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

Ocular War Injuries

307

to the secondary glaucoma. Latent and rare

and these features are its virtue from the military point

complication of mustard gas action may be irreversible

of view. Usually impurities give it brown coloring and

superficial corneal opacification, requiring keratoplasty,

odor similar to that of geraniums. Which can be

and/or recurrent conjunctivitis, keratitis, and blepharitis

undetectable in the battlefield. Lewisite, similarly to

(AmedP-6). An effect on the cornea is tetraphasic:

mustard gas, penetrates clothes, mucous membranes,

loosening of the epithelial intercellular junctions,

and skin. As it contains arsenic atom, lewisite disturbs

damage of stromal collagen, stimulation of the stromal

cellular energetic processes, blocking –SH groups in

neovascularizing factor, and apoptosis of endothelial

pyruvate dehydrogenase and inhibiting acetylco-

cells.

enzyme A synthesis.

Ocular symptoms herald other consequences of

Lewisite produces severe ocular injuries. The first

the contamination. They include: chemical skin burns

sign of ocular injury is painful blepharospasm, followed

with blisters, rhinorrhea, vocal cords injury with

by: chemosis and blepharoedema, keratitis and iritis

hoarseness or aphonia, increased mucus secretion in

with hypopyon within 1 hour after the contact.

the airways, bronchospasm, persisting cough, nausea

Inflammation usually resolves but the necrosis of

and vomiting, diarrhea. Other squeals include: skin

conjunctiva, corneal opacification, corneal pannus,

hyperpigmentation or discoloration, painful ulcerations

secondary glaucoma, and cataract may persist after

of the skin, aphonia or chronic hoarseness, chronic

severe injury.

obturative pulmonary disease (COPD), intestinal

Intensive pain of eyeballs, skin and blisters filled

hemorrhage and perforation, aplastic anemia,

with liquid toxic for not only surrounding tissue but

leucopenia, depression, loss of libido, anxiety. It was

also for medical staff is characteristic for lewisite

also found that mustard gas increases the risk of

contamination. It exerts a severe irritating effect on

pulmonary carcinoma in chemical causalities and

the airways, forcing the immediate use of anti-gas

manufacturers (Norman 1975, Woda et al 1968). It

facemask. Lewisite absorbed to the circulating blood,

should be born in mind that general symptoms, such

mainly through the respiratory tract, causes hemolytic

as headache and abdominal pain, nausea and

anemia, increased capillary permeability, pulmonary

vomiting, anemia, and leucopenia may be identical

edema, damage of both liver and kidneys, and

with those in radiation sickness.

hypovolemic shock.

Basic medical management of chemical causalities

The treatment includes copious eye irrigation with

is careful washing of skin and irrigation of eyes as well

water and normal saline. Topical antibiotic ointments,

as removal of the contaminated clothes. Eyes and

strong mydriatics (atropine solutions) are used. An

mucous membranes are washed with water or normal

important element of the treatment is BAL – British

saline and sodium bicarbonate for at least 2 minutes,

Anti Lewisite (dimercaptol) – chelating arsenic and

immediately after contamination with mustard gas

liberating –SH groups of pyruvate dehydrogenase. It

(Wilems 1989). Delayed eye irrigation is useless as

is used topically in the form of ophthalmic ointment,

mustard gas is already absorbed. Mustard gas is

skin ointment, and systematically in intramuscular

removed from the skin wooden spatula, when

injections.

contaminated clothing was removed, and powdered

iii.Phosgene oxime: Phosgene oxime, being

with anti-gas powder (calcium chloride or magnesium

oxide). Activated carbon and synthetic resins may also

classified as blister agent (vesicant), has an irritating

be used for this purpose(Smith et al 1991). Then,

action without producing the blisters. It is solid

exposed skin is washed with water and soap and

compound dispersed in the form of aerosol for military

normal saline. Treatment of ocular injuries include

purposes. Mechanism of its action is not clearly

application of topical antibiotic ointments,

explained, but most probably it damage protein and

corticosteroids, and mydriatics for dozens weeks to

enzyme structures. Contact with the eyes causes edema

several months (Safarinejad et al 2001). Then, the

of the conjunctiva and keratitis, leading to its

patients are followed-up for months to detect possible

opacification and marked decrease in visual acuity.

corneal and anterior chamber symptoms. Wartime

Typical for phosgene oxime action are skin lesions in

practice indicates, however, that for the treatment

the form of reddening and urticaria progressing to the

severity of injuries, depending on the dose and rapid

skin necrosis with suprainfections. Medical management

decontamination is more important than medical

includes decontamination with water and sodium

procedures.

bicarbonate. Then, topical antibiotics and preparations

ii. Lewisite: Lewisite was synthesized in by WL Lewis

accelerating the healing of cornea and skin are applied.

3. Remaining military toxic agents: One should

in USA in 1918 (it was named after him). Most

probably it was not used as chemical warfare agent

remember that each case of the conjunctival irritation

up-to-now. Pure lewisite is colorless and odorless liquid

manifested by reddening, burn sensation or lacrimation

Ocular War Injuries

309

toxin, produced by Clostridium botulinum. It inhibits

absorbed energy. Penetrating radiation is produced

acetylcholine release in the myoneural endings and

during nuclear explosion, lasts for dozen seconds, and

parasympathetic nerves. Ocular symptoms include:

is composed of electromagnetic gamma rays and

papillary dilatation, accommodation disorders and

neutron radiation. Radioactive pollution is related to

double vision. The general symptoms include: mouth

the radioactive dust fallout after explosion and

dryness, peristalsis impairment, speech and swallowing

radioactive substances formation by the neutron

disorders, breathing muscles paralysis. Antitoxin is used

radiation. It results in X, gamma, alpha, beta, and

in the treatment. Mortality rate in untreated subjects

proton rays emission, the most intense during a few

is about 65% in about 18 to 36 hours.

days but persisting for years.

Radiation sickness may develop within hours after

Nuclear Warfare

nuclear explosion. However, it should be born in mind

Nuclear weapon is characterized by the most

that now, when the nuclear weapons are banned,

symptoms of radiation sickness may result from

destructive action, out of all types of weapons. Its effect

inappropriate storage of the radioactive substances,

on the vision is connected with five elements of

leak of nuclear reactors cooling water, overheating or

explosion: blast, thermal radiation, shock wave,

explosion in the nuclear power plants. General

penetrating radiation, and radioactive pollution. Data

symptoms of the radiation sickness include: headache,

on the nuclear warfare effects on the human body

abdominal pain, nausea, vomiting, gastrointestinal

come from the end of the II World War, when USA

hemorrhage, skin burns. Later, anemia and leucopenia

dropped the atomic bombs on the Japanese cities

develop. Ocular effects of the radiation sickness include

Hiroshima and Nagasaki (on the 6th and 9th August

edema and reddening of eyelids with madarosis.

1945). Other nuclear explosions were related to the

Blisters on the eye lids skin, necrotic conjunctival

nuclear weapons testing carried out by several countries

ulceration, corneal erosion, and corneal stroma

during so-called Cold War. It should be assumed that

infiltrations follow. Ultimately, eye lids scar deformities,

such tests did not involve experiments on human

conjunctival adhesions, corneal defects with perforation

beings. The Cold War arming was followed by the

are observed. Typical sequel is postradiation cataract

period of nuclear disarmament. In 1963, United States,

that may develop from 3 months, already (Sinskey

Soviet Union, and Great Britain Kingdom signed an

1955). It begins with punctate dot opacification in the

agreement which banned testing in the atmosphere,

front of the posterior lens capsule, progressing to the

outer space, and underwater. However, tests

subcapsular discoid changes, and finally involves the

underground tests were permissible. In 1968, an

whole lens (Ham et al 1953). Patients with general

agreement on nuclear weapons non-proliferation,

symptoms of the radiation sickness manifested by

signed by 178 countries, and prolonged open-ended

hematopoietic disorders but without visible ocular

in 1995. A comprehensive test ban was approved by

problems require periodical eye fundus examination

UN General Assembly in 1996; 170 nations have now

signed. Actually, China, France, Russia, United States,

to detect possible intraretinal and preretinal

Great Britain, India, and Pakistan have nuclear

hemorrhages, hemorrhages into vitreous.

weapons. Moreover, it is stored in post-Soviet regions:

OCULAR WAR INJURIES RELATED TO THE

Bielarus, Kazkhstan, and Ukraine. It is probable that

also Israel and Iran have nuclear weapons.

LASER LIGHTAND EXPLOSION BLASTS

There are several typical ocular injuries in nuclear

Accidental laser use and explosion blasts produce

explosion survivors. Intensive light during nuclear

electromagnetic wave of the visible light, similar to

explosion causes transient central vision disturbances.

infrared light harmful for the macula. It results in the

Thermal radiation, related to the blast, produces eye

central vision disturbances, manifested by the visual

burns and lens opacification. This problem is discussed

acuity decrease, central scotoma and color sensitivity

in detail within the effects of explosion blast and laser

disorders. Mechanism of these pathologies involves

light. Shock wave means translocation of air with

photochemical macular metabolism disorders with

supersonic speed and it is not produced in case of

accompanying small foci of the internal structures

neutron bomb explosion. Shock wave may cause

edema and intraretinal blood extravasation. Listed

mechanical injuries related to the foreign bodies in the

disorders may persist for about 1 to 3 months. Lesions

eye and circulatory disorders due to the sudden change

to the macular pigmentary epithelium and its outer

of the air pressure (Flick 1948).

structures are also possible (Harris et al 2003). The

Nuclear explosion produces penetrating radiation

later occur, if the electromagnetic wave mainly consist

and radioactive pollution. Both may produce similar

infrared light, being a component of laser light, falling

disorders known as radiation sickness. Ocular and

vertically on the eye. Laser light falling on the eye under

systemic clinical effect will depend on the dose and

certain angle causes local skin, conjunctival and corneal

310

Clinical Diagnosis and Management of Ocular Trauma

lesions. Explosion blast is accompanied by thermal

14.

Heier JS, Enzenauer RW, Wintermeyer SF, et al. Ocular

radiation which causes eyelids skin, conjunctival and

injuries and diseases at combat hospital in support of

corneal burns as well as lens opacification (Harris

Operations Desert Shields and Desert Storm, Arch

et al 2003, Pariselle et al 1988). Prophylactic measures

Ophthalmol. 1993; 111(6): 795-8.

15.

Homblass A. Eye injuries in the military. Int Ophthalmol

include wearing of goggles, first of all. In the treatment

Clin 1981; 21: 121-38.

topical anti-inflammatory agents are applied. One

16.

Ko¿uchowska I. Injuries of globe and adnexa. In: Witold

should also consider the administration of anti-

Or³owski (Ed): Modern Ophthalmology vol. II, PZWL,

edematous drugs, such as carbonic anhydrase

Warsaw, 1986.

inhibitors. In more severe cases corticosteroids are

17.

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

injected periorbitally. Periodical ophthalmologic follow-

J, Treister G. A standardized classification of ocular

up central vision examinations are also necessary,

trauma. Ophthalmology. 1996; 103:240–243.

18.

Mader TH, Aragones JV, Chandler AC, et al. Ocular and

including visual acuity, color and contrast sensitivity,

ocular adnexal injuries treated by United States military

Amsler test, computer-assisted perimetry. Additional

ophthalmologists during Operations Desert Shield and

tests and examinations should also be considered:

Desert Storm, Ophthalmology. 1993; 100 (10): 1462-7.

fluorescein angiography, optical coherence

19.

Mariak Z, Mariak Z, Stankiewicz A, ¯ywalewski J. The

tomography, electrophysiological tests.

occurence of posttraumatic lesions of cranial nerves.

Okulistyka, 2002, 2:143–47.

20.

Muzaffar W, Khan MD, Akbar MK, et al. Mine biust

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314

Clinical Diagnosis and Management of Ocular Trauma

INVESTIGATIONS

Medical history is a very important issue. Specific

ophthalmic tests include: refraction, visual acuity,

keratometry, biometry, B-scan ultrasonography,

gonioscopy. Slit-lamp microscopy is a major method

of eye examination. During examination pupil should

be maximally dilated. In all cases of blunt trauma

particular attention should be paid to fundus

examination. Physician has to evaluate not only affected

eye but also the fellow eye when possible.

DIFFERENTIAL DIAGNOSIS

Fig. 50.5: Vossius ring on the anterior capsule of the

In blunt trauma scleral ruptures can be present without

eye with history of blunt trauma

being visible to the examiner. Rupture is being suspected

when the eye is soft.

TREATMENT

A medication in conjunctival hemorrhage does not

speed up blood resorption. The latter usually occurs

within several days or weeks depending on the amount

of blood. In conjunctival ballooning it has to be kept

lubricated with ointment until the swelling diminishes.

In hyphemas medications inducing mydriasis and

cycloplegia are indicated together with sedation and

patching of the traumatized eye. In severe hyphemas

systemic aminocapronic acid in a dose of 50 mg/kg

can sharply decrease the incidence of rebleeding. In

Fig. 50.6: Dislocated cataractous lens following blunt trauma

the hemorrhage does not resorb promptly, anterior

chamber lavage should be performed in order to

prevent blood staining of the cornea.

Careful monitoring of the intraocular pressure and

prompt treatment of ophthalmic hypertension are

mandatory. Beta-blockers, carbonic anhydrase

inhibitors and osmotic agents are widely used.

In cases of lens dislocation into the anterior chamber

leading to glaucoma emergency surgery is usually

indicated. Dislocation of the lens in the vitreous cavity

never requires emergency lens extraction. These

patients are managed surgically after inflammation

decrease.

The main treatment method of visually disabling

cataract is extraction. In general, traumatic cataracts

Fig. 50.7: Lens dislocated into anterior chamber

can be safely removed with phacoemulsification

followed by posterior chamber intraocular lens

implantation. Indications for the surgical tactics in each

In blunt injuries even in cases when conjunctiva

particular case vary extensively.

remains intact, rupture of sclera may occur. The most

Risks of the modern small incision cataract surgery

common sites of the rupture are: limbal area, rectus

are few if technically performed well. So the main source

muscle insertion and equator of the globe.

of complications is the ocular comorbidity. Special

In patients with previous surgery (corneal trans-

surgical techniques (vitrectomy, capsular tension rings,

plantation, radial keratotomy, cataract extraction) after

pupil expansion devices) and alternative methods of

blunt trauma postoperative wound dehiscence can

IOL fixation (i.e. scleral and iris fixation) should be

occur.

considered since zonular dehiscence, loss of capsular

316

Clinical Diagnosis and Management of Ocular Trauma

INVESTIGATIONS

all relevant factors. The risks of inflammation, toxic

Patient’s history and detailed description of the injury

chemical effects and fibrovascular proliferation should

be taken into consideration.

should be obtained.

These effects largely depend on the chemical nature

Single or double eversion of the lid is important

of the FB. If the foreign body contains iron or

in the search and visualization of the FB located in the

particularly copper treatment tactics should be

upper lid fornix. Direct visualization is very useful in

aggressive and early surgery is mandatory. The opposite

determining the presence and location of the foreign

is true in small non-magnetic FB containing no or

body. It is sometimes very difficult to visualize small

minimal concentrations of aggressive substances.

and transparent foreign bodies (for instance small

FB located in the anterior segment is not difficult

particles of glass or plastic) even with the slit lamp.

to remove. In many cases anterior segment foreign

Iris defects due to perforation may be visible under

bodies can be removed through the wound of entry.

direct light or with transillumination. Examination of

If the object is small (2-3 mm in diameter) extraction

the anterior chamber angle with the gonioscope can

with magnet through the entry route may be considered.

be useful in detecting small FB lying in the angle.

Larger object can be removed utilizing the limbal

Gonioscopy should be performed with caution not to

approach.

produce aqueous humor leak through the site of

Tears in the lens capsule of 2 mm in size can seal

penetration. Ophthalmoscopy after maximal pupil

without causing cataractous changes. Thus small foreign

dilation should be used in cases of suspected FB in

bodies can be left in the lens. Bigger FB causing diffuse

the vitreous or on the retina.

cataracts should be managed during cataract extraction.

In cases of opaque ocular media (extensive corneal

edema, hyphema, cataract and vitreous hemorrhage)

Intensive antibiotic treatment (topical, oral or IV)

A- and B-scans, X-ray examination, computerized

should be administered in all cases of intraocular FB.

tomograms must be performed in suspected cases.

With metal FB in the superficial corneal layers, after

Some of these examinations can also determine

topical anesthesia is being applied, the patient is brought

whether or not the FB is magnetic.

under slit lamp and the metal fragment is lifted with

the 25G needle on a syringe or a special instrument.

DIFFERENTIAL DIAGNOSIS

Foreign body located in the deep corneal layers should

be removed under the operating microscope. In cases

Main differential diagnosis relates to the fact whether

of full thickness corneal penetrations suturing of the

intraocular FB is present or not. Physician should keep

wound should be done in order to achieve watertight

in mind that multiple foreign bodies are not uncommon.

seal. Postoperatively patients should be treated with

The latter is characteristic to the explosions and blasting

antibiotics and cycloplegics.

injuries (multiple intracorneal rocks), shotgun blasts and

the like.

PROGNOSIS

TREATMENT

Once the presence of the FB in the eye has been

established, the prognosis depends on the variety of

In cases of perforating

ocular injuries prompt

factors. In the eye with the injury limited to the anterior

therapeutic intervention is justified. Local and systemic

eye segment prognosis is favorable in most cases and

wide spectrum antibiotics should be given.

depends of the effectiveness of the surgical repair and

Corticosteroids are administered in order to limit the

antibiotic treatment. In cases without good light

destructive effect of inflammation that accompanies

projection the prognosis is not infrequently poor. Foreign

infection.

bodies containing cooper or iron are particularly dange-

In most cases of globe lacerations urgent surgery

rous due to the chalcosis and siderosis development.

with the suturing of the wound site should be

Traumatic perforations of the cornea lead to scar

performed.

formation (Figs 50.10 and 50.11).

Clinical management in cases of FB largely depends

Consideration of the potential development of

of the judgment of the following factors: localization

sympathetic ophthalmia in perforating globe injury is

of the foreign body, its shape, size and composition,

extent of the trauma of surrounding tissues and the

absolutely necessary. Sympathetic ophthalmia is more

decision of whether remove it or leave in place.

likely in severe globe injury with excessive damage

The ophthalmologist must decide for or against

of the uveal tissue leading to eye globe atrophy (Fig.

removal of the foreign body after careful judgment of

50.12).