Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXIV: Wounds and Injuries of the Eye

Management: Major Injuries: Division Area

United States Department of Defense

Division Area - The management of ophthalmic injury begins as far forward as possible Only first aid, including foreign body removal as previously discussed, is administered in these forward areas, and all significant casualties are evacuated to facilities where a physician is assigned. Early identification of ocular injury is an urgent matter. Serious eye injuries are second in priority of evacuation only to lifethreatening wounds. In severe injury to the globe, inadvertent delay in ophthalmologic care can mean the difference between salvage and loss of the eye.

Any abnormality in the appearance of the eye injured by blast or fragmentation weapons, or by severe blunt trauma, demands the following course of action preparatory to evacuation:

1. Instruct the patient not to squeeze his eyelids.

2. Do not remove any penetrating foreign body protruding from the globe or the conjunctival fornices, as ocular contents may be extruded.

3. Occlude both eyes, but avoid any pressure directly on the eyes. The battle dressing tied around the head suffices.

4. Give systemic analgesics for moderate to severe pain.

5. Evacuate immediately as a supine litter patient to a forward hospital, preferably with ophthalmology capability.

Where penetrating injury to the globe is suspected, the patient's eye can be protected from his own reflex lid squeezing by administration of a Nadbath block as follows: 1.0 cc of 2% xylocaine is injected using a 23 to 27 gauge needle no longer than 10mm. The area immediately behind the ear is palpated, and the needle is placed perpendicular to the anterior surface of the mastoid in the triangular space formed by the ear anteriorly, the mandible inferiorly, and the mastoid process posteriorly. The needle is advanced to the hub, delivering the anesthetic to the facial nerve as it exits the region of the stylomastoid foramen.

Ocular burns are usually first seen in the division area. Ultraviolet, thermal, and non-alkali chemical burns are treated as for corneal abrasions. However, non-alkali chemical burns require initial irrigation with tap water or saline solution for 10-15 minutes under topical anesthesia.

With white phosphorous burns of the eye, instillation of 0.5% copper sulfate solution identifies particles, which are otherwise presumptively located by foci of smoke or by darkening the particles. Larger particles may require removal with a needle or spud. The particles should be continuously irrigated to retard their further oxidation (reignition) and resultant tissue damage. These patients urgently require treatment by an ophthalmologist, in whose hands continuous irrigation with ophthalmic antibiotics in Ringer's solution may be performed by a percutaneous, indwelling, superior fornix angiocatheter, since severe edema of the lids often prevents the conventional administration of topical medication. Alkali burns may result from exposure to sodium hydroxide, lye, quick lime, ammonia, and agents often found in degreasing solvents. These burns represent an ocular emergency! Chemical penetration is so rapid that irrigation with copious volumes of water or sterile saline must be initiated within seconds. This irrigation must be continuous for at least 60 minutes. Irrigation ,should be continued until the pH remains below 8.0 for at least rive minutes after irrigation ceases. An alkali burn is potentially devastating and prognosis may be poor, especially if the cornea appears cloudy or the conjunctive blanched. Atropine sulfate 1% and chloramphenicol ointments should be applied 3-4 times a day. Phenylephrine, which will further constrict blood vessels and worsen limbal ischemia, should not be used. Steroid ointment should be used only in the most severe burns and only during the first three days, as its use later may promote stromal melting. In an effort to reduce erosion of the corneal stroma when evacuation must be delayed beyond three days, N-acetyl-L-cysteine (MUCOMYST) may be applied by dropper in a 20% solution as frequently as each hour. Prompt evacuation is necessary.  

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Operational Medicine 2001

Health Care in Military Settings

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