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

Examination and Diagnosis

United States Department of Defense

As in any echeloned system of care, if the patient can communicate and combat conditions permit, an ocular examination should always begin by recording the circumstances of injury and the type of wounding agent. A penetrating ocular injury should be suspected in every wound of the eye and of the upper portion of the face until it is proved not to exist. The preliminary examination, should be conducted with the lids retracted, after loose foreign matter has been flushed out of the conjunctival sac with copious irrigations of plain water or physiologic salt solution or wiped out with a wet cottontipped applicator. Foreign bodies in contact with the eyeball should be removed from the lids. Since voluntary opening of the eyelids is often impossible, topical anesthesia (proparacaine hydrochloride 0.5%) and gentle lid separation with Desmarres retractors may be required for both vision testing and inspection. In the absence of available lid retractors, a pair of paperclips can be opened and bent into a curved blade configuration to serve as retractors, and any force required should be applied to the orbital bones, not the globe itself, The slightest pressure on the globe which has been lacerated or perforated may cause irretrievable loss of the vital contents.

Visual acuity, the most important parameter in evaluating the seriousness of the eye injury, should be recorded as follows: no light perception, light perception, perceives hand motions, counts fingers, or reads. In evaluating light perception, it is important to pass a very bright light alternately in front of and away from the eye. At the same time, the other eye must be completely shielded, and the patient must be questioned carefully to detect inaccurate responses. Spurious perception of light may result simply from the patient's natural desire to see, from an awareness of heat from the light, from a sensation of air movement on the skin produced by motion of the light source, or from incomplete shielding of the other eye. The other tests of visual acuity should be utilized with as much precision as circumstances permit.

It is imperative to inspect the anterior chamber of the eye with a bright light placed near the cornea and directed from the temporal to nasal side. A magnified view can be obtained by employing either a +18D refracting lens, or the high plus (black numbered) lenses on the ophthalmoscope. A marked deepening of the anterior chamber compared to the normal side, coupled with loss of the normal red reflex when the eye is illuminated and viewed in the axial direction, indicates the presence of a posterior segment penetrating injury which may be hidden and seemingly associated with only minor lid lacerations. These wounds may have actually perforated the lids and penetrated the globe. Additional findings on this inspection may include pupillary irregularities, blood within the anterior chamber (hyphema), shallowing, or even collapse of the anterior chamber, where loss of aqueous humor causes the iris to impinge directly against the posterior surface of the cornea. Lacerations of the eyelids, cornea, or sclera; foreign bodies within the eye or orbit; or disruption of the glove may be present. Gross contamination by dirt or other particulate matter frequently accompanies these injuries.

Corneal lacerations are usually evident by loss of the anterior chamber and distortion of the pupil. Iris incarceration or prolapse through the wound is common. Scleral lacerations often exhibit extruding, darkly pigmented choroid. However, small perforating wounds and even large scleral lacerations may be obscured by subconjunctival hemorrhage. More extensive prolapse of intraocular contents (vitreous humor, uvea, even lens and retina) may present within the lips of any laceration of the globe.

If the general appearance of the eye is undistorted and careful inspection reveals no site of ocular penetration, gross differences in intraocular tension may be estimated by very gentle digilal palpation. The tips of the index fingers are used in ballottement of the globes through the upper, closed eyelids. First, test the tone of the unaffected eye, and then compare with that of the injured eye Asymmetric tension is indicative of serious ocular injury to the softer eye.

Unless total disruption is evident, the possibility of salvaging the eye should be considered. This possibility exists even in the face of questionable light perception since vitreous hemorrhage alone may mask the perception of light. Since the advent of vitreous surgery, many eyes previously considered hopelessly damaged may now be salvaged. For this reason, the decision to enucleate any eye must be made by the most skilled specialist available. The principle goal of all others who manage the patient is to protect the eye from further damage.  

Approved for public release; Distribution is unlimited.

The listing of any non-Federal product in this CD is not an endorsement of the product itself, but simply an acknowledgement of the source. 

Operational Medicine 2001

Health Care in Military Settings

This web version is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

Contact Us  ·  ·  Other Brookside Products