|Year : 1968 | Volume
| Issue : 4 | Page : 198-201
Ocular battle casualities
Government Ophthalmic Hospital, Egmore, Madras-8, India
|Date of Web Publication||24-Dec-2007|
Government Ophthalmic Hospital, Egmore, Madras-8
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Balakrishnan E. Ocular battle casualities. Indian J Ophthalmol 1968;16:198-201
The type of injuries in a battle vary with the weapons employed. Air evacuation, early administration of antibiotics and facilities for transfusion even at Regimental Aid Posts have greatly helped in reducing the mortality. But as per the records, the incidence of ocular casualities seems to be on the increase. Their prognosis is complicated by retained intraocular foreign bodies of non-magnetic origin, as the missiles are made of alloys, tin, copper, plastic and other non-magnetic materials. In the following article an analysis is made of ocular battle casualties received by a general hospital in a field area in 54 days during infiltration of irregulars and Indo-Pakistan flap in 1965. Some special problems of diagnosis are mentioned with the hope to evolve better methods in the future.
Ocular Battle Casualties: Out of the total number of casualties (602) received during the 54 days of the Indo-Pakistani flap of 1965, the number of injured in eyes was 33 (5.4%), out of which 28 cases were of uniocular injury and 5 had injuries in both eyes.
[Table - 1] shows the comparison of ocular casualties in the different armed conflicts.
| Treatment on reception of casualties|| |
The Ophthalmologist did not wait for a specialist call; as the patients were unloaded and shifted to the beds the eyes were examined routinely with a torch and loupe. When they were treated for the shock, the lids and the surrounding areas were gently cleaned and the conjunctival sac was irrigated with sterile saline; penicillin drops and a sterile dressing were applied. Almost all the injured eyes were associated with injuries of the hand, facio-maxillary region, chest and limb. Often the latter injuries were serious requiring immediate surgery. After treatment of shock, they were operated by the Surgical specialist under general anaesthesia. The Ophthalmologist also utilised this opportunity in carrying out detailed examination of the eyes with retractors and Ophthalmoscope. Foreign bodies from the cornea and conjunctiva were removed; prolapsed uveal tissue was excised; conjunctival hooding, suturing of the cornea, toileting and debridement of tissues were done. During war, after this preliminary surgery, the patients were airlifted to the base hospital. When the evacuation was delayed due to adverse circumstances, this period was utilised for localisation of intra-ocular foreign bodies and their removal. Badly ruptured globes were enucleated; secondary suturing of the wounds were done.
| Special programmes|| |
Problems of X-Ray Localisation of Minute Intra-ocular Foreign bodies from the overlapping shadows of Extra-ocular foreign bodies.
In all these battle casualties, the eyes and their surroundings were peppered with minute foreign bodies. In X-Rays of the antero-posterior view of the orbit, the shadows of foreign bodies in the subcutaneous position of the lids and the surrounding skin of the orbit were seen to be inside the orbit; in the lateral view, the shadows of foreign bodies from the temple and nasal wall were overlapped making it almost impossible to decide which of them were intraocular. In those cases X-Rays with corneal ring and movement of the globe did not help in the localisation. In some cases the foreign bodies were so small that they were mostly invisible in the routine X-Rays. So the following modification of Vogt Bone Free Technique was adopted. When there was no open wound in the orbit or globe, after anaesthetising the eye with a few drops of cocaine or Anethaine, the patient was positioned on X-Ray table with the tube kept pointing from the foot end to head focusing on the eye ball. A dental film was sterilised by applying spirit on its outer cover and was inserted deep into the upper fornix as the patient was looking downwards. The film was kept steady and a soft X-Ray was taken. It showed the convex surface of the corneal epithelium and any foreign body inside the globe. To help further localisation, a corneal ring was kept on the cornea as the patient was looking down steadily and an X-ray was taken. No sutures were necessary. It is presumed that the foreign body nearer to the optic disc may not be visualised, since the dental film could not be inserted that deep in an intact upper fornix. In most of the cases, where foreign bodies were too small to be seen in the ordinary X-ray, they were easily visible in this bone free soft X-ray. This is of great advantage in diagnosing very minute intra-ocular foreign bodies, which otherwise would have been missed.
The Problem of non-magnetic Foreign bodies:
Five of the foreign bodies were removed from intra-corneal, subconjunctival, episcleral regions and one from vitreous in a badly ruptured globe. None of these were magnetic. They were from enemy mines, hand grenades, bomb and shell. There were fourteen other intra-ocular and three intra-orbital foreign bodies diagnosed and transferred to the base hospital. Since all of them were from the same type of weapons, as from which the foreign bodies removed and found to be non-magnetic, these fourteen were also suspected to be non-magnetic. Further localisation was necessary with Berman locator or by other instruments and so they were transferred to the base hospital.
| Some interesting cases|| |
Shell Injury of the Eye - Penetrating: A bunker was hit by enemy anti-tank shells and a lot of dust particles struck the right eye of a sepoy. He was treated with irrigation, removal of dust particles and application of Terramycin ointment by his Regimental Medical Officer.
Though he had a lot of relief and sent back to duty mild congestion persisted and was referred to the ophthalmologist. Vision in that eye was 6/6. Slight circum-corneal congestion with multiple islands of superficial corneal opacities was present. Under the slit lamp, minute foreign bodies were seen projecting into the anterior chamber from the posterior surface of the cornea; These minute foreign bodies were surrounded by exudates. No hypopyon and no keratic precipitates - were seen. A few foreign body specks were seen on the anterior surface of the Iris. Vision and fundus were normal. On treatment with Efcorlin ointment the congestion was cleared and he was evacuated to the base hospital.
Bomb Injury face - Fracture of both Lacrimal bones.
A hand grenade burst near a sepoy destroying the bridge of the nose and inner canthi of both eyes. The right eve ball was completely ruptured and the lids were torn. Luckily the left globe escaped unhurt with the destruction of left lower lid. When the Otologist carried out debridement he noticed herniation of the brain matter through the wound. The patient was given broad spectrum antibiotics and was evacuated to the base hospital for further surgery.
Shell injury frontal region and eye - penetrating:
A sepoy was semi-conscious with lacerated wound right frontal region; brain matter herinated out of the wound. The right upper lid, portions of the Frontalis muscle and Orbicularis oculi were all hanging down in one mass. After treatment of shock, under general anaesthesia, he was operated simultaneously by the Surgeon and the Ophthalmologist. Debridement of the wound and gently sucking of the brain matter was done. The right eye ball was found to be ruptured with the fracture of the roof of the orbit. The remnant of the globe was excised by the frill method; gelfoam and firm bandage to the orbit was applied. He was given 50% glucose fifty cc, intravenously twice daily; Intravenous Reverine was also given by the drip method. After three days he was evacuated to the base hospital.
Mine-injuries both eyes - Penetrating:
When a mine exploded, a sepoy squatted ten feet away protecting his face by both palms. He was treated for multiple injuries of both hands and was evacuated to the base hospital in a few hours. After treatment and sick leave when he rejoined the unit, he complained of watering of the left eye. He was found to be suffering from chronic dacrayocystitis left eve and was referred to the Ophthalmologist. His vision was left eye 6/18 and right eye 6/12. Both fundi showed multiple patches of choroiditis in the periphery and multiple small foreign bodies in both retinae. They were confirmed by the Vogt Bone Free X-ray technique and was evacuated to the base hospital.
Mine injury Nose and Eye-Penetrating:
While laying mines, one accidentally exploded injuring a sepoy. He had edema of the right maxillary region, without any wound on its surface; oedema of nasal mucous membrane with bleeding and blocking of the nose, forcing him to breathe by the mouth. There was a penetrating wound in the middle of the right lower lid; the right eye vision was only three meters; the right pupil semi dilated and sluggish. Fundus examination showed generalised oedema of retina with a detachment in lower quadrant and a foreign body was seen at seven 0' clock position, four disc diameter away from the optic disc. X-rays confirmed the intraocular foreign body, and a cluster of foreign bodies in the right maxillary sinus, which must have penetrated through the right nostril producing bleeding and oedema of the nasal mucus membrane. He was evacuated to the base.
Ocular injuries received in this small conflict were varied and many. Since they were combined with injuries of other regions the treatment of the patient as a whole was carried out jointly both by the general surgeon and the ophthalmologist operating at the same time and on some occasions in collaboration with each other.
Unlike the insolated injury of the eye met with in Civil practice, war injuries usually have multiple foreign bodies on the face and in the orbit. Some of them were difficult to localise by routine X-rays and even with the help of a corneal ring. Modified Vogt Bone free Method had helped in solving the problem partially. However if the foreign bodies were near the optic disc this method was still a failure. Five intra-ocular foreign bodies removed were non-magnetic and the rest were also presumed to be non-magnetic since they were from the same type of missiles. However the author was informed that among the cases evacuated to command Hospital, Delhi cantt. some of the foreign bodies, removed were magnetic. Berman Locator or other localising instruments are necessary in treating these cases of non-magnetic foreign bodies.
I thank colonel G. B. Battacharya for providing me with all the facilities to treat the ocular battle casualties. I thank Lt. Col. A. K. Ray, Surgical Specialist for his valuable suggestions and co-operation, in carrying out combined treatment in some of these cases. Sub-Kunjan Singh A M C radiographer, enthusiastically helped me in taking Vogt Bone Free X-Ray and I am thankful to him.
| References|| |
Hamilton-Bailey Surgery of Modern Warfare Pages 3 and 13. E & S Livingstone Teviot Place Edinburgh, (1941).
Hull. Lt. Col. F. E. "Management of Eye Casualties In the Far East Command during the Korean Conflict - A preliminary Report". Transaction of Industrial Ophthalmology 1951 Nov. - Dec. U.S.A. Pages 885 to 891.
Duke-Elder, S. W. Vol. VI Text Book of Ophthalmology. p. 5743, 6271. Henry Kimpton, Lond: (1954).
[Table - 1], [Table - 2]