vary in severity from a black-eye to rupture of the eyeball. In severe contusions there is usually edema of the conjuctiva and cornea, and blood in the anterior chamber (fig. 3). With this there is often edema of the retina manifested by a great increase in shiny light reflexes. All but the most minor contusions should be treated by binocular bandages and evacuation as litter patients to an ophthalmologist because of internal hemorrhages and the ever-present danger of retinal detachment. In this latter condition, the retina separates from the underlying choroid from which it receives nourishment. The detached portion dies within a few days to few weeks if it is not re-attached by absolute bed rest and surgery. The surgery consists of electrocoagulation through the sclera with production of scar tissue. In Korea we encountered five patients with retinal detachment. Mydriatics should be avoided in contusions particularly in the presence of intraocular hemorrhages as they occasionally result in delayed massive hemorrhages.

3. Abrasions. The most common cause for abrasions was brushing against branches of trees and shrubs and accidentally scratching with fingernails. Oue patient's eye, however, was abraded by a missile, 10

FIGURE 3.


472

x12 x12 mm. in size, which skimmed the cornea and imbedded itself into the nose. The treatment of abrasions should consist of placing the eye at rest with aid of binocular bandages, mydriatics and antibiotics. The local antibiotic of choice again is sulfacetamide or bacitracin.

4. Penetrating Wounds. Penetrating wounds comprise the largest and most serious group. The causative agents are shown in table 1.

Table 1. Causative Agents

 

Number

Percent

High explosives

140

49

Mine

34

12

Hand grenades

31

11

Small arms

13

4. 5

Trip flare

4

1. 5

Accidental injuries:

      Weapons
      Industrial



26
38



9
13


Total


286


100

The simplest type are the superficial conjunctival and corneal foreign bodies. With care and a few simple instruments, these can be removed by general medical officers. Examination is best done by using oblique illumination, even with a good flashlight. The upper lid can be everted by having the patient look down, grasping the eyelashes and pulling them forward, then pressing the skin above the tarsus downward. Foreign bodies of the conjunctiva can be removed with a cotton-tipped applicator stick.

Foreign bodies of the cornea require pontocaine (1/2 percent) anesthetic, a fine-tipped Bard-Parker blade or a hypodermic needle and a magnifying lens or a loupe. The tip of the knife is placed beneath the edge of the foreign body and it is flicked upward. This is repeated until the particle is lifted out. When a foreign body has been in the eye for many hours, there is apt to be a rust-colored ring around it. This tissue reaction is also irritating and it is removed by the same way as the foreign body itself. Removal must be followed by antibiotic ointment such as sulfacetamide or bacitracin and mydriatics, preferably 0.25 percent scopolamine. Atropine effect lasts 1 to 3 weeks resulting in too prolonged interference with visual efficiency; therefore, it has no place in treating minor injuries. Carelessness and excessive manipulation, such as repeated attempts with cotton swabs, sometimes result in infection as shown in figure 4, with grave damage to the eye. The prolonged use of anesthetic ointments should be avoided as they inhibit healing and enhance the progress of infection by paralyzing the corneal nerves.


473

FIGURE 4.

FIGURE 5.


474

Injuries of a more major nature may be injuries of the anterior segment (fig. 5), wounds of the cornea with and without involvement of the iris and lens, or those of the posterior segment involving wounds through the sclera into the vitreous. In these, the wound of entry is often not evident, but posterior segment injuries should always be suspected in injuries of the lid. Deep anterior chamber usually denotes severe injury. With high-speed missiles, total fragmentation of the eye is often encountered. In some of these, such as seen in figure 6, one has considerable difficulty in finding the various

FIGURE 6.


475

portions of the globe. Enucleation of such eyes can be made easier by first suturing the fragments together for traction and identification.

In all these injuries, the presence of foreign bodies must be suspected. The eye is capable of withstanding some of these foreign bodies for prolonged periods of time; others, especially copper-containing bodies, will produce rapid and inevitable degeneration of the eye.

The responsibility for giving definitive care for these major wounds must rest with the opthalmologist, as other physicians rarely have the necessary instruments or experience. The treatment must begin as soon as possible. The physiology of the eye depends greatly on maintenance of normal intraocular tension; therefore, early restoration of tension is of greatest importance. Certain other processes such as formation of adhesions will also be minimized by early definitive treatment. For this reason, early evacuation should be the principle at forward echelons. In order to place the eye at rest, both eyes should be bandaged and the patient should be evacuated by litter. Mydriatics should not be used in these wounds because of occasional complications of hemorrhage and anterior synechiae. Antibiotics such as penicillin and streptomycin, however, should be used liberally, as well as morphine and tetanus booster.

The principle of treatment by the ophthalmologist is to repair primarily any eye in which there has not been too great loss of intraocular contents. Many eyes which at the operating table were thought to be hopelessly lost ultimately recovered some sight. Surgeons who know the technic of enucleations but are not experienced in repair of eye wounds are likely to be tempted to enucleate eyes which could be repaired by an ophthalmologist. Conservative surgery is especially important in bilateral injuries.

During my 16 months of service in Korea we performed the following major operations on casualties:

Repair, wounds of sclera

110


    319=70 percent

Repair, wounds of cornea

116

Removal, F. B., vitreous

76

Removal, F. B., anterior chamber

17

Enucleation

129

 

Eviscerations

4

Lid repair (major)

68

Detachment of retina

5

Others

4

Total

529

Accurate localization of foreign bodies is of utmost importance and depends on competent use of x-rays. In the presence of various types of injuries and because of the patients' general condition, movements must be kept at a minimum in order to obtain good x-rays.


476

It has been the general experience that x-rays taken at forward installations rarely gave the opthalmologist all the information necessary, resulting in the necessity of exposing the patient to double manipulation. It is therefore most strongly advised that x-rays should not be taken at forward installations for localization, but only at the place of definitive treatment.

We had considerable success with stereo x-rays in localizing foreign bodies. The various more accurate methods of localization commonly used in the United States were not very feasible because of the variability of the power supply, the x-ray equipment, the poor cooperation of the patients and the presence of open wounds of the eye.

The stereo technic is also particularly suited to localization of multiple foreign bodies which are apt to be very confusing to other views. The routine view was the stereo-Waters view; i. e., chin and nose on the plate. For stereoscope, two prisms from an eye trial lens set were mounted to tongue depressors which yielded excellent stereopsis.

Complications. Endophthalmitis occurred in 25 out of 286 eyes; 10 of these, or 40 percent, were due to mine injuries (table 2).

Table 2. Endophthalmitis

 

Number

Percent of injuries

High explosives

7

5

Mine

10

29

Hand grenade

2

7

Small arms

1

-----

Stone

1

-----

Steel chip, hammer

1

-----

Unknown

3

-----


Total


25


9

Sympathetic ophthalmia, fortunately, does not pose the same problem that was encountered in the Civil War and the Spanish-American War. These instances were reduced to about 30 cases in both sides of the entire First World War, very few in the Second World War and I have not yet heard of one in Korea. With the advent of cortisone and with prolonged competent observation, eyes do not have to be primarily sacrificed because of possibility of sympathetic ophthalmia.

Military Aspects. During the Second World War, there was a relative shortage of ophthalmologists and as lateral evacuation was rarely possible, ophthalmologists could be assigned to base hospitals only. Furthermore, they had to contend with the slowness of evacuation. Nonetheless, they found that patients fared better if definitive surgery was not done by general surgeons in forward areas but by ophthalmologists farther in the rear. In Korea the situation was different: The


477

area was smaller, the lines of evacuation congregated at a more forward point which was relatively safe from attack, and both rapid and lateral evacuations were made possible by helicopters and Air Force evacuation planes. The type of injuries was also different as the mine and grenade wounds were well contaminated with the human manure from the rice paddies, which necessitated earlier débridement.

At the beginning of the war, definitive surgery was done mostly at Tokyo Army Hospital and some at a hospital ship in Pusan. The time elapsed between injury and arrival at Tokyo was often in excess of 24 hours. We found that the patients operated on by an ophthalmologist aboard the ship arrived in better condition at Tokyo than those who came directly, thus indicating the need for earlier surgery. For this reason, ophthalmologists were pushed forward into evacuation hospitals in Korea. Thereafter, definitive treatment could be given in 6 to 18 hours from even the most distant portions of the front line. In the opinion of everyone, the end-results justified this system.

Thus, in the light of the experience in both wars, it is recommended that ophthalmologists be placed as far forward as possible, depending on their availability, to enable preoperative time lags of less than 12 to 18 hours.

Concomitant Injuries. Attention is invited particularly to the 32 eye injuries which were seen in conjunction with neurosurgical injuries and to the 47 with maxillofacial wounds (table 3).

Table 3. Concomitant Injuries

 

Number

Percent

Surgical of face

42

14

Maxillofacial

47

17

Neurosurgical

32

11

Thorax

6

2

Abdomen

3

1

Extremities

48

17

None

59

21

Unknown

49

17


Total


286


100

As these injuries also require specially trained and equipped personnel, this high proportion of coexisting wounds points to the advisability of placing an ophthalmologist, a maxillofacial surgeon and neurosurgeons in the same hospital.

In Korea this was achieved by the addition of a neurosurgical team to an evacuation hospital. Later, however, this excellent arrangement was disrupted and the neurosurgical team was moved forward to a MASH, 40 minutes helicopter travel time away. This entailed frequent trips to the MASH to operate on combined casualties. Except for the fortunate coincidence that the ENT surgeon was also a trained ophthalmologist, this system would have resulted in serious damage.


478

When a second neurosurgical team was sent to the east coast, an ophthalmologist was sent with them. In view of the great number of combined injuries, ophthalmologists should be placed in hospitals providing treatment of all wounds, including neurosurgical and maxillofacial injuries.

The advice of consultants was given great weight in matters of assigning personnel as well as of maintaining high caliber of medical care. This system worked out very well in Korea and it should be continued in the future.

The number of ophthalmologists needed in combat is one Board-qualified or Board-certified man and one slightly lesser trained man for each two corps. These lesser trained men, however, must spend some time with an ophthalmologist who is experienced in traumatic surgery prior to being assigned to a hospital of their own. This estimate, however, assumes good evacuation facilities.

The equipment available to ophthalmologists in Korea was greatly dependent on resourcefulness of the ophthalmologist and on the power given the Far East Consultant in recommending supplies. In many instances we were hampered by lack of equipment and at times found sorely needed equipment in hospitals lacking ophthalmologists. These difficulties can be avoided in another conflict by issuing to each qualified ophthalmologist his own equipment. A compact kit is currently being developed by the Ophthalmic Research Unit at Walter Reed Army Hospital.

Prevention. When one observes these casualties, one is struck by the large number of eyes lost because of tiny missiles. I also had the privilege of seeing soldiers whose eyes were protected by their glasses when their face was peppered by small particles. I feel that commercial safety glasses will protect against almost all fragments, 1 x1 x 2 mm. in size and many of 2 x 2 x 2 mm., depending on the velocity, angle of impact, etc. You will note in table 4 that 115 out of 218 missile wounds, or 53 percent, would definitely have been prevented and 143 out of 218, or 66 percent, probably prevented by commercial safety glasses.

Table 4. Small Missile Wounds Causing Loss of Eyes

Size of missiles

Number

Percent

Less than 1 x 1 x 2 mm.

115

53

Less than 2 x 2 x 2 mm.

28

13

Less than 5 x 5 x 5 mm.

26

12

Over 5 x 5 x 5 mm.

49

22


Subtotal


218


100

None

22

-----

Unknown

46

-----


Total


286

 

479

It is impossible to prevent all wounds, except by heavy steel goggles. As these are hot and restrict the field of vision, they would be totally unacceptable to the troops. Safety glasses, however, like body armor, would soon find acceptance.

Glasses were provided by having a refractionist and an optician with each division issuing 80 to 120 glasses a month. At corps level there was an optical repair truck which supplied 1,000 to 1,400 pairs of glasses per month and there was a base depot at Pusan. At the 121st Evacuation Hospital, an optometrist and I refracted the eyes of 500 to 700 soldiers per mouth. This system enabled a 24-hour service on almost all glasses. It is most advantageous to have such a system of procurement in forward echelons as this minimized time lost from the organizations. Although the prescription for glasses is supposed to be recorded on the immunization records, these were often not available to the optician or did not contain the prescription.

Summary

In summary, the Korean conflict taught us the following important lessons regarding care of eye casualties:

1. Definitive care should be done by an ophthalmologist.

2. Early evacuation is necessary with both eyes bandaged and on a litter.

3. Ophthalmologists should be assigned to hospitals to which patients arrive in less than 12 to 18 hours after injury.

4. Such hospitals should also have an ENT surgeon and neurosurgeons in addition to the usual complement of general surgeons and orthopedists.

5. Each ophthalmologist should be supplied with his own instruments.

6. Safety glasses should be issued to all troops in combat.