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

Bottle Cork Injury to the Eye

299

These cases prove that bottle cork eye injury can

5.

Koval R, Teller J, Belkin M, Romem M, Yanko L, Savir

involve very severe traumas, although most patients re-

H. The Isaraeli ocular injuries study. A nationwide

cover almost totally with appropriate medical treatment.

collaborative study. Arch Ophthalmol 1988;106:776-80.

More information and prevention is needed,

6.

Archer D, Galloway NR. Champagne-cork injury to the

particularly in certain periods of the year and in specific

eye. Lancet 1967;2:487-9.

areas of the country. It is advisable to fit bottles with

7.

Delori F, Pomerantzeff O, Cox MS. Deformation of the

safety devices and/or include captions describing the

globe under high-speed impact: its relation to contusion

hazard posed by bottle caps/corks.4 Moreover, the

injuries. Invest Ophthalmol 1969;8:290-301.

introduction of a standardized type of screwable cork

8.

Greven CM. Retinal Breaks. In: Yanoff M, Duker JS (eds)

could be effective in preventing ejection. Alternatively

Opthalmology. Mosby, Philadelphia, section 8,

the use of a contention system, connecting the cork

1999;38.2.

9.

Rubsamen PE. Posterior Segment Ocular Trauma. In:

to the bottle neck with a wire, could represent another

Yanoff M, Duker JS (eds) Opthalmology. Mosby,

preventive possibility.

Philadelphia, section 8, 1999;43.2-3.

References

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Cavallini GM, Lugli N, Campi L, Pagliani L, Saccarola P.

Bottle –cork injury to the eye: a review of 13 cases. Eur

1. Al Salem M, Sheriff SMM. Ocular injuries from carbonated

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soft drink bottle explosions. Br J Ophthalmol 1984;

11.

Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers

68:281-3.

JB, Treister G. A standardized classification of ocular

2. Gupta AK, Nadiger M, Moraes O. Ocular injury from a

trauma. Ophthalmology 1996;103(2):240-3.

carbonated beverage bottle. J Pediatr Ophthalmol

12.

Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, Bridges WZ

Strabismus 1980;17:394-5.

Jr, Capone A Jr, Cardillo JA, de Juan E Jr, Kuhn F,

3. Sellar PW, Johnston PB. Ocular injuries due to exploding

Meredith TA, Mieler WF, Olsen TW, Rubsamen P, Stout

bottles of carbonated drinks. BMJ 1991;303:176-7.

4. Kuhn F, Mester V, Morris R, Dalma J. Serious eye injuries

T. A system for classifying mechanical injuries of the eye

caused by bottles containing carbonated drinks. Br J

(globe). The Ocular Trauma Classification Group. Am J

Ophthalmol 2004;88:69-71.

Ophthalmol 1997;123(6):820-31.

Ocular War Injuries

301

ophthalmologic service in the transportation base

Mechanical Ocular War Injuries

support hospital during 9 months in 1995 (Bancroft

et al 2001). Remaining 168 (11%) patients presented

GLOBEAND ADNEXAL INJURIES

with ocular diseases, requiring an intensive treatment.

Global and adnexal injuries may be classified in several

Nine patients required evacuation from the military

ways. First of all, they may be classified by causative

operation region but not necessary surgical treatment

factor as: incised, punctured, crushed, lacerated, and

in other specialist centers. However, this hospital was

contused injuries. Ocular injuries may also be classified

located some hours of drive from the front line.

by anatomical structures involved. To unify the classi-

Statistics cited by the authors working in vicinity

fication of mechanical ocular injuries the International

of the military operations are far worse. Thach et al

Trauma Classification was approved in 1996 (Table

noted 797 severe ocular injuries, including as many

49.1) (Fryczkowki et al 2003), Kuhn et al 1996,

as 438 open globe injuries, in the war in Iraq during

Pieramici et al 1997).

34 months (from March 2003 to December 2005)

(Thach et al 2008). Enucleation was performed in 116

TABLE 49.1: International ocular trauma classification

cases, including 6 patients with bilateral enucleation.

Open

Closed

Heier reported 108 (14%) patients with ocular injuries

out of 767 wounded, including 20 patients had to be

Type

A Rupture

A Contusion

evacuated for further specialist treatment, during

B

Penetrating

B Laceration

Operation Desert Storm (1990-1991) (Heier et al

C IOFB

C Superficial FB

1993). Retrospective study carried out by Muzaffar

D Perforating

D Mixed

E

Mixed

-

-

et al. a total of 91 eyes of 51 men, clearing landmines

Degree

1

>20/40

1 >20/40

in the aftermath of the Russo-Afghan war, were

operated within 39 months (from November 1992

by visual

2

20/50–20/100

2 20/50–20/100

acuity

3

19/100–20/800

3 19/100–20/800

to January 1996) (Muzaffar et el 2000). Total blindness

4

19/800–LP

4 19/800–LP

(NPL) was seen in 37.5% of the eyes, and visual acuity

5 NLP

5 NLP

was below cfbe. in further 20.8%. Only 16.4% of

Zone

I

Cornea to

I

External

injuries were classified as mild with VA over 0.3. Eyelids

corneoscleral

plasty (50% of eyes), evisceration (23.1%), and

limbus

vitrectomy (17.6%) predominated in the treatment.

II

Within 5 mm of

II

Anterior segment

It should be mentioned that all these patients

the limbus

worked without any eye protection. Bajaire et al

III Sclera more than

III Posterior segment

published data on performed vitreo-retinal surgeries

5 mm from limbus

during a 8-year follow-up period (from January 1995

Marcus

Positive

Positive

to June 2003) (Bajaire et el 2006). As much as 40%

Gunn

Negative

Negative

of injuries involved zone I to the corneal limbus, 44%

– zone II from the corneal limbus to 5 mm behind

Below ocular injuries that may result from the

it, 16% of injuries were localized in zone III in the

military operations are briefly discussed. However, the

posterior globe pole. Visual acuity in 98% eyes was

authors focus on the specific ocular war injuries. Sequels

below 1/40. During vitrectomy, silicone oil was used

of the globe injuries by anatomical structures presents

in 65% of cases, perfluorocarbons in 21%, lensectomy

Table 49.2.

in 82%, IOFB was removed in 72% of cases, and

Management varies in dependence on the type of

endolaser was used in 81% of cases. Improvement

injury. As it is seen in the table, the treatment is

was seen in 43%, stabilization in 41%, and sight

frequently surgical. Therefore, knowledge, experience,

worsening in 15% of cases. Factors of poor prognosis

proper equipment in the wards and OR are required.

included: lesions in zone III, retinal detachment,

Applied procedures do not differ from these used in

intraocular inflammation, and perforating trauma.

any ophthalmologic center.

From the above listed data, it results that ocular

injuries constitute serious problem, not only medical

Open Globe Injuries

but also social and economic. Americans estimated that

Open globe injuries are one of the most severe ocular

the cost of one soldier exclusion from the service due

to ocular injury for 5.9 days on average amounted

injuries. They are most frequently produced by

to $6295 (Buckingham et al 2001). Ocular injuries

landmine blasts or hand grenades. It is estimated that

may be classified as multiorgan, when the eye is only

such injuries constitute 50 to 80% of trauma in the

one of many damaged organs, and uniorgan, involving

contemporary battlefields with penetrating and

the eye and adnexa only.

perforating wounds with IOFB predominance, often

302

Clinical Diagnosis and Management of Ocular Trauma

TABLE 49.2: Globe injuries by anatomical structures

Anatomical structure

Type of injury

Sequel

Treatment

Prognosis

Eyelids

Abrasion, closed or open

Upper lid ptosis, lacrimal tract

S

Good

global injury

disruption, hemorrhage

Lacrimal apparatus

Dislocation

Edema

S

Good

Lacrimal ducts

Disruption

Lacrimation, inflammation

S

Good

Conjunctiva

Abrasion, rupture

Hemorrhage, defects

S

Good

Cornea

Epithelial abrasion

Recurrent defects

C

Good

Rupture of the

Scars, keratoconus,

C

Poor

posterior limiting

corneal edema,

membrane of the cornea

anterior adhesions

Sclera

Rupture

Uveal prolapse, vitreous prolapse,

C

Poor

retinal impaction, hypotonia, loss of vision,

inflammation, retinal detachment, glaucoma

Abrasion

Hemorrhage

C

Good

Anterior chamber

Rupture of the iris sphincter

Photophobia

C/S

Good

Iridodialysis

Inflammation

C/S

Good

Iridoschisis

Edema

C

Good

Angle recession

Inflammation

C

Hyphema

Corneal incrustation,

C/S

Favorable

secondary glaucoma

Pupillary muscles paralysis

Photophobia

C

Good

Traumatic iritis

Adhesions, secondary glaucoma

C

Good

Refraction disorders

Hypermetropia, myopia

C

Good

Vitreous hernia

Vitreous base avulsion, retinal

C

Good

detachment

Lens

Opacities (Vossius’

Cataract

C,

Good

rings, subcapsular,

sometimes

disseminated, diffused)

awaiting

Luxation

Deterioration of sight

C

Poor

Subluxation

Refraction disorders

C/S

Poor

Rupture of the

Opacity – cataract

S

Good

lenticular capsule

Vitreous

Hemorrhage

Opacities, sparkling floaters,

C/S

Poor

photoreceptors damage,

Posterior vitreous

retinal pigmentation

C

Good

detachment

Retina

Tear, detachment

Complete retinal detachment

S

Poor

from the limbus

Retinal detachment

Worsening, loss of vision

S

Poor

Commotio retinae

(Berlin’s edema,

Terson syndrome,

Purtscher’s angiopathic

retinopathy, peripheral

retinal edema)

Vision deterioration

C

Favorable

Hemorrhage

Vision deterioration,

proliferations, retinal detachment

C

Poor

Macular hole

Vision deterioration

Laser

Poor

therapy

Choroid

Rupture

Retinal detachment

C

Poor

Detachment of the

Intraocular pressure drop – papilledema,

C

Poor

ciliary body

retinal edema, choroidal detachment

Post-traumatic inflammation

Scotoma

C

Good

Lesions to the ciliary

Accommodation disorders, lens dislocation,

muscles or nerves

ciliary muscle spasm

C

Good

Orbit

Hemorrhage

Optic nerve and orbital structures compression

S

Soft tissues edema

Optic nerve and orbital structures compression

S/C

Poor

Fracture of the orbital walls

Orbital structures and eyeball damage

S

Poor

Optic nerve

Rupture of the optic

Partial damage

C

Good

nerve II vessels

Detachment

Vision loss

C

Poor

Legend: S – surgical treatment ; C– conservative treatment.

Ocular War Injuries

303

multiple (about 80%). Foreign bodies, both metallic

vitreous opacities, macular holes, orbital walls fractures,

and non-metallic may penetrate to the ocular adnexa,

post-traumatic cataract surgery, keratoplasty, anti-

eyeball, orbit or even maxillary sinusal structures or

glaucoma surgeries) may be delayed until partial healing

brain (Biehl et al 1999). Therefore, detailed diagnostic

of the post-traumatic wound have been achieved or

procedures with possible ultrasound, X-ray and CT

make the decision on surgical operation time

are very important in the field hospital already. Open

dependent on the course of therapy (Gos et al 2001).

globe injuries damage ocular adnexa (eyelids,

As it was already mentioned, the outcome of

conjunctiva, cornea, and sclera) in nearly all instances.

treatment is sometimes unsatisfactory for the patient

Copious hemorrhage, edema, and pain are usually

but adequate visual acuity may be preserved. The

seen. Plastic, gunpowder, sand, dust, and bacterial

treatment is always surgical in such cases and should

pathogens are deposited in the eye following open

be carried out in the specialist centers, following

globe injuries. Each ocular war open injury is

medical evacuation from the regions of direct military

considered infected and requires antibiotic therapy as

operations. It is always connected with the necessary

soon as possible. Therefore, an incidence of intraocular

hospitalization, surgical treatment, and sometimes

inflammation after any injury is rare because an early

discharge.

administration of antibacterial agents.

Closed Globe Injuries

It is different in case of the closed globe injuries. As

ocular wounds usually force the victim to seek medical

aid, contusions (especially mild) are often ignored.

Some authors estimate that contusions constitute about

50% of all ocular injuries (Kozuchowska 1986).

Symptomatology of these injuries varies from no

symptoms and signs to the immediate blindness of the

injured eye, depending on the severity of trauma. The

following symptoms usually accompany the contusion:

blurred vision, reddening, hemorrhage, pain,

photophobia, sensation of veils, dots, “curtains” in the

front of eye, sight instability (Szaflik et al 1998). All

these symptoms are usually the reason of early

Fig. 49.2: Scar after corneoscleral wound caused by

reporting to the ophthalmologic clinic, enabling an

early diagnosis and proper treatment which is often

landmine shrapnel in a soldier of Iraqi operation

less invasive (e.g. in retinal detachment) than that

The treatment is frequently two-staged. The firs stage

delayed. Post-traumatic sequels may develop

asymptomatically or the symptoms may be scare, slow

takes place as soon as possible after reporting to the

(e.g. retinal peripheral injuries), and may easily be

doctor. It comprises post-traumatic wounds care with

overlooked by the patient (Waclawiak-Dabrowska et

anatomical structures reconstruction and intensive anti-

al 2007). It may be the case of peripheral retinal

inflammatory therapy with antibiotic therapy. Foreign

detachment, which may lead to complete detachment

bodies are removed and eyelids, conjunctival, scleral,

of retina (Fig. 49.3). Similar situation concerns sequels

and retinal wounds are sutured.

of the peripheral hemorrhages into the retina.

Then, the patient should be evacuated to the

Fibroproliferative changes leading to the secondary

centers, where the treatment aimed at proper sight

retinal detachment may develop after months following

functioning reconstruction is possible. Timing plays an

the injury (Bajaire et al 2006). Properly performed

important role in the treatment of the open globe

laser therapy mainly protects the patient against such

injuries. The majority of surgeries should be carried

complications. However, the patient should regularly

out soon after injury, as remote outcome frequently

report to follow-up visits in order to not overlooking

depend on the time of surgery. It is especially true in

preventable complications.

case of retinal detachment, IOFB and intraorbital

foreign bodies removal, perforating eyeball wounds,

MULTIORGAN INJURIES

intraocular inflammation, prophylactic retinal

photocoagulation. Other injuries may (and sometimes

The firs group is usually related to multiorgan injuries,

should) wait until partial healing of the post-traumatic

mainly craniofacial. Ophthalmologists are participating

wound have been achieved. The treatment of some

to the specialist team dealing with the treatment and

open globe injuries (e.g. eyelids plasty, hemorrhagic

patients care. Prospective studies have shown that

Ocular War Injuries

305

PROPHYLAXIS OF THE OCULAR INJURIES IN

agents is determined by its localization, identity, and

THE BATTLEFIELD

neutralization. This action may be related to both

Prophylaxis is of utmost importance due to such

military and terrorist operations. In general, mass

serious complications of the ocular injuries. It is,

destruction weapon is divided into chemical warfare,

however, quite limited in the battlefield. Nevertheless,

biological warfare, and nuclear warfare. Mass destruc-

an incidence of ocular diseases may be partially reduced.

tion weapons may be transported by artillery shells,

It is justified by the health and economic reasons.

ballistic missiles or bombs. Chemical and biological

The most important is eye protection (special

warfare agents may additionally be thrown down in

protective goggles) during all military operations, which

containers or dispersed from aircrafts.

protect the eyes against dust and other contaminants

Chemical Warfare

and all minor ocular injuries. Glasses of eye protective

devices should be made of polycarbons of 2.3 or

History of sulphur fumes and hot pitch use is as old

3 mm thick. They may protect against injuries of kinetic

as history of wars. These agents were used in Greece

energy up to 18 J or even higher, depending on the

(Peloponnesian Wars) and in China already in the 5th

direction of action. Eye protective devices should be

century BC. Chemical warfare was extensively used

safe, comfortable, disperse an impact on the large

as battlefield weapons during the I World War. In 1914,

craniofacial surface, not limiting the field of vision, and

French and Germans use chlorine, and in 1915,

not to stem up. Sometimes such goggles are made

Germans used hydrogen cyanide (prussic acid) and

individually for every soldier, taking his sight defects,

Yperite (mustard gas). Ever since, an international

needs, habits, craniofacial anatomy, and type of effected

community elaborated various agreements that aimed

operations into consideration (Chizh et al 1999).

at disarming under strict and effective control. In 1925,

Moreover, wearing of contact lenses should be

chemical warfare was banned by the Geneva Protocol.

banned. Their proper cleaning and observation of rules

The Polish government put a motion on biological

concerning the wear of these lenses are difficult during

warfare ban, which was added to this Protocol. In

military operations. Between military operations,

1972, Biological and Toxic Weapons Convention was

recommendations depend on the climatic conditions

agreed upon and ultimately signed by 108 countries

and environment. Military operations in the deserts

in 1975. In 1993, Chemical Weapons Convention on

require wearing sunglasses with side shield, protecting

the Prohibition of the Development, Production,

not only against excessive insolation but also against

Stockpiling and Use of Chemical Weapons and on

sand. It the tropics, special attention should be paid

Their Destruction came into force. Unfortunately, there

to insects as their bites may produce not only diseases

are cases of unobserving these agreements.

but also allergic reactions.

Chemical warfare agents can be grouped into

military toxic agents (military gases, volatile liquids

Non-mechanical Ocular War

dispersed as aerosols), and military auxiliary agents

(incendiary agents, defoliants, tear gas). Toxic effect

Injuries

of these agents always depends on the dose, i.e.

OCULAR WAR INJURIES RESULTING FROM

concentration and duration of action of the said

substance.

THE USE OF MASS DESTRUCTION WEAPONS

Military toxic agents

Use of the mass destruction weapons aims—from the

Depending on the effect, military toxic agents are

tactic point of view—at attaining the best possible

grouped into nervous system damaging agents (nerve

military effect without engaging a lot of means and

agents), blister agents, suffocating, choking, and

number of soldiers. Unfortunately, such an effect is

hallucinogenic compounds. Remaining agents may

related to not only maximum enemy loss but also civil

produce only transient ocular irritation manifested by

population and complete destruction of non-military

reddening and lacrimation.

objects and environmental pollution in case of nuclear

1. Phosphororganic compounds (nervous system

weapon use. However, maximum effect on the eyes

has chemical warfare agents, out of all types of

damaging agents, nerve agents): Phosphororganic

weapons. These agents significantly decrease ability to

compounds are volatile liquids. They absorbed from

carry military actions due to visual disturbances and

airways and conjunctiva as well as from the skin, if

accompanying ailments.

contaminated clothes were not earlier removed. They

Presenting an effect of chemical warfare agents on

were primarily used as insecticides (pesticides), i.e. plant

the organ of vision, we propose to use military and

protection agents. However, it was found that they

not medical terminology. An action of chemical warfare

are highly toxic for humankind. As chemical warfare

306

Clinical Diagnosis and Management of Ocular Trauma

the following compounds are used: tabun (GA), sarin

2. Blister agents: These agents serve to decrease

(GB), soman (GD), cyclosarin (GF), and X gases (VX

military capability by the local burning effects or forcing

or AX). Recent reports on the use of these agents come

wearing the protective clothes, which markedly reduce

from Iran-Iraq conflict in 1987. These agents act by

mobility. Such agents include: sulphur mustard gas

blocking acetylcholinesterase (AchE). Accumulation of

(HD), nitrogen mustard gas (HN), lewisite (L),

acetylcholine in the parasympathetic nerves endings

phosgene oxime (CX). These agents produce chemical

produce muscarinic effect in the iris and ciliary body,

ocular burns, burns of airways, skin, intestines, and

lacrimal gland and conjunctival blood vessels. Effects

affect circulatory system.

of nerve agents are also visible in the bronchi, bladder,

i. Mustard gas (Yperite): Sulfur mustard (sulfur

gastrointestinal tract, and heart. Nicotine effect is

Yperite) is one of the oldest and best-known chemical

connected with acetylcholine accumulation in the

weapons. It was used for the first time by Germans

postsynaptic part of the myoneural junction and some

sympathetic ganglia. Laboratory confirmation of

near the city of Ypres (Belgium; it took its name after

intoxication is a decrease in erythrocyte AchE.

the name of this city) in 1915. Later, it was used by

Ocular symptoms are the earliest and occur at the

Italians in Ethiopia in 1936, Japanese during the war

lowest dose. They include: Maximum miosis (lasting

with China in 1937, Iran-Iraq conflict in 1985-1988;

up to 14 days), sensation of pressure and weight in

Iraq used it also against Kurdish minority in 1988.

the eyeballs, ocular pain, injection of the conjunctiva.

Nitrogen mustard, manufactured for the first time in

Miosis may be accompanied by sight disorders,

1935, is a new generation of the burning chemical

especially peripheral, whereas ciliary body stimulation

warfare agents. One should remember that it might

– transient accommodation myopia. There may occur

be used in the contemporary battlefields.

intraocular pressure (IOP) disorders: decrease in IOP

Mustard gas is a liquid used in the form of an

related to the reduction in aqueous production or an

aerosol. It easily penetrates through military uniforms,

increase in IOP from the papillary block. Then, a

ordinary clothes, skin, and mucous membranes. This

sequence of general symptoms follows, including: pain

compound may also persist in humid soil and water

of the frontal region, rhinorrhea, hypersalivation,

in the colloidal form for days. Mechanism of its action

sweating, bradycardia, chest pain, bronchospasm and

on the tissues is not fully explained. However, it is

dyspnea, nausea, vomiting, abdominal cramps,

known that DNA, RNA, cellular membranes, enzymes

involuntary miction, and defecation, somnolence,

and proteins are damaged by the alkilation with

speech disorders, muscular tremor, convulsions,

particular affinity to guanine. This leads to cytotoxic,

parestesis, pulmonary edema, blood pressure drop,

cytostatic, and mutagenic effects (Dabrowska et al

paralysis of the respiratory muscles, respiratory arrest,

1994). Characteristic feature of mustard gas is latency,

and death. General symptoms may persist for some

lasting for several to dozens hours. Then, progressing

days. High doses cause death within some minutes.

lesions develop, producing irreversible damage.

Medical management of intoxication with phos-

The eye is the organ most sensitive to mustard gas.

phororganic agents includes so-called pretreatment,

Threshold of its stimulation is 10-fold lower than that

i.e. pyridostigmine administration. It reversibly binds

for skin and airways. Even if characteristic odor of

AChE for about 12 hours, blocking this way an entry

Yperite (mustard) is not detectable, the first ocular

of phosphororganic

agents.

Pyridostigmine

symptoms of contamination may appear within one

administration should immediately be discontinued,

hour. These ocular symptoms occur most frequently

if contamination was detected. Protection against

in about 4 to 6 hours in the form of burning sensation,

chemical attack in the battlefield includes wearing a

photophobia, blurred vision, and painful blepharo-

facemask, which protects the eyes and airways for

spasm. Simultaneously, mustard gas is penetrating the

about 30 minutes. Within aid procedures, prefilled

skin, leading to the general poisoning.

syringes with atropine should used (it has muscarinic

In order of incidence, the following symptoms are

anticholinergic activity), oxime drug (nicotinic

cholinergic action),

and

benzodiazepine

observed: mild conjunctivitis (75%), severe conjunc-

(anticonvulsant). Drugs should be injected

tivitis with superficial keratitis – a symptom of orange

subcutaneously or intramuscularly. Atropine dose is

rind, edema and eyelids reddening (15%), superficial

repeated every 5 to 15 minutes, depending on the

corneal abrasions – erosions, and inflammation with

degree of poisoning and achievement of the general

injection in the corneal limbus, lesions to the eyelids

atropinization. Next phase of management is victim

epithelium (10%), deep corneal injury with ulceration,

evacuation from the battlefield, removal of the

neovascularization, necrosis of conjunctiva, and deep

contaminated clothes, skin decontamination, airways

burns of eyelid skin (Solberg et al 1997). Ocular

cleaning (suction), oxygen therapy, and transportation

response to the contamination may include also

to the medical station.

adherence of the iris to the cornea, leading ultimately