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Injuries to the eye
Injuries ARTHUR
S
GERARD
DEVOE,
to the Eye M.D.,*
ERIOUS injury
to the eyebaI1 or periorbita1 structures is not a common occurrence in most forms of athIetic activity. In fact, the Iiterature is rather sparse, and what references there are reIate chiefly to boxing [1,2]. In this sport a deIiberate attempt is frequentIy made to inflict damage to the eyeIids in the form of lacerations, edema and hematomas. The resulting edema can incapacitate a boxer to the point at which his opponent can win by a technica knockout. Although it is not the conscious pIan of the attacker to injure the interna structures of his rival’s eye, this not infrequently happens. In no other sport is there a deliberate attempt to damage an opponent’s eyes. AIthough in other types of athletic activities serious ocuIar injury is rather rare, nevertheless, when it does occur, it can be a major catastrophe. In genera1 most ophthaImic injuries are due to the appIication of force (usuaIly bIunt) in one manner or another to the eye and surrounding orbit, the resulting injury differing IittIe, if at aI1, from those encountered in other types of physical activity common to industry, war and civi1 life. Duke-Eider [3] has devoted some 1,200 pages to ophthaImic injuries in his “Textbook of Ophthalmology.” These include discussions of chemica1 and therma burns, radiation injuries, contusion, concussion, incised wounds and foreign bodies. AIthough this is a valuable source book for anyone seeking information concerning specific detai1, in genera1 the Iesions cIinicaIly encountered are the resuIt of concussion and contusion. More rarely incised wounds, as from a spiked shoe, and foreign bodies may be a problem. On lirst thought, it is rather remarkable that such a delicate structure as the eyebaI1 is not more frequently injured in some of our more rugged contact sports. The fact that it is not is * Professor American
New York, New York
due primariIy to its favorable anatomic position. First of aI1, the gIobe itself is eIastic and can suffer considerable distortion iyithout permanent injury. SecondIy, it is imbedded in a resilient fat pad into which it can be retroplaced a considerabIe distance by the appIication of external force. This fat mass itseIf is encased in a bony cavity with overhanging rims, the supra- and infraorbita1 ridges, which being rounded and thickened can either deflect externa1 force or transmit it to adjacent structures. The size of the opening is reIatively smaI1 (35 by 40 mm.) so that Iarge objects such as a footbalI or basketbalI wiI1 tend to be deflected before their kinetic force can reach the eyebalI. The bony orbit is surrounded, in Iarge part, by the paranasa1 sinuses, the orbita waIIs of which are quite thin. When sufficient force is appIied to the eyebaI1, fracture of these waIIs can, and frequentIy does, take pIace. It is usualIy the medial or inferior wal1 which yieIds, aIIowing the expenditure of force in many directions so that it is not concentrated in the gIobe. Not uncommonly an eyebah may be dispIaced downward into the antrum so far as to be totaIIy lost from externa1 view and yet have its visua1 function undamaged. The zygomatic arch, orbital rims, waIIs and paranasa1 sinuses provide a Iight, yet strong, supporting structure to the orbital content, very much as arches and flying buttresses support the mass of a Gothic cathedra1. The optic nerve is considerabIy longer than is necessary to permit free rotation of the eyebaI1 in the orbit and therefore may be uninjured even though the eyebaIl may be Iuxated downward into the antrum or anteriorly through the eyelids. STANDARDS OF ELIGIBILITY
It is, or course, more sensible to avoid injury than to repair it. AIthough great strides have been made in the deveIopment of protective
and Chairman of the Department of OphthaImoIogy, ColIege of Physicians and Surgeons, CoIumbia University and Director, Institute of OphthaImology, Presbyterian HospitaI, New York City.
Journal
of Surgery,
Volume
98, September,
rgfg
384
Injuries
to Eye final decision would ha\-e to rest upon compctent o[>hthalmological examination since there arc t> pes of m> opin exhibiting considerable chorioretinal degeneration in which retinal detachment is more likeJ>- to dc\,eIop. There are other individuals with rnj-opia of cqui\~;~lent degree t\-ho have essentially nornlal cl!-cs. In these I would be inclined to ;Issume the calculated risk.
as bvitnessed by the now almost equipment, universal use of face masks by footbalI teams, improvements can still be made. There arc, ne\ crtheless, in spite of the best protective de\,&, certain individuaIs who are more prone to ocular injury than others. For this reason certain rather broad standards of physical rligibility have been set by most schools and collcgcs. Those persons with a high degree of subject to retinal In)-opia are notoriousIy detachment. It would be most unwise therefore to allow such individuaIs to box, high dive, or pIa!- football. The exact point at which to draw the Jine of eIigibiIity, particuIarIy in college and secondary- schooJ sports, is diffIcuIt to define and ma\- well vary from institution to institution. It. is acknowledged that a calcuIated physical risk must exist in all sports. We accept these risks, weighing as best we can the various f’actors invol\,ed. For some young men athletics is of such paramount importance that prohibition of a sport ma\- have serious psychoIogica1 repercussions. There are occasions when it is better judgment to take the additiona risk, which actualI?-, in most cases, is rather small. An instance comes to mind of a boy of secondary schoo1 age, who was an exceIIent soccer pIa\.er in spite of having one ambIyopic eye. He moved to a new school area where the regulations of the Board of Education prohibited contact sports for those with only one scrviceabie eye. The boy’s school work declined and his socia1 development left something to he desired unti1 as the result of considerable parental influence, the signing of waivers, and the utiIization of special headgear, permission \vas finaIIy granted the youth to take part in this sport. ReguIations concerning visual standards are excellent but there are occasions in which it may be wiser not to interpret them too rigidly. It. is usuaIIy agreed that those with only one useful eye shouId not take part in contact sports. This wouId exclude individuaIs who have Iost one eye from an accident, those in whom profound ambIyopia ex anopsia associated with strabismus has developed, and others who from an\’ number of causes mav have defective &ion. High degrees of myopia, as previously indicated, shouId be disqualifying but the term “ high ” is somewhat ephemera1. Certainly mJ-opia of - 10.00 diopters wouId universally be considered in this category. However, - 5.00 or-Loo diopters might be borderline. Here the
USF.
OF
GLASSES
Measurement of visual acuity per se is of somewhat dubious value except as a rough guide. Those with Iess than zo/200 uncorrectecl vision, or with corrected vision less than 20/20 should wisely be referred for special opinion. If no organic drsease is found, the individual, with the exceptions as noted, should be given free choice as to his choice of sports. There is no reason why wearing glasses should be a serious handicap to one engaging in a non-contact sport such as tennis, track, goIf, g>-mnastics, crew, skiing, shooting and the like. Even baseball pIayers can wear glasses satisfactorily. In a11 these sports, however, the use of non-shatterable gIasses should be insisted upon. These may be either in the form of plastic lenses which have the disadvantage of scratching easily, or in the form of case hardened lenses. RIan>- serious injuries to the eJ-e from squash, tennis and goIf balIs can be avoided if shatterproof Tenses arc worn. The use of contact lenses is eminentIj practical. They are now being u’orn bv man! professional and college athletes. Tno main types are currently in use (1,l cornea1 lenses which are smaI1 discs curved to fit the cornea to which they remain attached by capillary attraction, and (2) scIera1 contact Icnscs, which in addition to covering the cornea, extend out onto the scIera for some miIIimeters. Cornea1 Ienses are more comfortable to wear, more rapidly tolerated and in genera1 can be worn for a longer period. They are, however, more readily Iost from the eye either by quick movcment or sudden jolt of the head. They cannot be used by swimmers, since they would immediately wash off when the eyelids are open. ScIeraI contact Ienses, on the other hand, are in genera1 Iess comfortabIe, can usually be worn for lesser periods but do have the advantage that they are not easily disIodged since the e> eIids press them into position. These can be Lvorn 3%
DeVoe by swimmers. Recent tech&a1 modifications have improved their wearability. For those who cannot tolerate contact Ienses and yet need gIasses for visuaI purposes, severa types of eyegIass frames have been devised. These can be obtained from any competent optician.
the presence of obviousIy abnorma1 conditions, such as displacement of the pupi or eyeball, hemorrhage into the anterior chamber of the eye, and excessive edema and chemosis other than the usua1 “bIack eye.” CONTUSION
Contusion represents one of the most common types of injury and is ordinariIy manifested by the we11 known bIack eye. It is due to the rupture of smaI1 bIood vesseIs in subcutaneous tissues of the Iids. As with hemorrhage elsewhere in the body, it is usualIy self-Iimiting. Since the skin of the eyeIids is the thinnest in the body, and the subcutaneous supporting structures are equaIIy tenuous, hemorrhage in this area is manifested by more rapid and extensive sweIIing than is encountered with contusions in other parts of the body. The pertinent effect upon the athIete is that IocaI sweIling mechanicaIIy cIoses the eyelids so that it is impossibIe for him to see. In the past, professional trainers have been known to incise the skin of the swoIIen Iid with a razor blade in order to evacuate bIood and Iessen the mechanica1 sweIIing. This unwhoIesome practice is no Ionger countenanced but even if it were performed by a surgeon under aseptic conditions, it wouId probabIy have IittIe practica1 vaIue. BIood is diffusely spread through the tissues and not Ioculated so that it can be easiIy evacuated. The usua1 first aid measures of iced packs, apphcation of beefsteak and simiIar have IittIe vaIue other than procedures, psychotherapeuticalIy. Once bIood has extravasated into tissues from a ruptured bIood vesse1, external applications wiI1 be of IittIe heIp in hastening its absorption. We have not been enthusiastic about the use of systemic enzymes, such as trypsin, folIowing a recent experience in which a large but we11 Iocalized periorbita1 hemorrhage promptIy extravasated into the face, neck and chest, after the administration of the enzyme. Because of extensive vascuIar suppIy to the Iids, heaIing is prompt and absorption of ffuid and bIood products occurs within a few days. RareIy does a Iocalized hematoma become infected or require surgica1 evacuation. Contusion aIone can cause disIocation of the Iens, hyphema, retina1 edema, retina1 hemorrhage, vitreous hemorrhage, retina1 tears and retina1 detachment. It may aIso rupture the gIobe subconjunctivaIIy. Such severe injuries,
INJURIES
When an injury to or about the eye occurs, the question immediateIy arises as to its degree of seriousness and whether ophthatmological advice shouId be secured. The dividing Iine between trauma which is essentiaIIy innocuous and that which is potentiaIIy dangerous to eyesight, may be fine and at times may be impossibIe to estabIish. If one is abIe to estimate the degree of force applied, one may hazard a guess that no serious sequeIae wiI1 eventuate. That such estimate may be unreIiabIe is exempIified by the history of a recent patient, who whiIe sitting quietly at a restaurant tabIe was struck in the orbita region by a waiter carrying a tray of dishes. OnIy a minor external contusion was noted immediateIp, yet dipIopia shortIy appeared and roentgenograms of the orbit demonstrated a dispIaced fragment of the media1 orbita waI1. This had not been promptIy noted because the paucity of presenting symptoms did not make roentgenoIogica1 study mandatory. In many instances a competitor in the excitement of a game, may underestimate the severity of a bIow and pay IittIe attention to it. It is not at al1 uncommon for ophthaImoIogists to see individuaIs who have been hit in the eye with some such object as a squash or a tennis baI1. The immediate history is one of temporary blurring of vision and recovery, only to be foIIowed some weeks Iater by marked loss of vision. Examination thereupon reveaIs detachment of the retina. If a competent funduscopic examination with the pupi fuIIv diIated had been made immediately after the incident, it is IikeIy that hemorrhage and edema wouId have been seen in the periphera1 retina, and in a11 probabiIity a smaI1 tear wouId have been observed. With present methods of observation and treatment such smaI1 tears can be readiIy treated with very IittIe discomfort to the patient. CertainIy any injury in which there is subjective disturbance of vision, such as alteration in visua1 acuity, Ioss of visual fieId, or dipIopia, calIs for an immediate ophthalmologica survey. In addition, similar advice shouId be sought in
386
Injuries
to Eye artery behind the ciIiary body, (6) hemorrhages into nerve sheaths, (7) cicatricial contraction of orbita tissue following inflammation, (8) cicatricial adhesions to the eyeball, (Q) cicatricial contraction of the extraocular muscles, (IO) absorption of orbital fat due to the pressure incident upon severe cellulitis, (I I) similar pressure atrophy foIIowing an orbital hematoma, and (12) gross destruction of orbital content. As Pfeiffer has pointed out, adequate roentgenographic technic will demonstrate a depressed fracture of the orbital floor in almost every case. A not uncommon orbita fracture is that in which the force of the blow is transmitted through the eyeball to the medial wall of the orbit resulting in a fracture of the lamina papyracea of the ethmoid. The patient most frequentIy becomes aware of this when, upon blowing his nose, the eyelids and at times the conjunctiva suddenly balloon up and close the eye. Upon gentle palpation of the lids, the examining physician can readily feel crepitation in the tissues. When the patient is advised to discontinue blowing his nose, the condition ordinarily subsides promptlv. In general, treatment of orbital fractures is beyond the scope of the usual team physician, but his alertness to its possible presence, and prompt diagnosis with adequate roentgenographic facilities, may save the patient considerable future distress. A rather rare, but thoroughly frightening experience both to the patient and to the physician who has never encountered the condition, is the complete anterior luxation of the globe betlveen the eyehds. \Vhen this occurs the lids clamp down behind the proptosed gIobe. Retroposition is a difficult matter, which is not aided by the apprehension of the patient. Reduction shouId be performed promptly and in the following manner: With the patient lying in a recumbent position, instillation of’ a local anesthetic such as tetracaine 0.5 per cent on the eyeball and gentle retraction of the lids with muscle hooks or small retractors, will permit the physician to return the globe to its proper position, usualI\, none the worse for its experience.
holvever, are aImost invariably accompanied by intraocular hemorrhage and loss of vision which is obvious to the patient. AI1 such injuries require specialized ski11 for both diagnosis and treatment, and this shouId be immediateIy 0l)t:lincd. ORBITAL
FRACTURES
It has been noted herein that due to the arrangement of bones of varying density, as well as the curves, buttresses and tiebars exemplified by the zygomatic arch and orbita rim, considerable resistance to injury is present. Force from a blow to the area is transmitted in a variety of directions so that no concentration is dircctcd at the eyeball. Not uncommonIy a depressed fracture of the orbital floor may occur without injury to the orbita rim. The clinical result is traumatic retro- and inferoplacement of the gIobe producing the entity of traumatic enophthalmos. During the first week or so the presence of this condition may be masked by edema and hemorrhage in the orbit. It may be first suspected when edema has subsided sufftciently so that the patient can open his eyeIids and note the presence of diplopia. The importance of its recognition lies in the fact that treatment, if accomplished within the first week to ten days, is a reIatively eas) matter, but that after &is period enough fibrosis and repair have occurred so that reduction of the fracture is a considerably more complicated procedure. Diagnosis depends upon exacting roentgenographic technic. In fact, the condition although known was largely unrecognized until Pfeiffer [4] emphasized not oIlI> its frequency, but particularly the necessity of correct radioIogica1 technic. The importance of proper centering and positioning of the head to obtain a symmetrica projection and the \-alue of stereoscopic examination were noted by him. Single films often give a picture which is difficult to distinguish from sinusitis, but stereoscopic projections in the CaldweII and WTaters position readily demonstrate depression of the orbital Boor into the antrum which even an inexperienced observer can see. At one time or another the condition of traumatic enophthalmos has been attributed to: (I) injury to MuelIer’s orbital muscle, (2) injurv to the check ligaments, (3) rupture of Tenon~‘s capsuIe, (4) atrophy of orbital tissue clue to injury of sympathetic and trigeminal nerves, (3) hemorrhages of the ophthalmic
LACERATIONS
OF
THE
EYELJDS
Lacerations of the skin alone, such as horizontaI tears which occur in the eyelid and eyebrow in boxing, can be repaired by ark>387
DeVoe
FIG. I. Repair
of Iaceration
of lid. HaIving
principIe.
surgeon. The use of No. 6-o black silk sutures cIoseIy spaced is recommended, but heahng in this area occurs quite readily and even rather roughly approximated wound edges in Iids heal usuahy without perceptibIe scar. Those Iacerations, either contused or incised, which split the Iid vertically and which go through its thickness, are an entireIy different matter. Their repair calls for speciaIized technic and, unIess performed by one who is trained in this lield, wiI1 eventuate in deformation of the Iid and a disliguring scar. The frequent partial avulsion of the lower lid which occurs at the inner canthus of the eye and is associated with a transection of the IacrimaI canaIicuIus belongs in this group. AIthough it is true that injuries of this type shouId be repaired as promptly as possibIe, nevertheless, if competent heIp is not immediately at hand it is better judgment to temporize until such technical ski11 is avaiIabIe. Should it be considered necessary to repair a vertica1 through and through Iaceration the foIlowing technical points are important: First, it shouId be remembered that anatomicaIly the lid can be divided into two haIves, the first or anterior haIf containing the skin and the orbicularis muscIe, the posterior half being made up of the tarsus and conjunctiva. The essential point in repairing injuries in this area is that the incisional closure Iine of the anterior haIf shouId not be directly over the incisional Iine of the posterior haIf. In other words, a haIf lap or halving joint of the carpenter should be the aim. To accomphsh this it is necessary to split the lid into its two component halves for a distance of I to 2 mm. on either side of the
FIG. 2. Repair
of Iaceration
of Iid. CIosure.
incisiona line. (Figs. I and 2.) A milIimeter or two of the tarsal-conjunctival half is removed from one side and a corresponding amount removed from the skin muscle layer of the opposite edge of the wound. Sutures (usualIy double armed No. 4-o black silk sutures on Atraumatic@ needles) are then placed so that snug approximation of the wound is produced. SuperliciaI closure of the skin is accompIished with No. 6-o bIack siIk. If the halving type of closure or some modification is not used, a disfiguring notch in the lid is virtuaIIy certain to occur in any injury which is through the fuI1 thickness of the upper or Iower eyeIid. Repair of a severed IacrimaI canaliculus is a difficult procedure at best, and one not IikeIy to be successfuhy accomplished by an untrained operator. In most instances, treatment of severe lacerations of the Iid will be limited to first aid measures by the team physician. Should the eyelid be partially avulsed exposing the cornea, it shouId be laid back gently into position over the cornea and a Iight dressing applied. If dehnite repair cannot be accomplished immediately, the use of a broad spectrum antibiotic is desirable. The usual antitetanus measures are in order. In this situation, the principal aim is to be sure that the cornea is properly protected, since without adequate lid covering serious dehydration of the cornea may occur rather rapidIy. UsualIy, sulhcient Iid tissue remains so that it can be used to cover the cornea, if necessary, a rough temporary approximation being accompIished with a No. 4-0 black silk suture. In the rather unusual situation in which there.has been total avulsion of an upper eyeIid
Injuries
to Eye It need hardI). be emphasized that at1~ perforating injur); demands immediate: attention. !Llost physlclans are aware of the peculiar entity, sympathetic ophthalmia, which seems to have no counterpart in other organs of the hod>.. In this disease a severe infIammator>process develops in the injured e~‘e, l\,hich after ;I varying period of time may be reproduced in the uninjured e?e. Quite frequentI\, the disease in the sympathizing or uninjured cyc may be far more severe t.han in the originally injured eye. Until the advent of steroid drugs, treatment was notoriously unsatisfactor!-. Even now treatment of the condition can he :i harrowing one to the physician ant1 patient alike, so that prevention rather than curt should be the aim. It is we11 known that removal of the injured eye, prior to the onset of inflammation in the sympathizing eye, wiI1 prevent its occurrence. Etiology is not definitely established hut is presumed to be due to the cIevelopment ot autosensitivity to some ocular tissue, probahl!. uvea1 pigment. DeveIopment of sympathetic ophthaImia rareIy, if ever, occurs before the tenth day foIlowing an injury and seems to be most apt to occur at about the thirty-day period. There are many cases on record in which the disease did not develop for months or even years folIowing an injury. It is apparent., therefore, that treatment caIIs for a considerable amount of clinical judgment. In generaI, unIess an eye is obvious11 injured beyond a11 repair, the course usually followed is Immediate repair of the injured eyebaI1 foIIowed by cIose observation for a period of ten days or so. If at the end of this time the patient has reasonably good vision, and the inflammatory process seems to be subsiding, it is generaIIy considered good judgment to assume the caIcuIated risk which follows any perforating injury and continue observation and treatment. If, on the other hand, at the end of the ten-da.3 period, the eye is blind, soft, and shows evidence of increased infIammatory response, further deIay shouId not. be permitted but the eye shouId be removed immediately.
Mithout injury to the eyeball, it is possible to secure temporary protection by forming a cone of cotton or gauze, filling it with some bland ointment and inverting it directIy on top of the cornea bvhcre it can be held in position with adhesive straps. Total avulsion of the lower lid is not a serious problem from the standpoint of preservation of function of the eyebaIl. FOKEIGN
BODIES
AND
OF THE
PERFORATING
WOUNDS
EYEBALL
Perhaps the most commonly encountered ocular injury- is the minor but annoying disturbance causecl by the retention of a smaI1 foreign body beneath the upper lid. It should be remembered that these usualI? Iodge in a narrow suIcus near the Iid margm and can be removed by everting the upper lid. This Iatter maneuver can be embarrassingly diffIcuIt at times but if the examiner ~111 remember to have the patient look extremely downward and wiIl pull the Iid outward before folding it upward, the procedure wiI1 be greatly faciIiated. It should also be noted that many foreign bodies give the sensation of being in the upper Iid when the! are embedded in the cornea. Their presence is frequently missed because the examination is improperIy performed. ObIique iIIumination from a smaI1 concentrated Iight source, such las a pencil flashlight, wiI1 immediateIy reveal the foreign body. RemovaI can usually bc effected with a cotton tipped appIicator or I>>-irrigation from a syringe. Embedded foreign bodies which do not wipe off readiIy should be handled bv a speciaIist. Any injury in which there is actua1 or suspectecl perforation of the eyeball with or without a retained foreign body, is an extremeIy serious situation demanding immediate attention. No such injury can be treated by one not specifically trained. If a foreign body is thought to have entered an eye, as might occur in rifle shooting in the presence of a defective breech mechanism, it may be heIpfu1 to save a piece of the original material from which the foreign body is thought to have fragmented. It may, for example, be heIpfu1 to determine the degree of magnetism of the materiaI in order to estimate the chances of its removal. Pending the arrival of an ophthaImic surgeon, a preliminary scout x-ray fiIm of the orbita region ma> be heIpfu1 in order to establish the presence or absence of foreign materiaI. Precise localization of an intraocuIar foreign body requires specialized equipment.
REFERENCES I. BOSHOFF, P. H. and JOKL, E. Boxing injuries of the eyes. Arch. Opbtb., 39: 643, 1948. 4. DOGCART, J. I-1. Fisticuffs and the visual organs. Tr. Opbtb. Sot. U. Kingdom, 71: 53-59, 1951. 3. DUKE-ELDER, S. Text Book of Ophthalmoloav. -” vol. 6. St. Louis, 1954. C. V. Moshy Co. 4. PFEIFFER, R. L. Traumatic enophthahnc~s. Arch. Opbtb., 30: 718-726: 1943.
389
S
GERARD
DEVOE,
to the Eye M.D.,*
ERIOUS injury
to the eyebaI1 or periorbita1 structures is not a common occurrence in most forms of athIetic activity. In fact, the Iiterature is rather sparse, and what references there are reIate chiefly to boxing [1,2]. In this sport a deIiberate attempt is frequentIy made to inflict damage to the eyeIids in the form of lacerations, edema and hematomas. The resulting edema can incapacitate a boxer to the point at which his opponent can win by a technica knockout. Although it is not the conscious pIan of the attacker to injure the interna structures of his rival’s eye, this not infrequently happens. In no other sport is there a deliberate attempt to damage an opponent’s eyes. AIthough in other types of athletic activities serious ocuIar injury is rather rare, nevertheless, when it does occur, it can be a major catastrophe. In genera1 most ophthaImic injuries are due to the appIication of force (usuaIly bIunt) in one manner or another to the eye and surrounding orbit, the resulting injury differing IittIe, if at aI1, from those encountered in other types of physical activity common to industry, war and civi1 life. Duke-Eider [3] has devoted some 1,200 pages to ophthaImic injuries in his “Textbook of Ophthalmology.” These include discussions of chemica1 and therma burns, radiation injuries, contusion, concussion, incised wounds and foreign bodies. AIthough this is a valuable source book for anyone seeking information concerning specific detai1, in genera1 the Iesions cIinicaIly encountered are the resuIt of concussion and contusion. More rarely incised wounds, as from a spiked shoe, and foreign bodies may be a problem. On lirst thought, it is rather remarkable that such a delicate structure as the eyebaI1 is not more frequently injured in some of our more rugged contact sports. The fact that it is not is * Professor American
New York, New York
due primariIy to its favorable anatomic position. First of aI1, the gIobe itself is eIastic and can suffer considerable distortion iyithout permanent injury. SecondIy, it is imbedded in a resilient fat pad into which it can be retroplaced a considerabIe distance by the appIication of external force. This fat mass itseIf is encased in a bony cavity with overhanging rims, the supra- and infraorbita1 ridges, which being rounded and thickened can either deflect externa1 force or transmit it to adjacent structures. The size of the opening is reIatively smaI1 (35 by 40 mm.) so that Iarge objects such as a footbalI or basketbalI wiI1 tend to be deflected before their kinetic force can reach the eyebalI. The bony orbit is surrounded, in Iarge part, by the paranasa1 sinuses, the orbita waIIs of which are quite thin. When sufficient force is appIied to the eyebaI1, fracture of these waIIs can, and frequentIy does, take pIace. It is usualIy the medial or inferior wal1 which yieIds, aIIowing the expenditure of force in many directions so that it is not concentrated in the gIobe. Not uncommonly an eyebah may be dispIaced downward into the antrum so far as to be totaIIy lost from externa1 view and yet have its visua1 function undamaged. The zygomatic arch, orbital rims, waIIs and paranasa1 sinuses provide a Iight, yet strong, supporting structure to the orbital content, very much as arches and flying buttresses support the mass of a Gothic cathedra1. The optic nerve is considerabIy longer than is necessary to permit free rotation of the eyebaI1 in the orbit and therefore may be uninjured even though the eyebaIl may be Iuxated downward into the antrum or anteriorly through the eyelids. STANDARDS OF ELIGIBILITY
It is, or course, more sensible to avoid injury than to repair it. AIthough great strides have been made in the deveIopment of protective
and Chairman of the Department of OphthaImoIogy, ColIege of Physicians and Surgeons, CoIumbia University and Director, Institute of OphthaImology, Presbyterian HospitaI, New York City.
Journal
of Surgery,
Volume
98, September,
rgfg
384
Injuries
to Eye final decision would ha\-e to rest upon compctent o[>hthalmological examination since there arc t> pes of m> opin exhibiting considerable chorioretinal degeneration in which retinal detachment is more likeJ>- to dc\,eIop. There are other individuals with rnj-opia of cqui\~;~lent degree t\-ho have essentially nornlal cl!-cs. In these I would be inclined to ;Issume the calculated risk.
as bvitnessed by the now almost equipment, universal use of face masks by footbalI teams, improvements can still be made. There arc, ne\ crtheless, in spite of the best protective de\,&, certain individuaIs who are more prone to ocular injury than others. For this reason certain rather broad standards of physical rligibility have been set by most schools and collcgcs. Those persons with a high degree of subject to retinal In)-opia are notoriousIy detachment. It would be most unwise therefore to allow such individuaIs to box, high dive, or pIa!- football. The exact point at which to draw the Jine of eIigibiIity, particuIarIy in college and secondary- schooJ sports, is diffIcuIt to define and ma\- well vary from institution to institution. It. is acknowledged that a calcuIated physical risk must exist in all sports. We accept these risks, weighing as best we can the various f’actors invol\,ed. For some young men athletics is of such paramount importance that prohibition of a sport ma\- have serious psychoIogica1 repercussions. There are occasions when it is better judgment to take the additiona risk, which actualI?-, in most cases, is rather small. An instance comes to mind of a boy of secondary schoo1 age, who was an exceIIent soccer pIa\.er in spite of having one ambIyopic eye. He moved to a new school area where the regulations of the Board of Education prohibited contact sports for those with only one scrviceabie eye. The boy’s school work declined and his socia1 development left something to he desired unti1 as the result of considerable parental influence, the signing of waivers, and the utiIization of special headgear, permission \vas finaIIy granted the youth to take part in this sport. ReguIations concerning visual standards are excellent but there are occasions in which it may be wiser not to interpret them too rigidly. It. is usuaIIy agreed that those with only one useful eye shouId not take part in contact sports. This wouId exclude individuaIs who have Iost one eye from an accident, those in whom profound ambIyopia ex anopsia associated with strabismus has developed, and others who from an\’ number of causes mav have defective &ion. High degrees of myopia, as previously indicated, shouId be disqualifying but the term “ high ” is somewhat ephemera1. Certainly mJ-opia of - 10.00 diopters wouId universally be considered in this category. However, - 5.00 or-Loo diopters might be borderline. Here the
USF.
OF
GLASSES
Measurement of visual acuity per se is of somewhat dubious value except as a rough guide. Those with Iess than zo/200 uncorrectecl vision, or with corrected vision less than 20/20 should wisely be referred for special opinion. If no organic drsease is found, the individual, with the exceptions as noted, should be given free choice as to his choice of sports. There is no reason why wearing glasses should be a serious handicap to one engaging in a non-contact sport such as tennis, track, goIf, g>-mnastics, crew, skiing, shooting and the like. Even baseball pIayers can wear glasses satisfactorily. In a11 these sports, however, the use of non-shatterable gIasses should be insisted upon. These may be either in the form of plastic lenses which have the disadvantage of scratching easily, or in the form of case hardened lenses. RIan>- serious injuries to the eJ-e from squash, tennis and goIf balIs can be avoided if shatterproof Tenses arc worn. The use of contact lenses is eminentIj practical. They are now being u’orn bv man! professional and college athletes. Tno main types are currently in use (1,l cornea1 lenses which are smaI1 discs curved to fit the cornea to which they remain attached by capillary attraction, and (2) scIera1 contact Icnscs, which in addition to covering the cornea, extend out onto the scIera for some miIIimeters. Cornea1 Ienses are more comfortable to wear, more rapidly tolerated and in genera1 can be worn for a longer period. They are, however, more readily Iost from the eye either by quick movcment or sudden jolt of the head. They cannot be used by swimmers, since they would immediately wash off when the eyelids are open. ScIeraI contact Ienses, on the other hand, are in genera1 Iess comfortabIe, can usually be worn for lesser periods but do have the advantage that they are not easily disIodged since the e> eIids press them into position. These can be Lvorn 3%
DeVoe by swimmers. Recent tech&a1 modifications have improved their wearability. For those who cannot tolerate contact Ienses and yet need gIasses for visuaI purposes, severa types of eyegIass frames have been devised. These can be obtained from any competent optician.
the presence of obviousIy abnorma1 conditions, such as displacement of the pupi or eyeball, hemorrhage into the anterior chamber of the eye, and excessive edema and chemosis other than the usua1 “bIack eye.” CONTUSION
Contusion represents one of the most common types of injury and is ordinariIy manifested by the we11 known bIack eye. It is due to the rupture of smaI1 bIood vesseIs in subcutaneous tissues of the Iids. As with hemorrhage elsewhere in the body, it is usualIy self-Iimiting. Since the skin of the eyeIids is the thinnest in the body, and the subcutaneous supporting structures are equaIIy tenuous, hemorrhage in this area is manifested by more rapid and extensive sweIIing than is encountered with contusions in other parts of the body. The pertinent effect upon the athIete is that IocaI sweIling mechanicaIIy cIoses the eyelids so that it is impossibIe for him to see. In the past, professional trainers have been known to incise the skin of the swoIIen Iid with a razor blade in order to evacuate bIood and Iessen the mechanica1 sweIIing. This unwhoIesome practice is no Ionger countenanced but even if it were performed by a surgeon under aseptic conditions, it wouId probabIy have IittIe practica1 vaIue. BIood is diffusely spread through the tissues and not Ioculated so that it can be easiIy evacuated. The usua1 first aid measures of iced packs, apphcation of beefsteak and simiIar have IittIe vaIue other than procedures, psychotherapeuticalIy. Once bIood has extravasated into tissues from a ruptured bIood vesse1, external applications wiI1 be of IittIe heIp in hastening its absorption. We have not been enthusiastic about the use of systemic enzymes, such as trypsin, folIowing a recent experience in which a large but we11 Iocalized periorbita1 hemorrhage promptIy extravasated into the face, neck and chest, after the administration of the enzyme. Because of extensive vascuIar suppIy to the Iids, heaIing is prompt and absorption of ffuid and bIood products occurs within a few days. RareIy does a Iocalized hematoma become infected or require surgica1 evacuation. Contusion aIone can cause disIocation of the Iens, hyphema, retina1 edema, retina1 hemorrhage, vitreous hemorrhage, retina1 tears and retina1 detachment. It may aIso rupture the gIobe subconjunctivaIIy. Such severe injuries,
INJURIES
When an injury to or about the eye occurs, the question immediateIy arises as to its degree of seriousness and whether ophthatmological advice shouId be secured. The dividing Iine between trauma which is essentiaIIy innocuous and that which is potentiaIIy dangerous to eyesight, may be fine and at times may be impossibIe to estabIish. If one is abIe to estimate the degree of force applied, one may hazard a guess that no serious sequeIae wiI1 eventuate. That such estimate may be unreIiabIe is exempIified by the history of a recent patient, who whiIe sitting quietly at a restaurant tabIe was struck in the orbita region by a waiter carrying a tray of dishes. OnIy a minor external contusion was noted immediateIp, yet dipIopia shortIy appeared and roentgenograms of the orbit demonstrated a dispIaced fragment of the media1 orbita waI1. This had not been promptIy noted because the paucity of presenting symptoms did not make roentgenoIogica1 study mandatory. In many instances a competitor in the excitement of a game, may underestimate the severity of a bIow and pay IittIe attention to it. It is not at al1 uncommon for ophthaImoIogists to see individuaIs who have been hit in the eye with some such object as a squash or a tennis baI1. The immediate history is one of temporary blurring of vision and recovery, only to be foIIowed some weeks Iater by marked loss of vision. Examination thereupon reveaIs detachment of the retina. If a competent funduscopic examination with the pupi fuIIv diIated had been made immediately after the incident, it is IikeIy that hemorrhage and edema wouId have been seen in the periphera1 retina, and in a11 probabiIity a smaI1 tear wouId have been observed. With present methods of observation and treatment such smaI1 tears can be readiIy treated with very IittIe discomfort to the patient. CertainIy any injury in which there is subjective disturbance of vision, such as alteration in visua1 acuity, Ioss of visual fieId, or dipIopia, calIs for an immediate ophthalmologica survey. In addition, similar advice shouId be sought in
386
Injuries
to Eye artery behind the ciIiary body, (6) hemorrhages into nerve sheaths, (7) cicatricial contraction of orbita tissue following inflammation, (8) cicatricial adhesions to the eyeball, (Q) cicatricial contraction of the extraocular muscles, (IO) absorption of orbital fat due to the pressure incident upon severe cellulitis, (I I) similar pressure atrophy foIIowing an orbital hematoma, and (12) gross destruction of orbital content. As Pfeiffer has pointed out, adequate roentgenographic technic will demonstrate a depressed fracture of the orbital floor in almost every case. A not uncommon orbita fracture is that in which the force of the blow is transmitted through the eyeball to the medial wall of the orbit resulting in a fracture of the lamina papyracea of the ethmoid. The patient most frequentIy becomes aware of this when, upon blowing his nose, the eyelids and at times the conjunctiva suddenly balloon up and close the eye. Upon gentle palpation of the lids, the examining physician can readily feel crepitation in the tissues. When the patient is advised to discontinue blowing his nose, the condition ordinarily subsides promptlv. In general, treatment of orbital fractures is beyond the scope of the usual team physician, but his alertness to its possible presence, and prompt diagnosis with adequate roentgenographic facilities, may save the patient considerable future distress. A rather rare, but thoroughly frightening experience both to the patient and to the physician who has never encountered the condition, is the complete anterior luxation of the globe betlveen the eyehds. \Vhen this occurs the lids clamp down behind the proptosed gIobe. Retroposition is a difficult matter, which is not aided by the apprehension of the patient. Reduction shouId be performed promptly and in the following manner: With the patient lying in a recumbent position, instillation of’ a local anesthetic such as tetracaine 0.5 per cent on the eyeball and gentle retraction of the lids with muscle hooks or small retractors, will permit the physician to return the globe to its proper position, usualI\, none the worse for its experience.
holvever, are aImost invariably accompanied by intraocular hemorrhage and loss of vision which is obvious to the patient. AI1 such injuries require specialized ski11 for both diagnosis and treatment, and this shouId be immediateIy 0l)t:lincd. ORBITAL
FRACTURES
It has been noted herein that due to the arrangement of bones of varying density, as well as the curves, buttresses and tiebars exemplified by the zygomatic arch and orbita rim, considerable resistance to injury is present. Force from a blow to the area is transmitted in a variety of directions so that no concentration is dircctcd at the eyeball. Not uncommonIy a depressed fracture of the orbital floor may occur without injury to the orbita rim. The clinical result is traumatic retro- and inferoplacement of the gIobe producing the entity of traumatic enophthalmos. During the first week or so the presence of this condition may be masked by edema and hemorrhage in the orbit. It may be first suspected when edema has subsided sufftciently so that the patient can open his eyeIids and note the presence of diplopia. The importance of its recognition lies in the fact that treatment, if accomplished within the first week to ten days, is a reIatively eas) matter, but that after &is period enough fibrosis and repair have occurred so that reduction of the fracture is a considerably more complicated procedure. Diagnosis depends upon exacting roentgenographic technic. In fact, the condition although known was largely unrecognized until Pfeiffer [4] emphasized not oIlI> its frequency, but particularly the necessity of correct radioIogica1 technic. The importance of proper centering and positioning of the head to obtain a symmetrica projection and the \-alue of stereoscopic examination were noted by him. Single films often give a picture which is difficult to distinguish from sinusitis, but stereoscopic projections in the CaldweII and WTaters position readily demonstrate depression of the orbital Boor into the antrum which even an inexperienced observer can see. At one time or another the condition of traumatic enophthalmos has been attributed to: (I) injury to MuelIer’s orbital muscle, (2) injurv to the check ligaments, (3) rupture of Tenon~‘s capsuIe, (4) atrophy of orbital tissue clue to injury of sympathetic and trigeminal nerves, (3) hemorrhages of the ophthalmic
LACERATIONS
OF
THE
EYELJDS
Lacerations of the skin alone, such as horizontaI tears which occur in the eyelid and eyebrow in boxing, can be repaired by ark>387
DeVoe
FIG. I. Repair
of Iaceration
of lid. HaIving
principIe.
surgeon. The use of No. 6-o black silk sutures cIoseIy spaced is recommended, but heahng in this area occurs quite readily and even rather roughly approximated wound edges in Iids heal usuahy without perceptibIe scar. Those Iacerations, either contused or incised, which split the Iid vertically and which go through its thickness, are an entireIy different matter. Their repair calls for speciaIized technic and, unIess performed by one who is trained in this lield, wiI1 eventuate in deformation of the Iid and a disliguring scar. The frequent partial avulsion of the lower lid which occurs at the inner canthus of the eye and is associated with a transection of the IacrimaI canaIicuIus belongs in this group. AIthough it is true that injuries of this type shouId be repaired as promptly as possibIe, nevertheless, if competent heIp is not immediately at hand it is better judgment to temporize until such technical ski11 is avaiIabIe. Should it be considered necessary to repair a vertica1 through and through Iaceration the foIlowing technical points are important: First, it shouId be remembered that anatomicaIly the lid can be divided into two haIves, the first or anterior haIf containing the skin and the orbicularis muscIe, the posterior half being made up of the tarsus and conjunctiva. The essential point in repairing injuries in this area is that the incisional closure Iine of the anterior haIf shouId not be directly over the incisional Iine of the posterior haIf. In other words, a haIf lap or halving joint of the carpenter should be the aim. To accomphsh this it is necessary to split the lid into its two component halves for a distance of I to 2 mm. on either side of the
FIG. 2. Repair
of Iaceration
of Iid. CIosure.
incisiona line. (Figs. I and 2.) A milIimeter or two of the tarsal-conjunctival half is removed from one side and a corresponding amount removed from the skin muscle layer of the opposite edge of the wound. Sutures (usualIy double armed No. 4-o black silk sutures on Atraumatic@ needles) are then placed so that snug approximation of the wound is produced. SuperliciaI closure of the skin is accompIished with No. 6-o bIack siIk. If the halving type of closure or some modification is not used, a disfiguring notch in the lid is virtuaIIy certain to occur in any injury which is through the fuI1 thickness of the upper or Iower eyeIid. Repair of a severed IacrimaI canaliculus is a difficult procedure at best, and one not IikeIy to be successfuhy accomplished by an untrained operator. In most instances, treatment of severe lacerations of the Iid will be limited to first aid measures by the team physician. Should the eyelid be partially avulsed exposing the cornea, it shouId be laid back gently into position over the cornea and a Iight dressing applied. If dehnite repair cannot be accomplished immediately, the use of a broad spectrum antibiotic is desirable. The usual antitetanus measures are in order. In this situation, the principal aim is to be sure that the cornea is properly protected, since without adequate lid covering serious dehydration of the cornea may occur rather rapidIy. UsualIy, sulhcient Iid tissue remains so that it can be used to cover the cornea, if necessary, a rough temporary approximation being accompIished with a No. 4-0 black silk suture. In the rather unusual situation in which there.has been total avulsion of an upper eyeIid
Injuries
to Eye It need hardI). be emphasized that at1~ perforating injur); demands immediate: attention. !Llost physlclans are aware of the peculiar entity, sympathetic ophthalmia, which seems to have no counterpart in other organs of the hod>.. In this disease a severe infIammator>process develops in the injured e~‘e, l\,hich after ;I varying period of time may be reproduced in the uninjured e?e. Quite frequentI\, the disease in the sympathizing or uninjured cyc may be far more severe t.han in the originally injured eye. Until the advent of steroid drugs, treatment was notoriously unsatisfactor!-. Even now treatment of the condition can he :i harrowing one to the physician ant1 patient alike, so that prevention rather than curt should be the aim. It is we11 known that removal of the injured eye, prior to the onset of inflammation in the sympathizing eye, wiI1 prevent its occurrence. Etiology is not definitely established hut is presumed to be due to the cIevelopment ot autosensitivity to some ocular tissue, probahl!. uvea1 pigment. DeveIopment of sympathetic ophthaImia rareIy, if ever, occurs before the tenth day foIlowing an injury and seems to be most apt to occur at about the thirty-day period. There are many cases on record in which the disease did not develop for months or even years folIowing an injury. It is apparent., therefore, that treatment caIIs for a considerable amount of clinical judgment. In generaI, unIess an eye is obvious11 injured beyond a11 repair, the course usually followed is Immediate repair of the injured eyebaI1 foIIowed by cIose observation for a period of ten days or so. If at the end of this time the patient has reasonably good vision, and the inflammatory process seems to be subsiding, it is generaIIy considered good judgment to assume the caIcuIated risk which follows any perforating injury and continue observation and treatment. If, on the other hand, at the end of the ten-da.3 period, the eye is blind, soft, and shows evidence of increased infIammatory response, further deIay shouId not. be permitted but the eye shouId be removed immediately.
Mithout injury to the eyeball, it is possible to secure temporary protection by forming a cone of cotton or gauze, filling it with some bland ointment and inverting it directIy on top of the cornea bvhcre it can be held in position with adhesive straps. Total avulsion of the lower lid is not a serious problem from the standpoint of preservation of function of the eyebaIl. FOKEIGN
BODIES
AND
OF THE
PERFORATING
WOUNDS
EYEBALL
Perhaps the most commonly encountered ocular injury- is the minor but annoying disturbance causecl by the retention of a smaI1 foreign body beneath the upper lid. It should be remembered that these usualI? Iodge in a narrow suIcus near the Iid margm and can be removed by everting the upper lid. This Iatter maneuver can be embarrassingly diffIcuIt at times but if the examiner ~111 remember to have the patient look extremely downward and wiIl pull the Iid outward before folding it upward, the procedure wiI1 be greatly faciIiated. It should also be noted that many foreign bodies give the sensation of being in the upper Iid when the! are embedded in the cornea. Their presence is frequently missed because the examination is improperIy performed. ObIique iIIumination from a smaI1 concentrated Iight source, such las a pencil flashlight, wiI1 immediateIy reveal the foreign body. RemovaI can usually bc effected with a cotton tipped appIicator or I>>-irrigation from a syringe. Embedded foreign bodies which do not wipe off readiIy should be handled bv a speciaIist. Any injury in which there is actua1 or suspectecl perforation of the eyeball with or without a retained foreign body, is an extremeIy serious situation demanding immediate attention. No such injury can be treated by one not specifically trained. If a foreign body is thought to have entered an eye, as might occur in rifle shooting in the presence of a defective breech mechanism, it may be heIpfu1 to save a piece of the original material from which the foreign body is thought to have fragmented. It may, for example, be heIpfu1 to determine the degree of magnetism of the materiaI in order to estimate the chances of its removal. Pending the arrival of an ophthaImic surgeon, a preliminary scout x-ray fiIm of the orbita region ma> be heIpfu1 in order to establish the presence or absence of foreign materiaI. Precise localization of an intraocuIar foreign body requires specialized equipment.
REFERENCES I. BOSHOFF, P. H. and JOKL, E. Boxing injuries of the eyes. Arch. Opbtb., 39: 643, 1948. 4. DOGCART, J. I-1. Fisticuffs and the visual organs. Tr. Opbtb. Sot. U. Kingdom, 71: 53-59, 1951. 3. DUKE-ELDER, S. Text Book of Ophthalmoloav. -” vol. 6. St. Louis, 1954. C. V. Moshy Co. 4. PFEIFFER, R. L. Traumatic enophthahnc~s. Arch. Opbtb., 30: 718-726: 1943.
389