Page 117 - JSOM Winter 2017

Evaluation and Treatment of Ocular Injuries and
Vision-Threatening Conditions in Prolonged Field Care

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Mark Reynolds, MD, MPH ; Carl Hoover, 18D ; Jamie Riesberg, MD ; Robert Mazzoli, MD ;
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Marcus Colyer, MD ; Scott Barnes, MD ; Christopher Calvano, MD ; James Karesh, MD ;
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Clinton Murray, MD ; Frank K. Butler Jr, MD ; Sean Keenan, MD ; Stacy Shackelford, MD *
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valuation and treatment of ocular injuries and vision- penetrate the eye and leave it appearing deceptively intact. An
Ethreatening conditions in a prolonged field care (PFC) situ- awake and alert patient can report change in vision or eye pain;
ation can be extremely challenging. These events can lead to an unconscious patient cannot. Thermal burns to the face fre-
irreversible loss of vision with lasting effects on military ser- quently cause eyelid burns and contraction, which increase the
vice and overall quality of life. The goal of this clinical practice risk for exposure keratopathy. Critical details in the evaluation
guideline (CPG) is to provide medical professionals with es- of ocular trauma include mechanism of injury and presence of
sential information on the recognition and treatment of ocu- properly worn ballistic eyewear at the time of injury.
lar conditions when evacuation to an eye specialist is delayed.
The guidelines are based on standard ophthalmic practice 2. Assess and document visual function.
adapted to address the austere or remote environment, when Visual acuity is the vital sign of the eye. Whenever possible,
the “Shield and Ship” guidelines are interrupted by delayed visual acuity should be assessed and documented. Visual func-
evacuation. tion immediately after trauma is an important prognostic in-
dicator for visual outcome. Visual acuity can be effectively
As with all medical concerns, recognition of the problem is estimated with several field-expedient methods, starting with
the first step. This is a particular challenge for ocular condi- ability to read any printed letters such as labels on medical
tions. Comprehensive ocular evaluation is not usually possible supplies. If the patient is unable to read letters, assess their
in austere locations and training in rapid recognition of ocu- ability to count fingers. If they cannot count fingers, evaluate
lar conditions may be limited. The ocular conditions covered for the ability to detect hand motions. If they cannot detect
in this guideline are the most common traumatic injuries and hand motion, evaluate light perception using a bright light.
vision-threatening conditions that require rapid identification Document visual acuity along with other vital signs.
and treatment to prevent loss of vision. A more comprehensive
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review can be found in the Joint Trauma System CPG or Wil- Assessing for a relative afferent pupillary defect (RAPD, also
derness Medicine textbook. 2 called the swinging flashlight test or Marcus Gunn Pupil; Ap-
pendix A) gives an indication of retina and optic nerve func-
tion. Shine a light in either eye; normally, both pupils should
Telemedicine: Management of eye injuries is complex. constrict equally. This reaction to light is equal unless there
Detailed physical examination information can only be is damage to the optic nerve or the retina, in which case the
communicated via pictures or video. Establish telemedicine pupil of the injured eye will dilate when the light is shone in
consultation as soon as possible. the injured eye. Evaluating for an RAPD is essential in condi-
tions such as retrobulbar hemorrhage (orbital compartment
syndrome) or suspected retinal detachment. Notation of an
Goals of Care
RAPD is also an important prognostic factor for ophthalmic
1. Maintain high suspicion for ocular injuries. providers at later level of care.
The mechanism of injury will often suggest an ocular injury.
Direct trauma with ocular laceration may be fairly obvious, 3. Examine for critical physical findings.
but blunt trauma leading to an occult rupture on the posterior An obvious globe laceration or rupture with prolapsed intra-
aspect of the globe or injury to the retina can be easily over- ocular contents can be a striking picture but may not be pres-
looked in a multitrauma patient. Small metallic fragments can ent in every severe eye injury. At times, the only findings of a
*Address correspondence to stacy.a.shackelford.mil@mail.mil
1 COL Reynolds, MC, USA, is an ophthalmologist currently serving as assistant director, Clinical Public Health and Epidemiology, US Army
Public Health Center. MSG Hoover, 18Z/D, USA, is the Senior Enlisted Medical Advisor for 1st Special Forces Command(A), Fort Bragg, NC.
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3 LTC Riesberg, MC, USA, is the 10th Special Forces Group (A) Surgeon, Fort Carson, CO, and is a member of the Special Operations Medical
Association Prolonged Field Care Working Group Steering Committee. MAJ Calvano, MC, USAR, is the USAR Ophthalmology Consultant to
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the Army Surgeon General and is a staff ophthalmologist at the San Antonio Military Medical Center, TX. Dr Karesh is an ophthalmologist at
the Vision Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD. LTC Colyer, MC, USA, is an associate profes-
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sor of surgery, director of the Triservice Ocular Trauma Skills Lab at Uniformed Services University, and vitreoretinal surgeon at Walter Reed
National Military Medical Center, Bethesda, MD. COL Murray, MC, USA, is the infectious disease consultant to the US Army Surgeon General.
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8 COL (Ret) Mazzoli, an oculoplastic specialist, is a professor of surgery (ophthalmology), Uniformed Services University of Health Sciences,
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and currently works at the Department of Defense-Veterans Affairs Vision Center of Excellence at Madigan Army Medical Center, WA. COL
(Ret) Barnes is a cornea and external eye disease specialist and served as the chief of Ophthalmology and the Warfighter Refractive Eye Surgery
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Program at Womack Army Medical Center, Fort Bragg, NC. CAPT (Ret) Butler is an ophthalmologist and chair of the Committee on Tactical
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Combat Casualty Care, Joint Trauma System, San Antonio, TX. COL Keenan, MC, USA, is command surgeon, Special Operations Command,
Europe, and a member of the Special Operations Medical Association Prolonged Field Care Working Group Steering Committee. Col Shackel-
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ford, MC, USAF, is chief of performance improvement, Joint Trauma System, San Antonio, TX.
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