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 ofthe management of eye casualties in Korea. The fact that many eyes weresaved and much total blindness was prevented attests to the soundness ofthe principles of treatment which were outlined for you today. My experiencein treating these patients from Korea begins farther back in the chainof evacuation-at Tripler Army Hospital in Honolulu-and at the final pointof evacuation for many, the eye center here at Walter Reed Army Hospital.
Major Edwards has summarized the important lessons which were learnedin Korea regarding the care of eye injuries. Many of these lessons werelearned in World War II and because of excellent teaching by our predecessorswere well applied in Korea. Other mistakes obvious in the last war wererepeated in Korea. These were notably the lack of an adequate field chestfor the ophthalmologist and the total absence of any protective deviceto prevent eye injuries. It was well established in Korea that ophthalmologistscan and should be assigned to forward installations to render treatmentto eye casualties as soon as possible. Rapid evacuation especially by helicopterand airplane has been a major advance in the conservation of vision.
It was also well established in the last war that the timeworn prioritiesof war surgery-the saving of life and limb-were superseded by a more realisticapproach-the saving of life, vision, and limb. A few of you mayargue that it is better to die than to be blinded, but I am sure none willdisagree that it is better to lose a limb than one's eyesight. If the sametrauma which causes a minor injury elsewhere to the body involves the eye,a serious handicap results. It incapacitates a soldier in battle and maynecessitate evacuation to the Zone of Interior. A survey of eye woundsin Korea by The Surgeon General's Office in 1951 revealed that 81 percentrequired evacuation to the United States. The majority (some 85 percent)of those injured in other areas of the body were returned to duty. Whenone hears the figures of about 5 percent of all battle casualtiesinvolving 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 millionsof 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 yourminds, "Just what should the general surgeon or medical officerdo when he is faced with an eye casualty?" In a talk which I presentedseveral years ago before a national society, I concluded with the statementthat "the Army ophthalmologist will gain much experience as a resultof the Korean conflict, fully realizing, however, that wars do not teachus what to do, but rather what not to do." I am sure that this statementholds true for every medical officer.
The Committee on Trauma of the American College of Surgeons has recentlypublished its policies regarding the treatment of acute injuriesof the eye. It feels that the early care of ocular injuries by nonophthalmicpersonnel should be limited to absolutely essential first aid, and thereafter,to refraining from doing harm. The most trivial eye wound may result intotal loss of vision, and therefore, they state that every injury of theeye is potentially serious. The Army has long recognized this and labelsa high priority for evacuation of eye casualties. The eye damage must becarefully assessed, as improper examination may result in the total expulsionof the ocular contents through a small and perhaps unrecognized wound.The operation of enucleation is never an emergency procedure, and it shouldbe reserved for the ophthalmologist. It is the most final of alleye operations just as the amputation is for wounds of the extremities.The only criticism a general surgeon can receive in treating wounds ofthe eyes is in doing too much-never, too little.
Major Edwards has mentioned the fact that most eye wounds are accompaniedby other injuries. It is the surgeon's responsibility not to overlook seriousdamage to the eyes by directing exclusive attention to other major wounds.The primary operation upon an eye is usually the definitive one and thesurgeon seldom has a second chance. This responsibility should thereforebe placed upon the eye surgeon who is charged with definitive care. Thecomplete examination which is necessary before surgery demands specializedequipment; this equipment and the small delicate instruments which arerequired for ocular surgery are not usually available to the general surgeon.
After examining the patient's eyes the medical officer should makecareful notes of his findings. These will be of great value later tothe ophthalmologist. The patient should then be evacuated as soon
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as possible, preferably in a smooth-riding helicopter rather than anambulance, as a litter patient with both eyes bandaged. The bandages areworthless and may be harmful unless they are firmly and tightly appliedto prevent any winking or motion of the eyelids. It is well to sedate thepatient to allay the fear and apprehension which usually follows coveringboth eyes. Opiates may be used unless, of course, they are contraindicatedin the presence of a head wound.
The next consideration in the emergency care of the eye casualty isthe prevention of infection. Minor trauma does not demand as vigorousmeasures as more serious injury. Overtreatment should be avoided and theindiscriminate use of antibiotics is to be condemned. There are many antisepticsand chemotherapeutic agents available for use as local bacteriostatic agentsfor minor trauma. Zephiran, furacin, metaphen, merthiolate and propionicacid may be employed. Boric acid, argyrol, silver nitrate, zinc sulfateand yellow oxide of mercury are not recommended as dependable inprophylaxis. Chemotherapeutic agents such as the sulfonamides are wellapplied following minor trauma. Antibiotics are unnecessary, and indeedmuch harm may result from their indiscriminate use ranging from local allergyto general sensitivity, and the development of bacterial resistance andcross-resistance, or superinfections.
In major extra-ocular trauma-which to me should include cornealabrasion in addition to severe lacerations of the lids, conjunctiva andadnexa-every effort is demanded to prevent infection. Antibiotics are usuallypreferred and they may be employed locally and systemically. Penicillinshould not be used locally as allergy is frequent and there are more organismsresistant to penicillin than to any other antibiotic. As you know, thisis variously estimated as 30 to 48 percent for Staphylococci, and Streptococcimay also be resistant. All antibiotics penetrate the intact cornea poorlyexcept for chloromycetin. Sodium sulfacetimide pentrates better than othersulfonamides. They all penetrate the abraded cornea well. The action ofointment is more prolonged than that of solutions; however, this vehicleis contraindicated in a perforating wound of the eyeball. Many authorsrecommend the local use of antibiotics (or combinations) which are unlikelyto enjoy widespread systemic use because of their toxicity, such as bacitracin,neomycin and polymyxin. We prefer the combination of terramycin and polymyxinwhich offers powerful antibacterial action against gram-positive and gram-negativeorganisms including Pseudomonas aeruginosa. This bacillus, the pyocyaneus,was common in Korea and is much feared by the oculist. It causes a fulminatinginfection 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 theeye is usually lost. Local antibiotic prophylaxis must be supplementedby oral or parenteral therapy. I mentioned that procaine penicillin combinedwith streptomycin, intramuscularly, is an effective prophylaxis in traumato the eyelids and adnexa. It penetrates the eyeball poorly, however, andis not recommended for the prevention of intra-ocular infection followinga perforating wound to the globe. As you know, the absorption of intramuscularlyadministered antibiotics is retarded and erratic in shock. This combinationdid not produce a satisfactory concentration in wounded tissues in Korea.Later in the war change was made to aqueous penicillin G, administeredintravenously at the battalion aid station level, as soon after woundingas possible, in doses of 500,000 to 1,000,000 units every 8 to 12 hoursdepending upon the severity and multiplicity of injuries. Streptomycin0.5 gram is given at the same time. This is excellent prophylactic therapyfor 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 intramuscularpenicillin. If the wound perforates the eyeball, a local antibiotic insolution form (not ointment) should be supplemented by massive doses ofaqueous penicillin G with streptomycin intravenously. As most eye casualtiesalso suffer from other injuries, this latter therapy will usually havealready been administered.
Major Edwards has also recommended that the ophthalmologist be suppliedwith better instruments for diagnosis and treatment. Figures 1 and 2 showthe 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 civilianophthalmologists in the Army during the last war. In Korea there was nofield chest available and the ophthalmologist had to use what he couldobtain through normal supply channels. Many of them supplied their owninstruments. I have been told that stones from the beaches have been usedas orbital implants following enucleations in some instances because ofthe lack of proper plastic implants. The Ocular Research Unit here at WalterReed gave a high priority to the development of a modern eye field chestduring the Korean conflict. This chest (fig. 3) was given a field trialfor a time during the last year of the war, and it is presently in theprocess of standardization. It contains all of the equipment, in miniatureform, which is available in any well organized eye section. Much researchwas required to develop many of these items, which include a miniatureslit lamp, a small hand electromagnet, a lightweight folding perimeterand fine eye-cutting instruments with changeable blades.
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FIGURE1. 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 toprevent eye wounds resulting from small particles. We have also been concernedwith this serious problem. The Ocular Research Unit held numerous meetingsattended by national experts in industrial ophthalmology; Army, Navy andAir Force specialists; and foreign scientists; in an attempt to recommendthe proper protective device. The Surgeon General transmitted these findingsto the Quartermaster Corps 6 months before the truce, over 11/2years ago, recommending the trial of certain types of commercial industrialprotective eyeglasses in Korea. To date we have not received any progressreports despite numerous inquiries.
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I shall not have time today to discuss the ocular conditions of repatriatedAmerican 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 15of these have been discharged as totally blind from ocular disease secondaryto avitaminosis and malnutrition.
FIGURE2. World War II eye field chest.
In conclusion, I should like to thank Major Edwards for his fine presentationand for the privilege of allowing me to discuss it. Great credit is duethe young ophthalmologists who performed so well in Korea and kept theloss of eyes at a minimum figure.
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FIGURE3. New eye field chest.
