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 generalmedical officers who have to deal with them in forward echelons In thisdiscussion I shall present what we have found in Korea to be the most satisfactorymethods of handling these casualties, both from the medical and the militarystandpoints.
The seriousness of the problem is mainly due to the severity of theinjuries and their likelihood to result in permanent and grave disabilities.The number of eye casualties has been only about 5 percent of the totalinjured in both World Wars and Korea, but in Korea alone, 1,071 soldierssuffered 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 muchof the time, both in offense and in defense. The skull above them is protectedagainst small missiles by the helmet, but the eyes'only protection is theirlocation in the bony orbit and the winking reflex of the lids which isnot 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) chemicalor (b) thermal.
a. Chemical. In Korea the most frequent offenders were batteryacids, lye used in cleaning solutions, and brake fluid (fig. 1). The damagedone by chemical agents depends not only on the amount and concentrationbut also on the length of time in which they are able to act. This is particularlytrue of alkalis where the end product, in itself, is strongly alkaline.It is, therefore, imperative that all chemicals spilled in the eye be washedout immediately with whatever water may be available. It happens, unfortunately,all too often that patients are brought in to medical installations severalminutes 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.
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though local source of water was available. This indoctrination shouldbe done in basic training and repeated as often as may be necessary. Thepain which occurs with burns and with trauma in general is in a large partdue to a reflex spasm of the ciliary bodies and the iris which can be relievedby the use of mydriatic drugs such as homatropine, scopolamine and atropine.These drugs should be used along with local antibiotic agents of whichsulfacetamide and bacitracin ointments are the safest and most effective.
A special type of burn is due to phosphorus. In this, the treatmentconsists of thorough débridement of all phosphorus particles andneutralization of any remaining fragments with copper sulfate. Two percentcopper sulfate is used, then washed out with saline. The hazards of coppersulfate are well recognized, yet the penalty for failure to remove allphosphorus 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 fortunatelyseldom serious because of the excellent protective mechanism provided bythe closing of the lids. Third degree burns of the lids, however, are verydisfiguring and disabling if not properly cared for. This is due to thecontracting scars separating or everting the lids (fig. 2). This lack ofprotection to the eye may ultimately result in drying, then infection withloss of sight or even loss of the entire eye. Therefore, it is emphasizedthat even small third degree or questionable third de-
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gree burns of the eyelid be treated by prompt tarsorrhaphy. This shouldbe accomplished as early as possible and certainly within the first 72hours even at installations not giving definitive eye care. As a temporarymeasure, a simple suture connecting the marginal surfaces of the lids willsuffice. This can be improved upon by making a shallow incision in eachlid in the gray line which lies between the row of lashes and the openingsof the Meibomian glands and suturing the marginal
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surfaces together. The resulting scar tissue will yield a firm closurewhich can later be released with ease.
2. Contusions. Contusions encountered in Korea came from twosources: from accidental injuries such as those caused by fists, automobileaccidents and rifle barrels, and from combat injuries such as those frommines, 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 edemaof the retina manifested by a great increase in shiny light reflexes. Allbut the most minor contusions should be treated by binocular bandages andevacuation as litter patients to an ophthalmologist because of internalhemorrhages and the ever-present danger of retinal detachment. In thislatter condition, the retina separates from the underlying choroid fromwhich it receives nourishment. The detached portion dies within a few daysto few weeks if it is not re-attached by absolute bed rest and surgery.The surgery consists of electrocoagulation through the sclera with productionof scar tissue. In Korea we encountered five patients with retinal detachment.Mydriatics should be avoided in contusions particularly in the presenceof intraocular hemorrhages as they occasionally result in delayed massivehemorrhages.
3. Abrasions. The most common cause for abrasions was brushingagainst branches of trees and shrubs and accidentally scratching with fingernails.Oue patient's eye, however, was abraded by a missile, 10
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x12 x12 mm. in size, which skimmed the cornea and imbedded itself intothe nose. The treatment of abrasions should consist of placing the eyeat rest with aid of binocular bandages, mydriatics and antibiotics. Thelocal antibiotic of choice again is sulfacetamide or bacitracin.
4. Penetrating Wounds. Penetrating wounds comprise the largestand 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 |
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The simplest type are the superficial conjunctival and corneal foreignbodies. With care and a few simple instruments, these can be removed bygeneral medical officers. Examination is best done by using oblique illumination,even with a good flashlight. The upper lid can be everted by having thepatient look down, grasping the eyelashes and pulling them forward, thenpressing the skin above the tarsus downward. Foreign bodies of the conjunctivacan be removed with a cotton-tipped applicator stick.
Foreign bodies of the cornea require pontocaine (1/2percent) anesthetic, a fine-tipped Bard-Parker blade or a hypodermic needleand a magnifying lens or a loupe. The tip of the knife is placed beneaththe edge of the foreign body and it is flicked upward. This is repeateduntil the particle is lifted out. When a foreign body has been in the eyefor many hours, there is apt to be a rust-colored ring around it. Thistissue reaction is also irritating and it is removed by the same way asthe foreign body itself. Removal must be followed by antibiotic ointmentsuch as sulfacetamide or bacitracin and mydriatics, preferably 0.25 percentscopolamine. Atropine effect lasts 1 to 3 weeks resulting in too prolongedinterference with visual efficiency; therefore, it has no place in treatingminor injuries. Carelessness and excessive manipulation, such as repeatedattempts with cotton swabs, sometimes result in infection as shown in figure4, with grave damage to the eye. The prolonged use of anesthetic ointmentsshould be avoided as they inhibit healing and enhance the progress of infectionby paralyzing the corneal nerves.
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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 irisand lens, or those of the posterior segment involving wounds through thesclera into the vitreous. In these, the wound of entry is often not evident,but posterior segment injuries should always be suspected in injuries ofthe lid. Deep anterior chamber usually denotes severe injury. With high-speedmissiles, total fragmentation of the eye is often encountered. In someof these, such as seen in figure 6, one has considerable difficulty infinding the various
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portions of the globe. Enucleation of such eyes can be made easier byfirst 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 prolongedperiods of time; others, especially copper-containing bodies, will producerapid and inevitable degeneration of the eye.
The responsibility for giving definitive care for these major woundsmust rest with the opthalmologist, as other physicians rarely have thenecessary instruments or experience. The treatment must begin as soon aspossible. The physiology of the eye depends greatly on maintenance of normalintraocular tension; therefore, early restoration of tension is of greatestimportance. Certain other processes such as formation of adhesions willalso be minimized by early definitive treatment. For this reason, earlyevacuation should be the principle at forward echelons. In order to placethe eye at rest, both eyes should be bandaged and the patient should beevacuated by litter. Mydriatics should not be used in these wounds becauseof occasional complications of hemorrhage and anterior synechiae. Antibioticssuch 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 primarilyany 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 lostultimately recovered some sight. Surgeons who know the technic of enucleationsbut are not experienced in repair of eye wounds are likely to be temptedto enucleate eyes which could be repaired by an ophthalmologist. Conservativesurgery is especially important in bilateral injuries.
During my 16 months of service in Korea we performed the following majoroperations 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 anddepends on competent use of x-rays. In the presence of various types ofinjuries and because of the patients' general condition, movements mustbe kept at a minimum in order to obtain good x-rays.
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It has been the general experience that x-rays taken at forward installationsrarely gave the opthalmologist all the information necessary, resultingin the necessity of exposing the patient to double manipulation. It istherefore most strongly advised that x-rays should not be taken at forwardinstallations for localization, but only at the place of definitive treatment.
We had considerable success with stereo x-rays in localizing foreignbodies. The various more accurate methods of localization commonly usedin the United States were not very feasible because of the variabilityof the power supply, the x-ray equipment, the poor cooperation of the patientsand the presence of open wounds of the eye.
The stereo technic is also particularly suited to localization of multipleforeign bodies which are apt to be very confusing to other views. The routineview was the stereo-Waters view; i. e., chin and nose on the plate. Forstereoscope, two prisms from an eye trial lens set were mounted to tonguedepressors 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 | ----- |
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Sympathetic ophthalmia, fortunately, does not pose the same problemthat was encountered in the Civil War and the Spanish-American War. Theseinstances were reduced to about 30 cases in both sides of the entire FirstWorld War, very few in the Second World War and I have not yet heard ofone in Korea. With the advent of cortisone and with prolonged competentobservation, eyes do not have to be primarily sacrificed because of possibilityof sympathetic ophthalmia.
Military Aspects. During the Second World War, there was a relativeshortage 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, theyfound that patients fared better if definitive surgery was not done bygeneral surgeons in forward areas but by ophthalmologists farther in therear. In Korea the situation was different: The
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area was smaller, the lines of evacuation congregated at a more forwardpoint which was relatively safe from attack, and both rapid and lateralevacuations were made possible by helicopters and Air Force evacuationplanes. The type of injuries was also different as the mine and grenadewounds 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 TokyoArmy Hospital and some at a hospital ship in Pusan. The time elapsed betweeninjury and arrival at Tokyo was often in excess of 24 hours. We found thatthe patients operated on by an ophthalmologist aboard the ship arrivedin better condition at Tokyo than those who came directly, thus indicatingthe need for earlier surgery. For this reason, ophthalmologists were pushedforward into evacuation hospitals in Korea. Thereafter, definitive treatmentcould be given in 6 to 18 hours from even the most distant portions ofthe front line. In the opinion of everyone, the end-results justified thissystem.
Thus, in the light of the experience in both wars, it is recommendedthat ophthalmologists be placed as far forward as possible, depending ontheir availability, to enable preoperative time lags of less than 12 to18 hours.
Concomitant Injuries. Attention is invited particularly to the32 eye injuries which were seen in conjunction with neurosurgical injuriesand 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 |
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As these injuries also require specially trained and equipped personnel,this high proportion of coexisting wounds points to the advisability ofplacing an ophthalmologist, a maxillofacial surgeon and neurosurgeons inthe same hospital.
In Korea this was achieved by the addition of a neurosurgical team toan evacuation hospital. Later, however, this excellent arrangement wasdisrupted and the neurosurgical team was moved forward to a MASH, 40 minuteshelicopter travel time away. This entailed frequent trips to the MASH tooperate on combined casualties. Except for the fortunate coincidence thatthe ENT surgeon was also a trained ophthalmologist, this system would haveresulted in serious damage.
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When a second neurosurgical team was sent to the east coast, an ophthalmologistwas sent with them. In view of the great number of combined injuries, ophthalmologistsshould be placed in hospitals providing treatment of all wounds, includingneurosurgical and maxillofacial injuries.
The advice of consultants was given great weight in matters of assigningpersonnel as well as of maintaining high caliber of medical care. Thissystem worked out very well in Korea and it should be continued in thefuture.
The number of ophthalmologists needed in combat is one Board-qualifiedor Board-certified man and one slightly lesser trained man for each twocorps. These lesser trained men, however, must spend some time with anophthalmologist who is experienced in traumatic surgery prior to beingassigned to a hospital of their own. This estimate, however, assumes goodevacuation facilities.
The equipment available to ophthalmologists in Korea was greatly dependenton resourcefulness of the ophthalmologist and on the power given the FarEast Consultant in recommending supplies. In many instances we were hamperedby lack of equipment and at times found sorely needed equipment in hospitalslacking ophthalmologists. These difficulties can be avoided in anotherconflict by issuing to each qualified ophthalmologist his own equipment.A compact kit is currently being developed by the Ophthalmic Research Unitat Walter Reed Army Hospital.
Prevention. When one observes these casualties, one is struckby the large number of eyes lost because of tiny missiles. I also had theprivilege of seeing soldiers whose eyes were protected by their glasseswhen their face was peppered by small particles. I feel that commercialsafety 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 ofimpact, 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 Lossof 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 |
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None | 22 | ----- |
Unknown | 46 | ----- |
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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 totallyunacceptable to the troops. Safety glasses, however, like body armor, wouldsoon find acceptance.
Glasses were provided by having a refractionist and an optician witheach division issuing 80 to 120 glasses a month. At corps level there wasan optical repair truck which supplied 1,000 to 1,400 pairs of glassesper month and there was a base depot at Pusan. At the 121st EvacuationHospital, an optometrist and I refracted the eyes of 500 to 700 soldiersper mouth. This system enabled a 24-hour service on almost all glasses.It is most advantageous to have such a system of procurement in forwardechelons as this minimized time lost from the organizations. Although theprescription for glasses is supposed to be recorded on the immunizationrecords, these were often not available to the optician or did not containthe prescription.
Summary
In summary, the Korean conflict taught us the following important lessonsregarding 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 patientsarrive in less than 12 to 18 hours after injury.
4. Such hospitals should also have an ENT surgeon and neurosurgeonsin 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.
