14.1

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.

Triage 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.
14.2

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).
14.3

Ocular Injuries

 Schedule an urgent (within 24–48 h) referral to an ophthalmologist.

 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.
14.4

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.
14.5

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.
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Emergency War Surgery

ο Patching and use of topical anesthetics for pain control

are contraindicated (see pain control measures above).

ο Expedited referral to an ophthalmologist within 3–5 days

unless patient is not improving within 48 hours. Infection

may worsen, leading to permanent injury.

Conjunctival and Corneal Foreign Bodies

 Diagnosis.

ο Abrupt onset of discomfort and/or history of suspected

foreign body.

ο If an open globe is suspect, treat as discussed above.

ο Definitive diagnosis requires visualization of the offending

object, which may sometimes be quite difficult.

♦ A hand-held magnifying lens or pair of reading glasses

will provide magnification to aid in the visualization

of the foreign body.

♦ Stain the eye with fluorescein to check for a corneal

abrasion.

ο The casualty may be able to help with localization if asked

to indicate the perceived location of the foreign body prior

to instillation of topical anesthesia.

ο Eyelid eversion with a cotton-tipped applicator helps the

examiner identify foreign bodies located on the upper

tarsal plate.

 Treatment.

ο Superficial conjunctival or corneal foreign bodies may be

irrigated away or removed with a moistened sterile swab

under topical anesthesia.

ο Objects adherent to the cornea may be removed with a

spud or a sterile 22-gauge hypodermic needle mounted

on a tuberculin syringe (hold the needle tangential to the

eye).

ο If no foreign body is visualized, but the index of suspicion

is high, vigorous irrigation with artificial tears or sweeps

of the conjunctival fornices with a moistened cotton-tipped

applicator after topical anesthesia may be successful in

removing the foreign body.

ο If an epithelial defect is present after removal of the foreign

body, treat as discussed above for a corneal abrasion.
14.7

Ocular Injuries

Hyphema: Blood in the Anterior Chamber

 Treatment (to prevent vision loss from increased intraocular

pressure).

ο Be alert for a possible open globe and treat for that

condition if suspected.

ο Avoidance of rebleeds is a major goal of management.

♦ Avoid aspirin or nonsteroidal antiinflammatory drugs

(NSAID).

♦ No strenuous activity (bedrest) for 14 days.

♦ No reading for 7 days.

ο Prednisolone 1% drops 4 times a day.

ο Scopolamine 0.25% drops twice a day.

ο Cover eye with protective shield.

ο Elevate head of bed to promote settling of red blood cells

(RBC) in anterior chamber.

ο Provide a 24–48 hour referral to an ophthalmologist to

monitor for increased intraocular pressure (which may

cause permanent injury to the optic nerve) and to evaluate

for an associated open globe.

ο If evaluation by an ophthalmologist is delayed (> 24 hrs),

treat with a topical B-blocker (timolol or levobunolol) bid

to help prevent intraocular pressure elevation.

ο If intraocular pressure is found to be markedly elevated

(above 30 mm Hg) with a tonopen or other portable

tonometry device, other options for lowering intraocular

pressure include acetazolamide 500 mg PO or IV and

mannitol 1–2 g/kg IV over 45 minutes.

Retrobulbar (Orbital) Hemorrhage

 Keys to recognition: Severe eye pain, proptosis, vision loss,

decreased eye movement.

ο Marked lid edema may make the proptosis difficult to

appreciate.

ο Failure to recognize may result in blindness from increased

ocular pressure.

 Perform an immediate lateral canthotomy.

 Provide an urgent referral to an ophthalmologist, within 24–

48 hours.
14.8

Emergency War Surgery

 If evaluation by an ophthalmologist is delayed (>24 hrs), treat

with a topical B-blocker (timolol) bid to help lower intraocular

pressure elevation.

 If intraocular pressure is found to be elevated (>30 mm Hg),

treat as discussed above.

Lateral Canthotomy/Cantholysis

Do not perform such procedures if the eyeball structure has been

violated. If the eye is sliced open, apply a Fox shield for

protection and seek immediate ophthalmic surgical support.

 Inject 2% lidocaine with 1:100,000 epinephrine into the lateral

canthus (Fig. 14-1a).

 Crush the lateral canthus with a straight hemostat, advancing

the jaws to the lateral fornix (Fig. 14-1b).

 Using straight scissors make a 1-cm long horizontal incision

of the later canthal tendon, in the middle of the crush mark

(Fig. 14-1c).

 Grasp the lower eyelid with large toothed forceps pulling

the eyelid away from the face. This pulls the inferior crus

(band of the lateral canthal tendon) tight so it can be easily

cut loose from the orbital rim (Fig.14-1d).

ο Use blunt tipped scissors to cut the inferior crus.

ο Keep the scissors parallel (flat) to the face with the tips

pointing toward the chin.

ο Place the inner blade just anterior to the conjunctiva and

the outer blade just deep to the skin.

ο The eyelid should pull freely away from the face, releasing

pressure on the globe.

ο Cut residual lateral attachments of the lower eyelid if it

does not move freely.

ο Do not worry about cutting 1

/2 cm of conjunctiva or skin.

ο The lower eyelid is cut, relieving orbital pressure. If the

intact cornea is exposed, apply, hourly, copious

erythromycin ophthalmic ointment or ophthalmic

lubricant ointment to prevent devastating corneal

dessication and infection. Relief of orbital pressure must

be followed by lubricating protection of the cornea and

urgent ophthalmic surgical support. Do NOT apply

absorbent gauze dressings to the exposed cornea.
14.9

Ocular Injuries

Orbital Floor (Blowout) Fractures

These fractures are usually the result of a blunt injury to the

globe or orbital rim, often associated with head and spine

injuries. Blowout fractures may be suspected on the basis of

enophthalmos, diplopia, decreased ocular motility, hypoesthesia

of the V2 branch of the trigeminal nerve, associated subconjunctival hemorrhage, or hyphema. Immediate treatment

includes pseudoephedrine 60 mg q 6 hours and a broada

b

c

d

e

Fig. 14-1. Lateral canthotomy and inferior cantholysis are indicated

for casualties presenting with serious orbital hemorrhage.
14.10

Emergency War Surgery

spectrum antibiotic for 7 days, ice packs, and instructing the

casualty not to blow his nose. Definitive diagnosis requires CT

scan of orbits with axial and coronal views. Indications for repair

include severe enophthalmos and diplopia in the primary or

reading gaze positions. The surgery may be performed 1–2

weeks after the injury.

Lid Lacerations

Treatment guidelines for lid lacerations not involving the

lid margin

 Excellent blood supply — delayed primary closure is not

necessary.

 Eyelid function (protecting the globe) is the primary

consideration.

 Begin with irrigation, antisepsis (any topical solution), and a

check for retained foreign bodies.

 Superficial lacerations of the eyelid, not involving the eyelid

margin, may be closed with running or interrupted 6-0 silk

(preferred) or nylon sutures.

 Horizontal lacerations should include the orbicular muscle

and skin in the repair.

 If skin is missing, an advancement flap may be created to fill

in the defect. For vertical or stellate lacerations, use traction

sutures in the eyelid margin for 7–10 days.

 Antibiotic ointments qid.

 Skin sutures may be removed in 5 days.

Treatment guidelines for lid lacerations involving the lid margin

 Repair of a marginal lower-eyelid laceration with less than

25% tissue loss (Fig. 14-2).

ο The irregular laceration edges may be freshened by

creating a pentagonal wedge — remove as little tissue as

possible (Fig. 14-2b).

ο A 4-0 silk or nylon suture is placed in the eyelid margin

(through the meibomian gland orifices 2 mm from the

wound edges and 2 mm deep) and is tied in a slipknot.

Symmetric suture placement is critical to obtain post-op

eyelid margin alignment (Fig. 14-2c).
14.11

Ocular Injuries

ο The slipknot is loosened and approximately two or three

absorbable (Vicryl or gut) 5-0 or 6-0 sutures are placed

internally to approximate the tarsal plate. The skin and

conjunctiva should not be included in this internal closure

(Fig. 14-2d).

a

d

b

c

e

f

g

h

Fig. 14-2. Lid margin repair.
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Emergency War Surgery

ο Anterior and posterior marginal sutures (6-0 silk or nylon)

are placed in the eyelid margin just in front and behind

the previously placed 4-0 suture (Fig. 14-2e).

ο The middle and posterior sutures are left long and tied

under the anterior suture. Ensure that the wound edges

are everted (Fig. 14-2f).

ο The skin is closed with 6-0 silk or nylon sutures. The lid is

placed on traction for at least 5 days. The skin sutures are

removed at 3–5 days and the marginal sutures are removed

at 10–14 days (Fig. 14-2g).

Additional Points in Lid Laceration Repair

 Tissue loss greater than 25% will require a flap or graft.

 If there is orbital fat in the wound or if ptosis is noted in an

upper lid laceration, damage to the orbital septum and the

levator aponeurosis should be suspected.

 If the eyelid is avulsed, the missing tissue should be retrieved,

wrapped in moistened Telfa, and preserved on ice. The tissue

should be soaked in a dilute antibiotic solution prior to

reattachment. If necrosis is present, minimal debridement

should occur in order to prevent further tissue loss. The

avulsed tissue should be secured in the anatomically correct

position in the manner described for lid margin repair above.

ο Damage to the canalicular system can occur as a result of

injuries to the medial aspect of the lid margins. Suspected

canalicular injuries should be repaired by an ophthalmologist to prevent subsequent problems with tear

drainage. This repair can be delayed for up to 24 hours.

Laser Eye Injuries

 Battlefield lasers may be designed to cause eye injuries or

may be part of other weapons or sensor systems.

 Prevention is the best option! Wear eye protection designed

for the appropriate light wavelengths if there is a known laser

threat.

 The type of ocular damage depends on the wavelength of

the laser — retinal injuries are most common.
14.13

Ocular Injuries

 The primary symptom of laser injury is loss of vision, which

may be preceded by seeing a flash of light. Pain may not be

present.

 Immediate treatment of corneal laser burns is similar to that

for corneal abrasions.

 Laser retinal burns have no proven immediate treatment,

although improvement with corticosteroids has been

reported.

 Routine evacuation for evaluation by an ophthalmologist is

required.

Enucleation

A general surgeon in a forward unit should not remove a

traumatized eye unless the globe is completely disorganized.

Enucleation should only be considered if the patient has a very

severe injury, no light perception using the brightest light source

available, and is not able to be evacuated to a facility with an

ophthalmologist. Sympathetic ophthalmia is a condition that

may result in loss of vision in the fellow eye if a severely

traumatized, nonseeing eye is not removed, but it rarely

develops prior to 21 days after an injury. Delaying the

enucleation until the patient can see an ophthalmologist is

thus relatively safe.
14.14

Emergency War Surgery