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Discussion-Eye Casualties in Korea

Medical Science Publication No. 4, Volume 1

DISCUSSION-EYE CASUALTIES IN KOREA*

COLONEL J. H. KING, JR., MC

You have just heard an excellent though brief first-hand account of the management of eye casualties in Korea. The fact that many eyes were saved and much total blindness was prevented attests to the soundness of the principles of treatment which were outlined for you today. My experience in treating these patients from Korea begins farther back in the chain of evacuation-at Tripler Army Hospital in Honolulu-and at the final point of evacuation for many, the eye center here at Walter Reed Army Hospital.

Major Edwards has summarized the important lessons which were learned in Korea regarding the care of eye injuries. Many of these lessons were learned in World War II and because of excellent teaching by our predecessors were well applied in Korea. Other mistakes obvious in the last war were repeated in Korea. These were notably the lack of an adequate field chest for the ophthalmologist and the total absence of any protective device to prevent eye injuries. It was well established in Korea that ophthalmologists can and should be assigned to forward installations to render treatment to eye casualties as soon as possible. Rapid evacuation especially by helicopter and airplane has been a major advance in the conservation of vision.

It was also well established in the last war that the timeworn priorities of war surgery-the saving of life and limb-were superseded by a more realistic approach-the saving of life, vision, and limb. A few of you may argue that it is better to die than to be blinded, but I am sure none will disagree that it is better to lose a limb than one's eyesight. If the same trauma which causes a minor injury elsewhere to the body involves the eye, a serious handicap results. It incapacitates a soldier in battle and may necessitate evacuation to the Zone of Interior. A survey of eye wounds in Korea by The Surgeon General's Office in 1951 revealed that 81 percent required evacuation to the United States. The majority (some 85 percent) of those injured in other areas of the body were returned to duty. When one hears the figures of about 5 percent of all battle casualties involving the eyes, and 10 percent or more, of noncombat injuries, it does not sound


*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.


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high. Most of these result in some compensation, however, and many millions of dollars are being paid now to those who received ocular wounds in Korea.

I shall not elaborate further upon the importance of an eye injury, especially in combat. Most of you have had first-hand experience with that. At this point, however, I am sure many of you have the question on your minds, "Just what should the general surgeon or medical officer do when he is faced with an eye casualty?" In a talk which I presented several years ago before a national society, I concluded with the statement that "the Army ophthalmologist will gain much experience as a result of the Korean conflict, fully realizing, however, that wars do not teach us what to do, but rather what not to do." I am sure that this statement holds true for every medical officer.

The Committee on Trauma of the American College of Surgeons has recently published its policies regarding the treatment of acute injuries of the eye. It feels that the early care of ocular injuries by nonophthalmic personnel should be limited to absolutely essential first aid, and thereafter, to refraining from doing harm. The most trivial eye wound may result in total loss of vision, and therefore, they state that every injury of the eye is potentially serious. The Army has long recognized this and labels a high priority for evacuation of eye casualties. The eye damage must be carefully assessed, as improper examination may result in the total expulsion of the ocular contents through a small and perhaps unrecognized wound. The operation of enucleation is never an emergency procedure, and it should be reserved for the ophthalmologist. It is the most final of all eye operations just as the amputation is for wounds of the extremities. The only criticism a general surgeon can receive in treating wounds of the eyes is in doing too much-never, too little.

Major Edwards has mentioned the fact that most eye wounds are accompanied by other injuries. It is the surgeon's responsibility not to overlook serious damage to the eyes by directing exclusive attention to other major wounds. The primary operation upon an eye is usually the definitive one and the surgeon seldom has a second chance. This responsibility should therefore be placed upon the eye surgeon who is charged with definitive care. The complete examination which is necessary before surgery demands specialized equipment; this equipment and the small delicate instruments which are required for ocular surgery are not usually available to the general surgeon.

After examining the patient's eyes the medical officer should make careful notes of his findings. These will be of great value later to the ophthalmologist. The patient should then be evacuated as soon


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as possible, preferably in a smooth-riding helicopter rather than an ambulance, as a litter patient with both eyes bandaged. The bandages are worthless and may be harmful unless they are firmly and tightly applied to prevent any winking or motion of the eyelids. It is well to sedate the patient to allay the fear and apprehension which usually follows covering both eyes. Opiates may be used unless, of course, they are contraindicated in the presence of a head wound.

The next consideration in the emergency care of the eye casualty is the prevention of infection. Minor trauma does not demand as vigorous measures as more serious injury. Overtreatment should be avoided and the indiscriminate use of antibiotics is to be condemned. There are many antiseptics and chemotherapeutic agents available for use as local bacteriostatic agents for minor trauma. Zephiran, furacin, metaphen, merthiolate and propionic acid may be employed. Boric acid, argyrol, silver nitrate, zinc sulfate and yellow oxide of mercury are not recommended as dependable in prophylaxis. Chemotherapeutic agents such as the sulfonamides are well applied following minor trauma. Antibiotics are unnecessary, and indeed much harm may result from their indiscriminate use ranging from local allergy to general sensitivity, and the development of bacterial resistance and cross-resistance, or superinfections.

In major extra-ocular trauma-which to me should include corneal abrasion in addition to severe lacerations of the lids, conjunctiva and adnexa-every effort is demanded to prevent infection. Antibiotics are usually preferred and they may be employed locally and systemically. Penicillin should not be used locally as allergy is frequent and there are more organisms resistant to penicillin than to any other antibiotic. As you know, this is variously estimated as 30 to 48 percent for Staphylococci, and Streptococci may also be resistant. All antibiotics penetrate the intact cornea poorly except for chloromycetin. Sodium sulfacetimide pentrates better than other sulfonamides. They all penetrate the abraded cornea well. The action of ointment is more prolonged than that of solutions; however, this vehicle is contraindicated in a perforating wound of the eyeball. Many authors recommend the local use of antibiotics (or combinations) which are unlikely to enjoy widespread systemic use because of their toxicity, such as bacitracin, neomycin and polymyxin. We prefer the combination of terramycin and polymyxin which offers powerful antibacterial action against gram-positive and gram-negative organisms including Pseudomonas aeruginosa. This bacillus, the pyocyaneus, was common in Korea and is much feared by the oculist. It causes a fulminating infection which may result in total loss of the eye in a matter of hours.

In severe ocular trauma which involves penetration or perforation


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of the eyeball, drastic attempts must be made at once to prevent infection. Once an intra-ocular infection occurs, the prognosis is very poor and the eye is usually lost. Local antibiotic prophylaxis must be supplemented by oral or parenteral therapy. I mentioned that procaine penicillin combined with streptomycin, intramuscularly, is an effective prophylaxis in trauma to the eyelids and adnexa. It penetrates the eyeball poorly, however, and is not recommended for the prevention of intra-ocular infection following a perforating wound to the globe. As you know, the absorption of intramuscularly administered antibiotics is retarded and erratic in shock. This combination did not produce a satisfactory concentration in wounded tissues in Korea. Later in the war change was made to aqueous penicillin G, administered intravenously at the battalion aid station level, as soon after wounding as possible, in doses of 500,000 to 1,000,000 units every 8 to 12 hours depending upon the severity and multiplicity of injuries. Streptomycin 0.5 gram is given at the same time. This is excellent prophylactic therapy for a penetrating ocular wound.

In brief, after examining an injured eye, if the wound is external, a local sulfonamide should be applied and this may be supplemented by intramuscular penicillin. If the wound perforates the eyeball, a local antibiotic in solution form (not ointment) should be supplemented by massive doses of aqueous penicillin G with streptomycin intravenously. As most eye casualties also suffer from other injuries, this latter therapy will usually have already been administered.

Major Edwards has also recommended that the ophthalmologist be supplied with better instruments for diagnosis and treatment. Figures 1 and 2 show the small eye field chests which were available in World Wars I and II. They were totally inadequate and were the cause of much criticism by civilian ophthalmologists in the Army during the last war. In Korea there was no field chest available and the ophthalmologist had to use what he could obtain through normal supply channels. Many of them supplied their own instruments. I have been told that stones from the beaches have been used as orbital implants following enucleations in some instances because of the lack of proper plastic implants. The Ocular Research Unit here at Walter Reed gave a high priority to the development of a modern eye field chest during the Korean conflict. This chest (fig. 3) was given a field trial for a time during the last year of the war, and it is presently in the process of standardization. It contains all of the equipment, in miniature form, which is available in any well organized eye section. Much research was required to develop many of these items, which include a miniature slit lamp, a small hand electromagnet, a lightweight folding perimeter and fine eye-cutting instruments with changeable blades.


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FIGURE 1. World War I eye field chest.

There is also a modern set of implants to be used for enucleations, and a miniature refracting unit.

Major Edwards has also recommended the use of protective glasses to prevent eye wounds resulting from small particles. We have also been concerned with this serious problem. The Ocular Research Unit held numerous meetings attended by national experts in industrial ophthalmology; Army, Navy and Air Force specialists; and foreign scientists; in an attempt to recommend the proper protective device. The Surgeon General transmitted these findings to the Quartermaster Corps 6 months before the truce, over 11/2 years ago, recommending the trial of certain types of commercial industrial protective eyeglasses in Korea. To date we have not received any progress reports despite numerous inquiries.


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I shall not have time today to discuss the ocular conditions of repatriated American prisoners of war from Korea. Of the 148 released in Little Switch, 40, or 27 percent, suffered eye disabilities. In Operation Big Switch, 3,596 were released, with 93, or 2.6 percent, eye casualties. About 15 of these have been discharged as totally blind from ocular disease secondary to avitaminosis and malnutrition.

FIGURE 2. World War II eye field chest.

In conclusion, I should like to thank Major Edwards for his fine presentation and for the privilege of allowing me to discuss it. Great credit is due the young ophthalmologists who performed so well in Korea and kept the loss of eyes at a minimum figure.


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FIGURE 3. New eye field chest.