Morohunranti O. Oguntoye
Battalion Flight Surgeon, 1-501 Attack Reconnaissance Battalion, Jalalabad, Afghanistan 2012
BLUF Box (Bottom Line Up Front)
- 1.
If there is head trauma, there is likely eye trauma. If there is eye trauma, there is likely head trauma.
- 2.
Do not explore, irrigate, or debride a suspected open globe. If an open globe is suspected, place a shield on the eye and get them to the nearest ophthalmologist. Shield and ship.
- 3.
There is never a reason to patch an eye in an emergency.
- 4.
Do not attempt open globe repair.
- 5.
There is rarely a reason for emergency enucleation.
- 6.
Always avoid putting pressure on the globe, including an ultrasound probe.
- 7.
A firm, proptotic globe is a surgical emergency, requiring immediate treatment with a lateral canthotomy and cantholysis.
- 8.
A chemical injury is an ocular emergency requiring immediate copious irrigation to neutralize.
“Of all the senses, sight must be the most delightful.”Helen Keller
Life, Limb, and Eyesight
You are the trauma surgeon for a CSH and you are patting yourself on the back for having effectively managed and evacuated the five soldiers injured in the most recent IED blast. As you walk back to your hooch, you go back over the injuries encountered today: massive head wound, pneumothorax, open abdomen, and traumatic leg amputation. Your team managed each of these injuries like a well-oiled machine, honed by months in the desert. It is a fair bet that at least one of your patients had an eye injury . It is also a fair bet that you probably missed it.
Eye injuries are common but often unrecognized on the battlefield, with ocular injuries being the fourth most common injury during Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OI F). The incidence of eye injuries has increased with every conflict, from 0.5% in the American Civil War to 13% during Operation Desert Shield/Desert Storm. The implementation of the mandatory use of polycarbonate antiballistic eye protection (“eye pro”) has had a significant impact, dropping the incidence of eye injury to 6% from OIF/OEF. Nevertheless, eye injuries still occur, and, even when the eye injury is obvious, it is often managed incorrectly. A retrospective review of eye injuries in Afghanistan found only 39% of eye injuries were shielded (including 0% of avulsed eyes or those with orbit penetration), and only 20% of those that were shielded were shielded correctly, resulting in only 4% of eye injuries being treated properly (96% failure).
Eye injury is often missed because of its association with more attention-getting trauma. In one review, 85% of combat ocular trauma had other systemic injuries, the most common being traumatic brain injury (TBI) (66%), followed by facial injury (58%), extremity injury (44%), traumatic limb amputation (12%), abdominal injury (8%), thorax injury (7%), and pelvic injury (4%). While all of these injuries are significant and require treatment, it is at this point the phrase “life, limb, and eyesight” is invoked to remind you of the importance of the eyes in caring for the trauma patient.
The Basics: Anatomy
The eyes occupy 0.1% of the total body surface area but comprise up to 13% of battlefield injuries. The eye is the brain and is notoriously unforgiving of injury and error. Therefore, ocular injuries require prompt evaluation and attention by ophthalmologists with the proper equipment. The first responder’s role, then, is largely to prevent further damage while evacuating to the ophthalmic consultant. Understanding the anatomy of the eye is fundamentally important to understanding the different types of eye trauma and setting the foundation for further treatment.
The Basics: Examination
An eye examination should be quick but should rule out any need for emergent intervention. If possible, determine the mechanism of injury and if the patient was wearing eye protection.
The first diagnosis to make is whether the globe is open or closed. If the globe is open, there is very little you need to do in the way of an eye exam short of checking vision and shielding the eye, and you should skip to the section titled “Open Globe.” Signs of an open globe can be subtle but include a soft or irregular-appearing globe, an irregular or peaked pupil, hemorrhagic swelling of the conjunctiva (especially if 360°) preventing a view of the sclera, leakage of fluid seen upon staining with fluorescein (positive Seidel’s sign), hyphema (blood in the anterior chamber), a shallow or deep anterior chamber (when compared to the uninjured eye), decreased eye movement, foreign body tract, and severe vision loss (Fig. 29.1). Any laceration on any part of the lid/eye that should otherwise be protected by eye pro should raise the suspicion of an open globe. When in doubt, treat the injured eye as an open globe: shield it and ship the person to the ophthalmologist.
Fig. 29.1
Highly suspicious for open globe and should be treated as such: hemorrhagic swelling of the conjunctiva, periocular ecchymosis (mechanism), and limited extraocular motility
Once you have confirmed that the globe is closed, you can continue your eye exam. Each eye should be examined separately .
Visual Acuity
Documenting visual acuity is more than an academic exercise; it is the eye’s vital sign. It is the most accurate predictor of ocular injury severity as well as eventual outcome: the poorer the vision , the more severe the injury and the worse the outcome. Because many combat casualties are intubated close to the point of injury (POI), a rapid field evaluation of vision at the POI may be the only vision documented preoperatively. It does not take sophisticated equipment to perform: a Snellen chart, a handheld vision card, even determining if they can simply identify a badge, rank insignia, or uniform name tape at a certain distance gives valuable information about the patient’s vision . You should check each eye separately and get the best visual acuity possible. The ability to discern any form of typeface is better than not being able to. Start with the Snellen chart, a handheld vision card, or any kind of printed text (including uniform name tapes). The smaller the font discerned, the better the prognosis. If the patient is not able to see “the big E” at the top of the chart or cannot read any size of text, this is not the end of the vision exam. Can they see how many fingers you are holding up? Visual acuity is count fingers (CF). Can they see you waving your hand? Visual acuity is hand motion (HM). Can they see a penlight shined into the eye? Visual acuity is light perception (LP). If they cannot see any light at all, the visual acuity is no light perception (NLP). Noting these visual acuities and at what distance (e.g., “hand motion at 2 feet”) provides a wealth of information to the ophthalmologist receiving this patient. It also gives an idea of urgency of evacuation: the worse the vision , the higher the priority. A patient with decreased vision should trump the fracture for the final seat on the outgoing flight.
Eyelids
Look for lacerations, particularly lacerations that may be full thickness and therefore indicate a globe injury. If the lids are tense, do not force them apart, but do gently retropulse the globe to determine if there may be a retrobulbar hemorrhage . In a retrobulbar hemorrhage , the lids may be open or closed, but they will be tense (see section “Retrobulbar Hemorrhage”). Look for foreign bodies in the fornices/inside of the eyelids. Look for singed lashes or chemical injuries to the lids that may indicate burns or chemical injuries to the eyes. Inspection of the eye itself should be very gentle. In the event swelling interferes with surface evaluation, you can fashion field expedient lid retractors from two paper clips to help separate the lids. Caution, however: use only very gentle force to elevate the lids and do not press on the globe or pull forcefully, as this may put dangerous pressure on the eye. Don’t force eyelids open. It is better to suspect a significant eye injury , shield the eye(s), and ship to the ophthalmologist.
Conjunctiva
Subconjunctival hemorrhage extending 360° around the cornea or extending posteriorly without a border is suspicious for an open globe and should be treated as such. White conjunctiva in an eye that has sustained chemical injury is equally concerning for extensive ischemic damage (see section “Chemical Injury”).
Globe
When possible, compare the injured eye to the non-injured eye. Look to see that the globe is well formed, not bulging forward or sunken in. If the globe is bulging forward, gently retropulse the eye and the fellow eye. If the injured eye has significantly more resistance to retropulsion, a retrobulbar hemorrhage should be suspected and requires immediate intervention (see section “Retrobulbar Hemorrhage”).
Extraocular Muscles
Have the patient look in the cardinal directions to ensure that the eyes move freely. If there is restriction to movement or the eye is sunken in, suspect an orbital fracture. Beware of the patient who becomes hypotensive, bradycardic, and/or nauseous when looking around—this could indicate a significant orbital fracture with muscle entrapment (causing an oculocardiac bradycardia/vagal reflex) requiring urgent ophthalmic or ENT intervention.
Cornea
Examine for obvious foreign bodies. The patient may be wearing contact lenses, which should be noted for later removal by the ophthalmologist. Do not attempt to remove them, as laser-assisted in situ keratomileusis (LASIK ) refractive surgery flaps can resemble contact lenses. A fluorescein exam with Wood’s lamp should show no evidence of uptake or leakage. If there is uptake, suspect an abrasion or laceration. If there is leakage or pooling of clear fluid (positive Seidel sign), this is an open globe (see section “Open Globe”).
Anterior Chamber
Examine for symmetric depth in the injured and uninjured eye. Look for pooling of blood in the anterior chamber (hyphema), which indicates significant intraocular damage. Look for foreign bodies in the anterior chamber, indicating an open globe.
Iris/Pupil
Look for reactivity to light. Look for irregularity of the pupil or the iris. If the pupil is peaked, look at the margins of the iris, as the iris will often be plugging a hole in the globe (Fig. 29.2).
Fig. 29.2
Open globe with peaked pupil. The peaked pupil points toward the corneal perforation, and the iris is plugging the wound. This eye should be treated as an open globe, a shield placed, intravenous antibiotics started, and the patient evacuated to the nearest ophthalmologist
Orbit
Check for lid and soft tissue crepitus, bony pain and step-offs, and facial deformities. Check for numbness on the cheek, teeth, or forehead which can indicate orbital wall/floor/roof fractures.
Open Globe
The good news is that, in the case of open globes, your first instinct when you see an eye injury is the correct one: cover it up and do not touch it. Do not irrigate, debride, excise, or reposit any tissue. You should obtain a visual acuity if possible, but do not force the lids open to do so. Do not attempt to measure the intraocular pressure (IOP) or do an ultrasound looking for foreign bodies (CT is better and you can’t do anything about them anyway. Leave the ultrasound to the ophthalmologist). Cover it properly with a shield (see Shield vs Patch) and get the patient to the nearest ophthalmologist. Open globes should ideally be repaired within 24 h.
If the patient is conscious, give antinausea medications with any narcotics to prevent Valsalva or vomiting. Avoid maneuvers that may cause gagging (e.g., placement of a nasogastric tube in an awake patient), Valsalva (e.g., patient moving himself from litter to litter), or coughing. Obtain imaging (preferably an axial face and orbit CT scan with coronal reconstructions) to rule out concomitant injuries or unidentified retained foreign bodies. Give intravenous antibiotics within 6 h of injury, ideally fourth-generation fluoroquinolones, as they have the best intraocular penetration. Scheduled systemic/intravenous antibiotics should be continued until the patient reaches definitive ophthalmic care . Do not apply topical medications or ointments. If necessary, give a tetanus shot. The acronym FART is useful in remembering the tenets of managing an open globe: Fox shield, Antibiotics/Analgesia, Radiographic imaging, and Tetanus shot.
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