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Everyday ocular injuries
EVERYDAY OCULAR C.
W.
RUTHERFORD, IOWA
T
INTRODUCTION
HE
impact of a foreign body against the cornea usuaIIy causes immediate pain which is soon accompanied by bIepharospasm, increased Iacrimation and photophobia. These symptoms arise from injury to the sensory nerves of the cornea directIy, or indirectIy through reff exes excited by the injury. OccasionaIIy a wound can be demonstrated objectiveIy when it is not accompanied by symptoms because the sensitive nerve terminaIs have been destroyed or obtunded. Those cases in which unimbedded foreign substances can be removed with a cottonwound probe wiI1 not be considered. Foreign bodies commonIy consist of detached bits of cinder, coa1, emery, grains of gunpowder, meta1, stone, gIass or wood chips. Leaves, twigs, thorns, wheat beards and so forth aIso can injure the eye. Before proceeding with an examination vaIuabIe information may be obtained by inquiring into the patient’s occupation and environment at the time of the accident. EXAMINATION
The examination is made first in good daylight and then under bright artificia1 light. The eyelids are separated and the patient is made to Iook in different directions, as the examiner desires, unti1 a11 of the cornea has been scrutinized; the use of a condensing Iens, Ioupe, or magnifying gIass is advantageous. A foreign body may be Iocated with the ophthaImoscope by using convex 7, 16 or 20 Ienses at appropriate distances ,with the iIIuminated pupi as a background. The next step is to stain the cornea, not onIy to Iocate the wound but to determine its extent and depth. A few drops of 5 per cent cocaine solution are instiIIed, and then
M.D.,
INJURIES* F.A.C.S.
CITY
a solution of ffuoresceine, 2 per cent, combined with sodium carbonate, 4 per cent. After waiting a few minutes the eye is irrigated with boric acid or norma saIt soIution. A bright green coIor appears at the site of any recent destruction of cornea1 epithelium. A circumscribed dark spot in a fieId of green indicates the position of a foreign body if present; perforating injuries do not exhibit a dark spot. Photophobia or pain make it diffIcuIt or impossibIe for the patient to keep the Iids separated. A few drops of 5 per cent soIution of cocaine or butyn in the conjunctiva1 sac generaIIy reduces the disability. A bIepharospasm that does not yieId to this expedient can be reIaxed by injecting I or 2 C.C. (16 to 31 drops) of 2 per cent solution of procaine, with or without 0.016 gm. (s/4 grain) of morphine sulphate, into the tissues outside the IateraI border of the orbit; the injections are made deepIy toward the externa1 auditory meatus and the ramus of the mandible. This paraIyzes important branches of the facia1 nerve. The eye shouId be protected by dressings for at Ieast six hours after the use of any IocaI or infXtration anesthetic. Genera1 anesthesia is advised for the examination and treatment of smaI1 chiIdren. TREATMENT The remova of a foreign body shouId be undertaken onIy with adequate iIIumination, effective anesthesia and aseptic precautions. A few drops of 40 per cent argyro1 soIution are instiIIed into the conjunctiva1 sac and the sac is then irrigated with steriIe norma saIt soIution or mercurophen I. 8000. The Iids can be heId apart with retractors or an eye specuIum. Magnification may be required as for the examination. Normal saIt
* Submitted for pubticationFebruary 7, 1929. 468
NEW
SERIES
VOL.
VI,
No.
4
Rutherford-Ocular
soIution shouId be dropped on the cornea frequentIy to prevent drying of its epithehum. The patient is instructed to fix the gaze on some seIected object with both qes open, in order that the eyebaI1 shaI1 be steady in position; a drop of cocaine soIution in the uninjured eye is heIpfu1. MagnetizabIe substances may be removed with an eye magnet; where they are obstinate the current shouId be made and broken rapidIy to create jerking puIIs. The removal of smaII foreign bodies from the cornea may be attempted with an eye spud or needIe, or the sharp point of a fine knife, such as a cataract knife. The instrument is worked around and under the body, which is th en lifted out. GIass is especiaIIy diffIcuIt because of its transparency. Powder grains are usuaIIy numerous and tedious to disIodge. Iron often Ieaves a rust stain which may be removed with a fine denta driI1 rotated by the operator’s fingers. A foreign substance free in the anterior chamber is removed by opening the chamber at the periphery and grasping the body with fine forceps. Where the body is Iodged in the iris both are grasped with forceps and drawn out only far enough to permit excision of the part of the iris which contains the body. The Iens must not be touched. These surgical wounds do not require sutures, but they shouId be dressed daily unti1 the anterior chamber has fuIIy reformed. Patients with foreign bodies situated posterior to the iris shouId be referred. Foreign bodies in the Iens are prone to cause cataract; those in the ciIiary body usuaIIy cause vioIent iridocyclitis and those in the posterior segment of the eye are removed onIy with great difEcuIty even by experienced operators. An object can perforate the cornea without remaining in the eye. FIaps are fashioned from the conjunctiva to cover the opening unti1 the cornea shaI1 have been heaIed and any Ieakage of aqueous stopped. The conjunctiva is incised I mm. from the cornea for about half of its circumference.
Injuries
American Journal of Surgery
469
The flap is formed by undermining the membrane, drawing it over the perforation Iike an apron and suturing it at each side
of the cornea with fine siIk (Fig. I). If the perforation is centra1 it is better to fashion a doubIe peduncuIated Aap. The first incision is made as in the former instance and another concentric with it and 3 or 6 mm. more peripheraIIy. The ffap is undermined, brought over the wound and fixed in pIace by sutures outside the cornea (Fig. 2). No suture or Ioose ends shouId Iie in contact with cornea1 tissue. OrdinariIy the sutures can be removed in five days. A negIected foreign body in the cornea may be overgrown with epitheIium and become encysted. If infection is present an abscess wiI1 form; it shouId be incised promptIy, cIeansed by gentIe irrigation, dried and then painted IightIy with pure pheno1. Otherwise the abscess may rupture and perhaps expe1 the body or it may Iead to Ioss of the gIobe. Cases of intraocuIar infection shouId be referred. BURNS
Burns are caused by boiIing liquids, steam, acids, aIkaIies, lime, Aame, curIing irons and spIashes of moIten meta1. Anesthesia is required as for foreign bodies. AI1 particIes of aIkaIi, Iime or meta must be removed from the cornea and conjunctiva1 sac. Lime tends to produce permanent opacities in the cornea; these cases are treated by removing the particIes with forceps, with sponges and irrigations freshIy prepared 2 per cent aqueous soIutions of neutra1 ammonium tartrate or
470
American Journal of Surgery
Rutherford-OcuIar
ammonium chIorid. These irrigations may have to be repeated daiIy or oftener for some time. The soIution of the tartrate shouId be graduaIIy increased in strength up to 20 per cent if toIerated. SmaII Iosses of conjunctiva can be repaired earIy with grafts of mucous membrane cut from the inner surface of a Iip, but in the case of aIkaIi, meta or other deep burns the ffap wiI1 probably be Iost by sIoughing unIess its appIication is postponed untiI the inffammation shaII have subsided. In burns involving the conjunctiva of the Iids and the cornea flat pIedgets of cotton impregnated with bichIoride ointment shouId be pIaced between the two structures as deepIy as the wound extends into the cuI-de-sac to prevent the formation of a symbIepharon. Ether may enter the eye accidentaIIy during its administration for anesthesia; it causes a painfu1 but superficia1 Iesion. Phenacaine ointment and bandage are appIied as often as necessary to controI pain. DRESSINGS
AND
AFTER
CARE
At the concIusion of the initia1 treatment for foreign bodies or burns the conjunctiva1 sac shouId be irrigated with a soIution of mercurophen or mercuric chIoride I : 8000. A drop of I per cent soIution of atropine is instiIIed; a drop of I per cent soIution of phenacaine hydrochIoride (hoIocaine) may be added. Ointment of I :3000 mercuric chIoride, made up with petroIatum and IanoIin as a base, is pIaced beneath the Iids and the cIosed Iids are covered with an eye-pad or bandage. The patient may be suppIied with a soIution of phenaCaine for pain and some bichIoride ointment for dressings. Instructions are given about proper care, the IiabiIity of infection and its consequences, and the reasons for reporting promptIy shouId the eye become red or painfuI. In miId cases the dressings +El%
APRIL, 1929
Injuries
may be discontinued after twenty-four hours. Severe cases require further attention. PainfuI wounds sometimes need dionine in 5 or IO per cent soIution or ointment two or three times a day. Phenacaine may be combined with the dionine. Some apparentIy heaIed cornea1 wounds are characterized by instabiIity of the new epitheIium. When the patient opens the eyes on awaking, the Iids scrape off the new ceIIs and pain of a few hours’ Such eyes shouId be duration ensues. dressed with 5 per cent dionine ointment or 2 per cent yeIIow oxide of mercury ointment at bedtime. White opacities occasionaIIy remain in the cornea after heaIing has been accompIished; in recent cases IO per cent dionine and light massage daiIy are often of benefit in heIping to restore transparency. CONTUSIONS
Contusions of the eyebaI1 are frequentIy foIIowed by an edema of the cornea with cIouding which may resembIe an interstitia1 keratitis. The history of injury, prompt appearance of the opacity and an earIy recovery wiI1 be of heIp in making the differentiation. Sometimes an attack of true interstitia1 keratitis is precipitated by a contusion in congenitaIIy syphiIitic patients; uniIateraIity is characteristic of this condition. The treatment of contusions is by coId compresses for ten minutes every two hours, dionine in 5 per cent soIution or ointment twice daiIy and Iight massage once daily. Whenever the cornea is insensitive the eye shouId be protected with ointment and bandage. Hemorrhages sometimes occur into the anterior chamber after trauma. The coIoring matter of the bIood may stain the cornea; cIearing begins at the periphery, but the restoration of transparency is greatIy deIayed and often incompIete.
W.
RUTHERFORD, IOWA
T
INTRODUCTION
HE
impact of a foreign body against the cornea usuaIIy causes immediate pain which is soon accompanied by bIepharospasm, increased Iacrimation and photophobia. These symptoms arise from injury to the sensory nerves of the cornea directIy, or indirectIy through reff exes excited by the injury. OccasionaIIy a wound can be demonstrated objectiveIy when it is not accompanied by symptoms because the sensitive nerve terminaIs have been destroyed or obtunded. Those cases in which unimbedded foreign substances can be removed with a cottonwound probe wiI1 not be considered. Foreign bodies commonIy consist of detached bits of cinder, coa1, emery, grains of gunpowder, meta1, stone, gIass or wood chips. Leaves, twigs, thorns, wheat beards and so forth aIso can injure the eye. Before proceeding with an examination vaIuabIe information may be obtained by inquiring into the patient’s occupation and environment at the time of the accident. EXAMINATION
The examination is made first in good daylight and then under bright artificia1 light. The eyelids are separated and the patient is made to Iook in different directions, as the examiner desires, unti1 a11 of the cornea has been scrutinized; the use of a condensing Iens, Ioupe, or magnifying gIass is advantageous. A foreign body may be Iocated with the ophthaImoscope by using convex 7, 16 or 20 Ienses at appropriate distances ,with the iIIuminated pupi as a background. The next step is to stain the cornea, not onIy to Iocate the wound but to determine its extent and depth. A few drops of 5 per cent cocaine solution are instiIIed, and then
M.D.,
INJURIES* F.A.C.S.
CITY
a solution of ffuoresceine, 2 per cent, combined with sodium carbonate, 4 per cent. After waiting a few minutes the eye is irrigated with boric acid or norma saIt soIution. A bright green coIor appears at the site of any recent destruction of cornea1 epithelium. A circumscribed dark spot in a fieId of green indicates the position of a foreign body if present; perforating injuries do not exhibit a dark spot. Photophobia or pain make it diffIcuIt or impossibIe for the patient to keep the Iids separated. A few drops of 5 per cent soIution of cocaine or butyn in the conjunctiva1 sac generaIIy reduces the disability. A bIepharospasm that does not yieId to this expedient can be reIaxed by injecting I or 2 C.C. (16 to 31 drops) of 2 per cent solution of procaine, with or without 0.016 gm. (s/4 grain) of morphine sulphate, into the tissues outside the IateraI border of the orbit; the injections are made deepIy toward the externa1 auditory meatus and the ramus of the mandible. This paraIyzes important branches of the facia1 nerve. The eye shouId be protected by dressings for at Ieast six hours after the use of any IocaI or infXtration anesthetic. Genera1 anesthesia is advised for the examination and treatment of smaI1 chiIdren. TREATMENT The remova of a foreign body shouId be undertaken onIy with adequate iIIumination, effective anesthesia and aseptic precautions. A few drops of 40 per cent argyro1 soIution are instiIIed into the conjunctiva1 sac and the sac is then irrigated with steriIe norma saIt soIution or mercurophen I. 8000. The Iids can be heId apart with retractors or an eye specuIum. Magnification may be required as for the examination. Normal saIt
* Submitted for pubticationFebruary 7, 1929. 468
NEW
SERIES
VOL.
VI,
No.
4
Rutherford-Ocular
soIution shouId be dropped on the cornea frequentIy to prevent drying of its epithehum. The patient is instructed to fix the gaze on some seIected object with both qes open, in order that the eyebaI1 shaI1 be steady in position; a drop of cocaine soIution in the uninjured eye is heIpfu1. MagnetizabIe substances may be removed with an eye magnet; where they are obstinate the current shouId be made and broken rapidIy to create jerking puIIs. The removal of smaII foreign bodies from the cornea may be attempted with an eye spud or needIe, or the sharp point of a fine knife, such as a cataract knife. The instrument is worked around and under the body, which is th en lifted out. GIass is especiaIIy diffIcuIt because of its transparency. Powder grains are usuaIIy numerous and tedious to disIodge. Iron often Ieaves a rust stain which may be removed with a fine denta driI1 rotated by the operator’s fingers. A foreign substance free in the anterior chamber is removed by opening the chamber at the periphery and grasping the body with fine forceps. Where the body is Iodged in the iris both are grasped with forceps and drawn out only far enough to permit excision of the part of the iris which contains the body. The Iens must not be touched. These surgical wounds do not require sutures, but they shouId be dressed daily unti1 the anterior chamber has fuIIy reformed. Patients with foreign bodies situated posterior to the iris shouId be referred. Foreign bodies in the Iens are prone to cause cataract; those in the ciIiary body usuaIIy cause vioIent iridocyclitis and those in the posterior segment of the eye are removed onIy with great difEcuIty even by experienced operators. An object can perforate the cornea without remaining in the eye. FIaps are fashioned from the conjunctiva to cover the opening unti1 the cornea shaI1 have been heaIed and any Ieakage of aqueous stopped. The conjunctiva is incised I mm. from the cornea for about half of its circumference.
Injuries
American Journal of Surgery
469
The flap is formed by undermining the membrane, drawing it over the perforation Iike an apron and suturing it at each side
of the cornea with fine siIk (Fig. I). If the perforation is centra1 it is better to fashion a doubIe peduncuIated Aap. The first incision is made as in the former instance and another concentric with it and 3 or 6 mm. more peripheraIIy. The ffap is undermined, brought over the wound and fixed in pIace by sutures outside the cornea (Fig. 2). No suture or Ioose ends shouId Iie in contact with cornea1 tissue. OrdinariIy the sutures can be removed in five days. A negIected foreign body in the cornea may be overgrown with epitheIium and become encysted. If infection is present an abscess wiI1 form; it shouId be incised promptIy, cIeansed by gentIe irrigation, dried and then painted IightIy with pure pheno1. Otherwise the abscess may rupture and perhaps expe1 the body or it may Iead to Ioss of the gIobe. Cases of intraocuIar infection shouId be referred. BURNS
Burns are caused by boiIing liquids, steam, acids, aIkaIies, lime, Aame, curIing irons and spIashes of moIten meta1. Anesthesia is required as for foreign bodies. AI1 particIes of aIkaIi, Iime or meta must be removed from the cornea and conjunctiva1 sac. Lime tends to produce permanent opacities in the cornea; these cases are treated by removing the particIes with forceps, with sponges and irrigations freshIy prepared 2 per cent aqueous soIutions of neutra1 ammonium tartrate or
470
American Journal of Surgery
Rutherford-OcuIar
ammonium chIorid. These irrigations may have to be repeated daiIy or oftener for some time. The soIution of the tartrate shouId be graduaIIy increased in strength up to 20 per cent if toIerated. SmaII Iosses of conjunctiva can be repaired earIy with grafts of mucous membrane cut from the inner surface of a Iip, but in the case of aIkaIi, meta or other deep burns the ffap wiI1 probably be Iost by sIoughing unIess its appIication is postponed untiI the inffammation shaII have subsided. In burns involving the conjunctiva of the Iids and the cornea flat pIedgets of cotton impregnated with bichIoride ointment shouId be pIaced between the two structures as deepIy as the wound extends into the cuI-de-sac to prevent the formation of a symbIepharon. Ether may enter the eye accidentaIIy during its administration for anesthesia; it causes a painfu1 but superficia1 Iesion. Phenacaine ointment and bandage are appIied as often as necessary to controI pain. DRESSINGS
AND
AFTER
CARE
At the concIusion of the initia1 treatment for foreign bodies or burns the conjunctiva1 sac shouId be irrigated with a soIution of mercurophen or mercuric chIoride I : 8000. A drop of I per cent soIution of atropine is instiIIed; a drop of I per cent soIution of phenacaine hydrochIoride (hoIocaine) may be added. Ointment of I :3000 mercuric chIoride, made up with petroIatum and IanoIin as a base, is pIaced beneath the Iids and the cIosed Iids are covered with an eye-pad or bandage. The patient may be suppIied with a soIution of phenaCaine for pain and some bichIoride ointment for dressings. Instructions are given about proper care, the IiabiIity of infection and its consequences, and the reasons for reporting promptIy shouId the eye become red or painfuI. In miId cases the dressings +El%
APRIL, 1929
Injuries
may be discontinued after twenty-four hours. Severe cases require further attention. PainfuI wounds sometimes need dionine in 5 or IO per cent soIution or ointment two or three times a day. Phenacaine may be combined with the dionine. Some apparentIy heaIed cornea1 wounds are characterized by instabiIity of the new epitheIium. When the patient opens the eyes on awaking, the Iids scrape off the new ceIIs and pain of a few hours’ Such eyes shouId be duration ensues. dressed with 5 per cent dionine ointment or 2 per cent yeIIow oxide of mercury ointment at bedtime. White opacities occasionaIIy remain in the cornea after heaIing has been accompIished; in recent cases IO per cent dionine and light massage daiIy are often of benefit in heIping to restore transparency. CONTUSIONS
Contusions of the eyebaI1 are frequentIy foIIowed by an edema of the cornea with cIouding which may resembIe an interstitia1 keratitis. The history of injury, prompt appearance of the opacity and an earIy recovery wiI1 be of heIp in making the differentiation. Sometimes an attack of true interstitia1 keratitis is precipitated by a contusion in congenitaIIy syphiIitic patients; uniIateraIity is characteristic of this condition. The treatment of contusions is by coId compresses for ten minutes every two hours, dionine in 5 per cent soIution or ointment twice daiIy and Iight massage once daily. Whenever the cornea is insensitive the eye shouId be protected with ointment and bandage. Hemorrhages sometimes occur into the anterior chamber after trauma. The coIoring matter of the bIood may stain the cornea; cIearing begins at the periphery, but the restoration of transparency is greatIy deIayed and often incompIete.