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Preparedness critical to minimizing ocular trauma in emergencies
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Both general and specialist ophthalmologists should be familiar with the newest, most effective treatments for ocular injuries, experts say.
An estimated 2.4 million eye injuries are reported each year in the U.S., many occurring from common household accidents and work, as well as severe trauma such as burn and blast injuries. Immediate and effective ocular trauma treatment is key for optimal patient care.
Ferenc Kuhn, MD, PhD, executive vice president of the International Society of Ocular Trauma and president of the American Society of Ocular Trauma, said general ophthalmologists must educate patients about eye safety, including the importance of eye protection.
“Hopefully do it before and not after [an injury],” Dr. Kuhn said. “This is something that is so important to emphasize.”
 Ferenc Kuhn, MD, PhD, said general ophthalmologists must educate patients about eye safety, including the importance of eye protection. Image: Takács G |
Recent innovations in the field of ocular trauma have helped save more eyes than in the past. The Birmingham Eye Trauma Terminology System and the Ocular Trauma Score, two systems providing a common language and scoring system for ocular trauma for all physicians, have assisted in structuring trauma treatment, Dr. Kuhn said. He helped devise both systems.
In addition, he helped plan the first symposiums at major U.S. and world meetings, including the recent World Ophthalmology Congress in Berlin, about ocular trauma resulting from terrorist attacks. He said ophthalmologists are beginning to realize that readiness for future disasters, whatever the cause, is necessary. Many ocular facilities around the world have been cutting back their hours and are no longer open all day, every day. This trend could be devastating in disasters but is also problematic in everyday accidents, Dr. Kuhn said.
“I think a lot of people realize this problem. They are willing to do whatever they personally can, but this is a problem that is bigger than any single ophthalmologist,” he said.
Prevention of ocular trauma
General ophthalmologists should have a good working knowledge of ocular injuries, including prevention and treatment of the two most common causes, mechanical and chemical, Dr. Kuhn said. A 2009 report from the American Academy of Ophthalmology’s EyeSmart campaign found that 56% of ocular injuries were treated in ophthalmologists’ offices, and 32% were treated in a hospital emergency department or emergency room.
Common causes of ocular injury in the U.S. include fireworks, motor vehicle crashes and lawn maintenance. Most injuries result from accidents, with a lesser number caused by assaults.
The EyeSmart report found that 48% of injuries in the U.S. happened in the home, and of those, about one-third were due to recreation or sports. More than one in five at-home injuries resulted from home repair or power tool use. “Home warriors” who perform home renovations with power tools do not always use eye protection, Dr. Kuhn said, and open-globe injuries have been on the rise as a result.
“I remember one case … it was a man, a car mechanic, who came in with an intraocular foreign body that he got into the eye while he was working on a car,” Dr. Kuhn said. “I asked him, ‘Don’t you wear eye protection?’ and he said, ‘Yes, at work I do, but this was in my own garage.’ So the reason why he wore it was not because he was afraid of getting injured, of course; it was because it was mandatory in the workplace. And he immediately took it off when he was outside the workplace.”
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The 2009 report, compiled from 627 completed questionnaires, showed that of ocular injuries that occurred in the home, nearly one-third happened in living areas of the house, including the kitchen, bedroom, bathroom and living room. The yard and garden were the most common places where injury occurred.
A common indoor rupture injury, occurring most frequently in the elderly, is caused by the patient falling over or onto blunt household objects and striking their eyes, Dr. Kuhn said. These cases often have serious prognoses because of pre-existing conditions and slower healing time in the elderly. General ophthalmologists can help prevent such injuries by educating patients about good nighttime lighting and other factors, he said.
“You have to remove objects from the straightest route from the bed to the bathroom. You have to get furniture out of the way. You leave the door open so the doorknob is not in the way. You make the floor and the bathtub non-slippery,” Dr. Kuhn said.
Mechanical ocular trauma
The most common mechanical ocular injury in the U.S. is rupture caused by blunt objects, followed by open-globe injuries from sharp objects, Dr. Kuhn said.
In rupture injuries, lumber and wood often play a significant role in serious trauma. Ocular rupture injuries can include tissue loss, retina involvement and other secondary complications from scarring such as proliferative vitreoretinopathy.
“Rupture is an injury caused by a blunt object, which would cause the intraocular pressure to elevate. And the reason for this, of course, is because the eye is basically a sphere filled with liquid. As all liquids are incompressible, the pressure rises. And once that elevated pressure is greater than the resistance of the eye wall, the eye will rupture from the inside,” Dr. Kuhn said.
In open-globe injuries, the risk of scarring is high when an object enters and exits the eye out of the same wound or different wounds, such as in a perforating injury. Cases with different exit and entrance wounds are especially difficult to treat because of the risk of proliferative vitreoretinopathy. Many of those eyes are lost from subsequent scarring, he said.
A few years ago, Dr. Kuhn was treating a young boy with a perforating injury. When selecting the best treatment option, he recalled that choroid removal performed for a malignant choroidal melanoma involved leaving bare sclera at the operation site and resulted in a low proliferative vitreoretinopathy rate.
“I [thought], what if I tried to do that very same surgery for this case? I removed the retina and the choroid around the wound and the boy had no [proliferative vitreoretinopathy],” he said. Dr. Kuhn termed the procedure prophylactic chorioretinectomy.
A multicenter international trial of prophylactic chorioretinectomy in ocular injuries, including perforating wounds, at high risk for proliferative vitreoretinopathy is now being conducted. Rates of proliferative vitreoretinopathy are approximately 70% with typical treatment; with the prophylactic chorioretinectomy technique, the proliferative vitreoretinopathy rate is zero so far. Dr. Kuhn said the rate will most likely not remain this low in all prophylactic chorioretinectomy cases, but the surgery shows great promise for destroying cells that lead to proliferative vitreoretinopathy.
Chemical ocular trauma
Chemical burn ocular injuries, although not as common as mechanical injuries, can be severe and must be treated correctly for best outcomes.
Many chemical eye injuries are mitigated with whatever liquid agent is available, whether the chemical is an acid or a base. Physicians are taught to use water to dilute the chemical agent, a good way of addressing the ocular surface injury, Dr. Kuhn said. However, water is not as effective for a secondary complication in chemical ocular injury, the anterior chamber impact, he said. Chemical injuries can result in severe interior scarring and glaucoma.
In chemical injuries, the eye’s pH changes occur both on the surface and intraocularly. A study by Schrage and colleagues explained that water is hypotonic to the corneal stroma. Chemicals can penetrate into the deeper corneal structures through an osmolarity gradient that increases water influx into the cornea.
“By irrigating the surface, you deal with one aspect of the problem, but you don’t deal with the other aspect,” Dr. Kuhn said.
Dr. Schrage has shown that the amphoteric agent diphoterine is effective against both acids and bases, working to preserve the surface and interior ocular pH. It should be readily available in all ophthalmologists’ offices and emergency rooms, and general ophthalmologists and specialists who encounter such injuries should be aware that diphoterine is an excellent treatment option, Dr. Kuhn said.
“It neutralizes the agent, whatever it is, much sooner — on the surface but especially inside. Many times why the eye is lost is not the superficial scarring; it’s the inside scarring and glaucoma especially, because it destroys the outflow mechanism,” he said.
Readiness for ocular trauma
Preparedness is necessary to effectively treat ocular injuries sustained in mass casualty emergencies, including natural disasters and terrorist attacks, experts say. These injuries may more likely be treated by general ophthalmologists and subspecialists because of limited access to care outside the immediate vicinity. General ophthalmologists should have up-to-date skills in treating facial injuries, including the globe and eyelid, retired U.S. Army Col. Robert Mazzoli, MD, said.
“Even if you did a few [extracapsular cataract extractions] or several open globes during residency, if it’s been 5, 10 years since you’ve done corneal suturing, it’s probably not a bad idea to look at … maintaining that skill. The time to be developing that skill, the time to be knocking the rust off that skill, is not the time that you absolutely need that skill,” Dr. Mazzoli said.
 Robert Mazzoli |
For instance, natural disasters such as the earthquake in Haiti and Hurricane Katrina have presented sudden, serious ocular trauma. Other incidents, such as the recent oil spill in the Gulf of Mexico, can present potential for ocular injuries. The Centers for Disease Control and Prevention (CDC) along with state and local health departments have been monitoring health conditions in the four Gulf coastal states — Alabama, Florida, Louisiana and Mississippi — that have been impacted by the spill. Thus far, eye irritation after possible exposure to oil from the spill has been reported in Florida.
Hospital facilities, especially those in larger U.S. cities, should be prepared for mass casualty situations, Dr. Mazzoli said.
The Tel Aviv Medical Center in Israel has such a plan, according to Adiel Barak, MD, head of Vitreoretinal Service at the center. He said that following a mass casualty incident in Tel Aviv, all physicians report to the emergency room. Ophthalmologists examine each injured patient. The physicians at the level 1 trauma center providing tertiary care have extensive experience treating ocular injuries sustained in suicide bombings, which Dr. Barak outlined in a 2008 study. The study looked at patients from 13 suicide bombing attacks treated at the center from 2000 to 2004.
Of the 352 casualties from suicide bombings in the study that were treated, 17 involved ocular/periocular trauma. Of those, six eyes needed urgent primary closure of lacerations in primary repair of an open globe, two eyes had exploration of subconjunctival hemorrhage and one eye underwent primary enucleation. Foreign bodies accounted for additional surgical intervention in four eyes. Eight patients were treated and received follow-up.
“The main thing you have to do is prepare the hospitals,” Dr. Barak said. “We speak mostly about terrorist-related injuries because that’s more what you’ll see in the West, but it can happen if you have a bus crash. … You have to find your way to work through the system and prepare for it, because we’re not used to working with other doctors. We’re used to sitting in our quiet room and working by [ourselves].”
Terrorism and war-related ocular trauma
Ocular trauma is frequently sustained in terrorist-related attacks, experts say. Injuries may include corneal abrasion, corneal laceration, conjunctivitis and/or conjunctival irritation, hyphema, corneal burn, traumatic cataract, subconjunctival hemorrhage, retinal detachment, and orbital and intraocular foreign body.
Dr. Kuhn attributed the rising rate of ocular injuries, despite the relatively small area of the body that the eye occupies (1%), partly to human beings’ instinctive need to view potential danger.
“The eye is almost always turned toward harm’s way, because you have to look at what happened. So, that exposes the eye, say, more than your back. The second reason is because it’s a sensitive tissue, and also because the significance of the eye injury is much greater than an injury to your skin,” he said.
After the Sept. 11 terrorist attacks on the World Trade Center, the rate of survivor ocular injuries was 26%, according to a CDC report. In the 1995 Oklahoma City bombing, 8% of survivors had ocular injuries. An estimated 1.4% of survivors of the 1998 U.S. Embassy attack in Kenya sustained ocular injuries.
In military combat situations, eye injuries have risen to about 12% to 15% of all injuries. The U.S. Congress has appropriated extramural research funds to investigate ocular trauma and traumatic brain injury. Funds are granted in a competitive, peer-reviewed process to academic institutions across the country for ocular trauma research.
Another reason that ocular injuries could be sustained in terrorist attacks is that terrorists might be targeting eyes, Dr. Mazzoli said. For instance, in the U.S. Embassy attack in Kenya, a strong secondary blast occurred after a weaker first blast, he said. The first blast brought people to windows, to observe what was happening outside. Then the subsequent, more powerful blast exploded. It created shrapnel from window glass and other debris, causing severe ocular injuries.
Possible future terrorist incidents in U.S. and European cities could create “walking wounded” with serious ocular injuries that would need immediate and expert treatment, Dr. Mazzoli said.
Natural disaster-related ocular trauma
Following the Haitian earthquake in January, eye-related injuries were commonly encountered. Philip R. Rizzuto, MD, FACS, an oculoplastic specialist working with Project Medishare in conjunction with University of Miami Global Health Initiative and Bascom Palmer Eye Institute, was asked to assist with the relief effort. Dr. Rizzuto said eye and facial injuries that he encountered related to the earthquake included superficial and complex eyelid lacerations, trauma to the lacrimal drainage system and multiple facial lacerations. More complex injuries included facial and orbital fractures, ruptured globes and traumatic visual loss related to blunt trauma.
 Philip R. Rizzuto |
Arriving a few weeks after the earthquake, Dr. Rizzuto was impressed with the triage and initial stabilization and repair of eye-related injuries by Haitian ophthalmologists. “The professionalism and skill of the physicians residing in Haiti towards their fellow countrymen was excellent. Unfortunately, the number of injuries encountered was somewhat overwhelming,” Dr. Rizzuto said. “One of the most difficult aspects of dealing with a natural disaster is the follow-up care needed after the initial eye-related trauma has been addressed.”
Dr. Rizzuto worked with the Haitian Ophthalmology Society and its team of surgeons to address those patients requiring additional treatment such as enucleations and socket reconstruction, eyelid reconstruction for scarred and contracted eyelids to prevent lagophthalmos, and other procedures to help preserve vision.
The working conditions were suboptimal, mostly due to structural damage from the earthquake. But Dr. Rizzuto said that all the medical professionals he worked with at Project Medishare and within Port-au-Prince showed great camaraderie and compassion.
“Everybody worked together at the field hospital, so you weren’t alone. If I needed help on an orbital case, a general surgeon, plastic surgeon or internist would step up. If help was needed on a general surgery or neurosurgical case, I was happy to lend a hand. You adapted to the situation and utilized whatever tools you had. Ultimately, a smile or subdued thank-you from the Haitian people made the work so rewarding,” he said.
In order to help understand how to treat ocular injuries following a disaster, ophthalmologists should be prepared to adapt to working under different and difficult conditions, Dr. Mazzoli said.
“I think what we need to do is increase the community’s awareness of what we need and the need for our contributions in that kind of injury. I suspect that we probably saw that in Haiti and in Katrina,” he said. “That whether it is the lid or globe, they require a specific level of expertise. … The general ophthalmologist may well be the oculoplastic specialist of the day. There may not be an oculoplastic specialist available to help on the lid. There might not be a cornea specialist to help on the cornea.” – by Erin L. Boyle
References:
- Barak A, Verssano D, Halpern P, Lowenstein A. Ophthalmologists, suicide bombings and getting it right in the emergency department. Graefes Arch Clin Exp Ophthalmol. 2008;246(2):199-203.
- Kuckelkorn R, Schrage N, Keller G, Redbrake C. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand. 2002;80(1):4-10.
- Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-210.
- Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002;15(2):163-165, vi.
- Mines M, Thach A, Mallonee S, Hildebrand L, Shariat S. Ocular injuries sustained by survivors of the Oklahoma City bombing. Ophthalmol. 2000;107(5):837-843.
- Thach A. Eye injuries associated with terrorist bombings. Dept. of the Army; 2003:421-429.
- Adiel Barak, MD, is head of Vitreoretinal Service at the Tel Aviv Medical Center in Israel. He can be reached at 972-3-6973408; e-mail: adielbarak@gmail.com.
- Ferenc Kuhn, MD, PhD, can be reached at 1201 11th Ave. South, Suite 300, Birmingham, AL 35202; 205-558-2588; fax: 205-933-1341; e-mail: fkuhn@mindspring.com.
- Philip R. Rizzuto, MD, FACS, is a clinical assistant professor of surgery at the Warren Alpert Medical School of Brown University. He can be reached at Ophthalmic Plastic Surgery, 120 Dudley St., Suite 301, Providence, RI 02905; 401-274-6622; fax: 401-490-7051; e-mail: prizzuto@eyeplasticri.com.
- Robert Mazzoli, MD, can be reached at robert.mazzoli@comcast.net.
