Ординатура / Офтальмология / Учебные материалы / Clinical Diagnosis and Management of ocular trauma

Management of Travel Eye Injuries

287

Cigarette smoke or outdoor air pollution can

3.

If you are a frequent flyer, avoid using high water

worsen allergy symptoms. To avoid excess air pollution

contact lenses because this type of lens dries and

when traveling by automobile, it is better to travel in

distorts easier. Materials such as silicone hydrogel

early morning or late evening, when the air quality

or rigid gas permeable lens may help.

is better and it is possible to avoid heavy traffic.

4. Contact lens care systems which

contain

Air quality on planes can greatly affect the allergic

moisturizing agents as HPMC and Propylene Glycol

patient. While all domestic flights are now smoke free,

can create a shield of moisture between the lens

many international flights are not. If traveling abroad,

and the eye, to ensure prolonged lubrication. For

allergic patients should make sure they are seated as

sensitive eyes, a hydrogen peroxide system may

far as possible from the smoking section when getting

help in reducing irritation.

a seat assignment.

5. Use lubrication drops during the flight. A lubricating

Many travelers stay at hotels. Hotel rooms,

eye drop containing sodium hyaluronate, has been

however, often contain large concentrations of dust

proven to effectively reduce dry eye symptoms.

mites and molds in carpeting, mattresses and

Use a preservative-free formula for sensitive or

upholstered furniture that can worsen allergy

allergy-prone eyes.

symptoms. Irritant fumes from cleaning products may

6. Carry a pair of spectacles with you. If dryness

also cause problems. When making hotel reservations,

persists, remove the lenses and wear the spectacles.

it is important to ask if there are allergy-proof rooms

7.

Under new flight security regulations, there are

available. If the patient is sensitive to molds, it is better

limitations on carrying liquid over 100 ml per

to request a sunny, dry room away from areas near

container in hand baggage. In this case, you can

indoor pools. Also, for those who have allergies to any

carry a contact lens case containing fresh multi-

animals, it is important to inquire about the hotel’s

purpose contact lens solution. If you experience

pet policy, and request a room that has been pet-free.

any discomfort, simply remove your lenses and

According to Aslam et al4, at the emergency

place them in the lens case.

department of the Chelsea and Westminster Hospital

8.

In desert, beaches and tropical countries it is very

in London, UK, 12% of the emergencies involving the

important to use sunglasses with U-V protection.

ocular surface are related to contact lens wearers. The

Make sure the label states that the lenses block 99

main environmental factor in pressurized cabins that

to 100 percent of both UVA and UVB rays. When

can affect eyes is low humidity.3 The optimum humidity

you are driving the sunlight can reflect from the

range for comfort is between 40% and 60%. However,

road pavement, or when you are shipping, the

cabin humidity may drop to 11% after takeoff. The

water like the snow in skiing, can burn the eyes

low cabin humidity during air travel increases aqueous

surface.

tear evaporation and can cause ocular discomfort such

DIRECT TRAUMATIC INJURIES

as dryness, especially for contact lens wearers. The

presence of a contact lens in the eye can produce a

In a study published in 1998 by the Flight Safety

condition called contact lens-induced dry eye (CLDE),

Foundation,5 there are an estimated 4,500 incidents

in an otherwise normal individual. Contact lenses may

of injuries from falling baggage each year in the U.S.

disrupt normal tear physiology through thinning and

and about 10,000 such events worldwide. Baggage

breakup of the tear film, interrupt tear film reformation

can emerge uncontrolled from overhead

and rupture the lipid layer with consequent increase

compartments if the contents shift in flight or if the

in tear film evaporation. The symptoms include

compartments were loaded beyond their capacity. This

grittiness, scratchy eyes, lens intolerance, and blurred

study was based on a survey of 462 falling baggage

vision. Therefore, contact lens wearers should know

events on the 757 aircraft of an unnamed major U.S.

preventive measures as follows:

airline. Of these 462 events, which occurred during

1. Beverages containing alcohol or caffeine and certain

the mid-1990s, a person was struck in 397 cases. In

medications can exacerbate dryness. If lenses are

those cases where a person was struck, there were 67

worn during air travel, avoid alcohol and coffee

injuries involving bruising, 53 injuries involving

consumption.

lacerations, and 277 cases resulting in no injuries. More

2. Lens deposits reduce lens wetting and increase tear

than 90 percent of the injury cases involved head

evaporation. Clean the lenses thoroughly before

injuries to aisle seat passengers.

the journey. If you are a disposable lens wearer,

In automobile trips we have to consider the air bag,

insert new fresh lenses. If you are a yearly

an inflatable device designed to decrease the morbidity

replacement lens wearer, use a protein remover

associated with high speed vehicle collisions. Front air

in addition to your normal lens cleaning regime

bags, for the driver and right-front passenger, mainly

before the journey.

provide protection against head contact with the

Management of Travel Eye Injuries

289

Conclusion

Eternal vigilance is the price of safety. The greatest

deterrent to ocular injury is educated awareness of

risk and careful avoidance procedures. Trauma, usually

needless, continues to be one of the major causes of

lost eyes. Automobile crashes continue to be one of

the most common causes of death from age 1 to 24

years. Males distinctly predominate in the statistics of

ocular injury and are increasingly represented in motor

vehicle crash. Proper and complete assessment of any

patient with ocular trauma is the basic prerequisite for

anatomical and visual rehabilitation of a patient with

Fig. 46.3: Operating microscope view of a corneal laceration

ocular trauma.

in the right eye of a 4-year-old boy after a lateral car crash.

There was a significant hyphema (iris details are obscured),

soft globe, expulsion of the lens and iris extrusion

References

that serious ocular injuries may result, although most

1.

Rappon JM. Ocular Trauma Management for the Primary

injuries heal without detrimental long-term effects.

Care Provider. In: www.opt.pacificu.edu. Accessed June

15, 2008.

However, there can be serious consequences if the

2.

White MF Jr, Morris R, Feist RM, Witherspoon CD, Helms

child is too close to the air bag when it deploys. The

HA Jr, John GR. Eye injury: Prevalence and prognosis

most serious injuries in these children were cataracts

by setting. South Med J 1989;82(2):151-8.

and glaucoma. Other injuries were blood in the front

3.

Wong Gunter.In: Leaving on a Jet PlaneTips for

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In:www.useronline.org. Accessed June 15, 2008.

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Aslam SA, Sheth HG, Vaughan AJ. Emergency manage-

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under the outer surface of the eyeball, corneal lesions

5.

Rozmaryn L. Head Injury risks from overhead luggage.

and abrasions, and iris inflammation. Figure 46.3

The AirSafe J 1999;13.

shows the right eye of a 4-year-old boy seriously

6.

Braver ER, Ferguson SA, Greene MA, Lund AK.

injured after a vehicle (Fiat Uno) lateral crash. The

Reductions in deaths in frontal crashes among right front

child was unbelted and seated in the rear of the car.

passengers in vehicles equipped with passenger air bags.

His eye was hit by fragments of glass from the broken

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JAMA 1997;278:1437-9.

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Smally AJ, Binzer A, Dolin S, Viano D. Alkaline chemical

keratitis: eye injury from airbags. Ann Emerg Med

Chemical eye injuries may also affect travelers, and

1992;21:1400-2.

they are potentially blinding injuries. If chemicals are

8.

Ingraham HJ, Perry HD, Donnenfeld ED. Airbag Keratitis.

splashed into the eye, the eye and the conjunctival

N Engl J Med 1991;324:1599-600.

sacs (fornices) should be washed out immediately with

9.

Spoor TC. An Atlas of Ophthalmic Trauma. Editora

copious amounts of water. Alkali injuries are more

Manole Ltda, Sao Paulo, Brasil, 1999;3:35-44.

common and can be more deleterious. Bilateral

10.

Lueder GT. Airbag-associated ocular trauma In children.

chemical exposure is especially devastating, often

Ophthalmology 2000;107:1472-75.

11.

Driver PJ,Cashwell LF,Yeatts RP. Air bag associated

resulting in complete visual disability. Immediate,

bilateral hyphemas and angle recession. Am

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prolonged irrigation, followed by aggressive early

Ophthalmol 1994;118:250-51.

management and close long-term monitoring, is

12.

Fukagawa K, Tsubota K, Kimura C. Corneal endothelial

essential to promote ocular surface healing and to

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292

Clinical Diagnosis and Management of Ocular Trauma

TABLE 47.5: Estimated effectiveness of occupant

protective systems in reducing injury

Injury severity

System used

front damage

Moderate

Air bag+lap-shoulder belt

61%

Air bag alone

6%

Manual lap-shoulder belt

56%

Serious

Air bag+lap-shoulder belt

69%

Fig. 47.1: Visual acuity distribution after injuries

Air bag alone

–8%

Manual lap-shoulder belt

74%

had no light perception. 4.81% there was light

perception. 7.79% of patients had a visual acuity of

NHTSA reported 113 fatalities attributed to airbag

less than 0.05. 2.41% had a final visual acuity of 0.01,

deployment as of September 1,1998.57

Forty-seven

12.63% had a best-corrected visual acuity of less than

were adults, only 13 of whom were properly restrained.

0.4, 24.32% had less than 0.7 and 25.85% had a

Fifteen infants in passenger-side rear-facing car seats

final visual acuity of less than 1.0 (Fig. 47.1).

were killed. The infants head was too close to the

In the age group of 18 to 22 years old has the

expanding bag. Fifty-one children aged 1 to 12 were

highest risk of injury. The most number of accidents

killed, none of whom were properly restrained.

(85%) were during the night, it is said between 18.00

Children should be in the back seat and belted! The

and 06.00 o’clock and during winter time, from

Insurance Institute for Highway Safety updates these

October to March. 17.9% patients admitted that, at

statistics periodically.58 Spontaneous deployment of

the time of the accident, they were under the influence

airbags also has been reported.59 Several large-scale

of alcohol.

recalls have occurred because of the potential threat

Discussion

of spontaneous airbag deployment. Occupants

positioned within 25 centimeters of the wheel or

A 58 to 73% reduction of penetrating ocular injuries

dashboard cannot avoid being injured.

occurred when use of a car seat belt became obli-

NHTSA has permitted manufacturers to “depower”

gator.54-56 The seat belt protects the eye from injury

the airbag by 20 to 35%.20 Depowering the bag should

as it prevents the forward movement of the body and

reduce airbag-induced injuries in smaller and average-

consequently the possible hit of the head against the

sized occupants but may place larger individuals at

windshield of the car.

increased risk of injury, particularly during high-speed

Airbags are most effective in preventing fatal driver

crashes. Side airbags already have been placed in the

injury in pure frontal crashes but also are effective in

newer car models. Concern has been expressed for

10 o’clock to 2 o’clock frontal arc crashes. They play

passenger-side children as well as adults resting against

no role in side, rear, or rollover crashes. In crashes

the door. So-called “smart bags” are being developed.

of all types, the airbag and seat belt combination

The next generation of sensors will enable the airbag

reduced fatalities 50 compared with unbelted drivers

to deploy according to the severity of the impact, the

in a passenger car without an airbag (Table 47.4).

proximity of the occupant to the bag, and the weight

The airbag alone reduced driver fatality 13%, and the

and height of the occupant. The development of this

seat belt alone, 45%.20

NHTSA has calculated the

effectiveness of occupant protective systems in reducing

technology is ongoing and will be phased in over the

next few years.

moderate and serious driver injury in frontal crashes

Seat-belt performance varies greatly between

compared with unbelted drivers with no airbag

manufacturers. The configuration of airbags and their

(Table 47.5). The airbag is less effective than a

speed and pattern of deployment vary by model and

combination of seat belt and airbag or the seat belt

manufacturer. These factors, which are very important

alone.

to the safety engineer, could not be documented in

these cases. Although the airbag deployment and the

TABLE 47.4: Estimated effectiveness of occupant

eye injury seem to be cause and effect in most cases,

protection system in reducing fatality risk for passengers

other elements, such as collision with the rear-view

and drivers in all types of crashes

mirror, side window, or loose articles within the car

System used

Fatality Reduction

interior, may have played a role. These precautions

Air bag+lap-shoulder belt

50%

not withstanding, this investigation serves to increase

Air bag alone

13%

the awareness of the role of occupant safety systems

Manual lap-shoulder belt

45%

in motor vehicle accidents and to document air-bag-

Ocular Injuries after Vehicular Accident and Possible Prevention

293

related eye injuries and the factors associated with their

clinically.14, 29, 65 In one patient with irreversible bullous

occurrence.

keratopathy, a corneal transplant was required.13 Burns

The majority of the ocular injuries in this series are

have been estimated to occur in 7.8% of all injuries

the result of blunt trauma between the occupant and

associated with airbag deployment.25, 66 Burns may be

the airbag, in either its expanding phase or its fully

due to vented hot nitrogen gas or melting of clothing

inflated status. Obviously, a greater impact force will

or may be chemical in origin.67 Chemical keratitis is

be generated when a forward-moving eye strikes an

the result of corneal contact with the ammonia, sodium

expanding bag. Penetrating injuries and alkali burns

hydroxide, and the alkaline aerosol that are emitted

are exceptions to the blunt trauma mechanism.27, 32,

as by-products of the combustion of sodium azide,

47 Severe blunt trauma has been shown experimentally

which is used to inflate the airbag.2, 68

While the hot

to decrease the anterior-posterior diameter of the globe

nitrogen gas and the by-products are vented away

by 41%.60 Reduction of the anterior-posterior diameter

from the occupant, accident circumstances may bring

of the globe beyond 60% will result in rupture.61 The

the alkali into contact with the eyes. Resulting burns

flattening of the anterior chamber may cause the

will depend on the amount and duration of corneal

corneal endothelium to come in contact with the iris

exposure to the alkali.

and anterior surface of the lens. There is an expansion

Hyphema injury, along with angle recession, is the

of the equatorial diameter of the globe. Severe traction

result of the sudden increase in pressure created by

on the vitreous base develops during the initial phase

the flattening of the anterior chamber following. The

following impact.61 This has been demonstrated

aqueous has nowhere to go and dissects the angle

experimentally with pellet guns and is believed to

and iris root.63 Most hyphemas absorbed. The long-

explain much of the ocular damage sustained in

term potential complication of angle recession

nonperforating BB gun injuries.62 Most of the ocular

injuries to the iris, angle, lens, vitreous, retina, and

glaucoma should be discussed with patients.

The majority of developed cataract were described

choroid documented in this study are compatible with

as an opacification of the anterior capsule and cortex.

a blunt trauma injury mechanism.63 It has been shown

that the airbag dramatically decreases brain injury in

They are the result of contact between the corneal

motor vehicle accidents.20, 24 The combination of airbag

endothelium and the anterior lens surface. The integrity

plus a lap-shoulder belt reduces the risk of moderate

of the lens capsule was compromised in other cases,

and serious head injury to drivers in frontal crashes

leading to more severe opacification. Dislocation and

by 75%, compared with a 38% reduction for seat belts

subluxation of the lens are the result of zonular rupture

alone. However, the brain is fully encased by rigid

secondary to deformation of the globe. Bilateral lens

bone. The eye has an open surface.

dislocation occurred in one case.38

A great deal of publicity has been given to the

The rapid horizontal expansion of the globe at the

increased risk of airbag injury to individuals of small-

vitreous base creates traction that results in retinal breaks

stature who, presumably, are positioned closer to the

and dialysis in this area.62, 64 Several clinical studies have

steering wheel. Many of the reports reviewed in this

demonstrated the preponderance of retinal damage

investigation mention this circumstance. NHTSA’s

associated with blunt trauma to occur at the ora serrata

comprehensive report contains information suggesting

and vitreous base.69-71 The position of the retinal tears

that occupants of small-stature are at greater risk of

and detachments in this study was not described in

injury.20 While this sounds very reasonable, hard data

sufficient detail to allow further speculation on an

are lacking. Driver position in relation to the steering

airbag trauma pattern. All patients with air-bag-related

wheel is more important than actual stature.

injuries should have a thorough indirect ophthalmo-

The corneal abrasions are the result of impact with

scopic examination when possible and ultrasound

the airbag, either directly or in an abrasive “slap”

examination in those cases in which vitreous hemor-

motion from an unfolding bag. Most of the corneal

rhage or hyphema prevents adequate visualization.

surface often is involved. Generalized stromal edema

Commotio retinae and macular holes injuries are the

and folds in Descemet’s membrane frequently are

result of a countercoup-type force commonly found

present. One investigator described the imprint of the

in blunt trauma to the globe.63

airbag on the cornea. The imprint of an open eye,

Likewise, those patients who have undergone

complete with eye shadow, mascara, and lashes has

refractive surgeries, including RK, PRK and LASIK, are

been seen on the airbag. The airbag deploys quicker

also more at risk for development of severe ocular

than a blink. Fortunately, most corneal abrasions heal

injuries, secondary to compromised corneal integrity.72,73

without sequellae, although a decreased endothelial

The airbag is appropriately labeled SRS (Supple-

cell count has been demonstrated experimentally and

mental Restraint System). The best way to reduce the

294

Clinical Diagnosis and Management of Ocular Trauma

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