Ocular Injury

Treat a Casualty with an Ocular Injury

INTRODUCTION

It is common for individuals working in hazardous environments to sustain soft tissue injuries to the head. The delicate structures, such as the eye, demand the health-care provider be diligent in the care of injured and damaged sensory organs.

Anatomy and physiology of the eye and skull

Characteristics, structures and functions of the eye

(1) Characteristics

(a) Delicate organs adapted to provide vision

(b) Protected by skull, eyelids, eyelashes, and tears

(2) Structures and functions of the eye

(a) Sclera

(i) Tough layer (white of the eye) that protects inner layer of the eye

(ii) Connected to six muscles which allow the eye to look up, down, and side-to-side

(b) Conjunctiva

(i) It is the mucus membrane that lines the eyelid and extends from the eyelid to the front of the eyeball.

(ii) Covers the anterior portion of the sclera

(i) Inner layer

(ii) Contains rods and cones - the receptors of vision allowing us to see images

(iv) Rods - highly sensitive to light; receive only black and white images

(v) Cones - function in bright light; sensitive to three types of color: red, green, or blue; allow us to see color

(d) Cornea

(i) Tough, transparent, and colorless; covers the pupil and iris

(ii) Injuries may cause opacity and stop light rays from entering the eye

(e) Lens

(i) Circular structure filled with jelly-like substance

(ii) Adjusts to focus both near and far objects

(f) Iris

(i) Colored part of the eye

(ii) Located between the cornea and lens

(iii) Controls the amount of light entering the eye

(g) Pupil

(i) Circular opening in the iris

(ii) The window of the eye through which light passes to the lens and the retina

(h) Lacrimal glands (tear glands)

(i) Located in the upper-outer aspect of each eye

(ii) Secrets bactericidal enzyme and salts

(iii) Prevents infection and moistens the eye

(iv) Drain through ducts located in the eyelids

Assess and provide emergency medical care for an injury to the eye

Assessment of Ocular Trauma

Ocular trauma is classified as penetrating or nonpenetrating.

Trauma can lead to serious damage and loss of vision. Eye injuries are common in spite of protection of eye by the bony orbit.

(1) History/Physical Examination

(a) Mechanism of injury - blunt trauma vs. penetrating injury? Was there a projectile or missile injury? (glass from a motor vehicle accident) Thermal, chemical or laser burn?

(b) Does the patient wear glasses?

(d) Visual Acuity-Most important first step in evaluating extent of injury. Screen with any available printed material. If unable to read print, have the patient count your upraised fingers or distinguish between light and dark.

(2) Signs and Symptoms

(a) Eyelid or corneal foreign bodies-pain, tearing, redness

(b) Contusions and abrasions - swelling, redness, and impaired or double vision

(e) Chemical burns - redness, severe pain, and tearing

(f) Avulsions - eyelid or eyeball protrudes or is pulled from its socket

(g) Orbit fractures - Pain, double or decreased vision, swelling, bruising and eyes not moving together if entrapment occurs

(h) Eyelid lacerations- bruising, unequal eye movements

Emergency Medical Care for Ocular Trauma

(a) Eyelid or corneal foreign bodies (dust or dirt) – Irrigate the eye with copious amounts of water or IV solution. When irrigating the affected eye, turn the patient to the lateral recumbent position, as to not contaminate the unaffected eye. If the foreign body is embedded, cover the eye and evacuate the patient for further medical care.

(b) Contusions and abrasions - Irrigate the eye, cover both eyes and evacuate

(c) Puncture wounds - If there is no impaled object, cover the eye with a loose dressing. If impalement is present, stabilize with gauze rolls or folded gauze pads and protect with a cup. Do not remove impaled object and never try to replace eye in socket or extruded eyeball. Evacuate immediately.

(d) Chemical Burns – Irrigate the eye with copious amounts of water or IV solution for at least 20 minutes while en route to the hospital

(e) Avulsions - Shield and gently cup the eye pulled from its socket with folded moist 4 x 4s. Do not try to force the eye back into its socket. Cover with a loose, moist dressing.

(f) Orbital fractures - Patch the affected eye

(g) With ANY eye injury, cover both eyes, even if only one eye is injured. The eyes use sympathetic movement. When one eye moves, the other eye duplicates the movement.

(h) With both eyes covered, the patient needs assistance for all activities, so you will have to serve as his eyes, keeping him reassured and oriented

Treatment steps for an ocular impalement

1. Stabilize the object. Place a roll of 3-inch gauze bandage or folded 4 X 4s on either side of the object, along the vertical axis of the head in a manner that will stabilize the object

2. Fit a disposable paper drinking cup or paper cone over the impaled object (In a field setting it is unlikely that a cup will be readily available. You will have to improvise using the underlying concept of object stabilization) and allow it to come to rest on the dressing roll. Do not allow it to touch the object. This will offer rigid protection and will call attention to the patient’s problem. (DO NOT use a Styrofoam cup, which will flake.)

3. Have another soldier stabilize the dressings and cup while you secure them in place with self-adherent roller bandage or with a wrapping of gauze. Do not secure the bandage on top of the cup.

4. The uninjured should be dressed and bandaged to reduce sympathetic eye movements

5. Provide oxygen and care for shock

6. Continue to reassure the patient and provide emotional support

SUMMARY

The soldier medic must understand that the emergency treatment for injuries of the eye may be disabling if not treated promptly, properly, and efficiently.