Ocular Trauma in Armed Conflicts

Foreword
Preface
Acknowledgements
Disclaimer
Contents
About the Editor
1: Changing Nature of Oculofacial Trauma in Armed Conflicts
1.1 Evolution of Weapons Leading to Changing Nature of Ocular Trauma
1.1.1 Prehistoric Era: The Era Before the Origin of Script
1.1.2 Ancient History Era: The Era of Written History
1.1.3 Wars in the Contemporary Age
1.2 Protective Gear
1.3 Changes in Medical Care Over the Years
References
2: Battlefield Trauma Care: Prehospital Management
2.1 The Echelon Concept of Care
2.1.1 First Echelon of Care
2.1.2 Second Echelon of Care
2.1.3 Third Echelon of Care
2.1.4 Fourth Echelon of Care
2.2 Care at First Echelon
2.2.1 Airway
2.2.2 Clear the Airway by
2.2.3 Treat Pneumothorax
2.2.4 Control Haemorrhage
2.2.5 Reassure Patients
2.2.6 Combat Hypothermia
2.2.7 Analgesia
2.2.8 Dress and Splint Limbs
2.2.9 Intravenous Resuscitation
2.2.10 Antibiotics
2.2.11 Tetanus Toxoid
2.2.12 Start Oral Feeds: A Hot Cup of Sweet Tea
2.2.13 Care of Ocular Injuries
2.2.14 Documentation
2.2.15 Priority in Casualty Evacuation
Appendix
References
3: Management of Battle Field Polytrauma: A Forward Surgeon’s Perspective
3.1 Introduction
3.2 War Injuries
3.3 Ballistics
3.4 Wound Ballistics
3.5 Priority of Trauma Patients and Scorings [4, 5]
3.6 AVPU Scale
3.7 Important Scoring Systems and Injury Scales
3.7.1 Red Cross Wound Score (Coupland Et al. [6])
3.7.1.1 Parameters of Wound Score
3.7.1.2 Total Scheme of Wound Score
3.7.2 Glasgow Coma Scale
3.7.3 Revised Trauma Score (RTS)
3.7.3.1 Other Scales
3.8 Eye Injuries
3.9 Evacuation Chain and First Aid
3.10 Management of War Wounds [2, 5]
3.11 Battlefield Surgical Experiences
3.12 Author’s Personal Experience at a High Altitude Peripheral Surgical Setup in War
3.13 Results and Discussion
3.14 Few Cases
3.15 Ocular Injuries
3.16 Conclusion
References
4: Open Globe Injuries: Initial Evaluation and Primary Repair
4.1 The Ocular Trauma Classification System for Open-Globe Injuries
4.2 Surgical Indications
4.3 Principles of Surgical Repair of Corneal Laceration
4.4 Surgical Technique
4.4.1 Suturing of the Cornea
4.5 Simple Full Thickness Corneal Laceration
4.6 Suturing of Zigzag Incision
4.6.1 Stellate Laceration Closure
4.7 Corneoscleral Lacerations
4.8 Scleral Lacerations
4.8.1 Non Perforating Corneal Injuries
4.9 Management of Tissue Loss
4.9.1 Effects of Suture Placement
4.9.2 Suture Tightening
4.10 Suture Removal
4.11 Prognostic Factors
4.12 Conclusion
References
5: Corneal Rehabilitation and Anterior Segment Reconstruction
5.1 Introduction
5.1.1 Corneal Scar
5.1.1.1 Phototherapeutic Keratectomy
5.1.1.2 Superficial Lamellar Keratoplasty
Manual Superficial Lamellar Keratoplasty
Microkeratome Assisted Lamellar Keratoplasty
Femtosecond Assisted Lamellar Keratoplasty: (FALK)
Hemi Automated Lamellar Keratoplasty (HALK)
5.1.1.3 PK with Antiglaucoma Surgery
5.1.1.4 PK with Vitreoretinal Surgery
5.2 Corneal Irregular Astigmatism
5.3 Corneal Decompensation/Perforation
5.4 Limbal Stem Cell Deficiency
5.4.1 Keratoprosthesis
References
6: Management of Lenticular Injury
6.1 Presurgical Considerations
6.2 Summary
7: Glaucoma in Trauma
7.1 Background
7.2 Prevalence and Incidence
7.3 Mechanisms of Glaucoma Secondary to Closed Globe Injury
7.3.1 Early Onset
7.3.2 Hyphema
7.3.3 Management
7.4 Delayed Onset Glaucoma
7.4.1 Angle Recession
7.4.2 Management
7.5 Ghost Cell Glaucoma
7.5.1 Management
7.6 Penetrating Trauma
7.6.1 Mechanisms of Glaucoma Secondary to Penetrating Trauma
7.6.2 Management
7.7 Chemical Injuries and Secondary Glaucoma
7.7.1 Alkali Burns
7.7.2 Management
7.7.3 War Time Injuries and Glaucoma
References
8: Posterior Segment Manifestations of Ocular Trauma and Their Management
8.1 Blast Injuries
8.2 Gunshot Injuries
8.3 Manifestations of Blunt Trauma
8.4 Manifestations of Penetrating Trauma
8.5 Conclusion
References
9: Intraocular Foreign Body: Approach to Management
9.1 Introduction
9.2 Epidemiology and IOFB Features
9.3 Location of Foreign Body
9.4 Pathophysiology
9.5 Approach to a Patient with Intraocular Foreign Body
9.5.1 History Taking
9.5.2 Examination
9.5.3 Investigations
9.5.4 Medical Management
9.5.5 Surgical Management
9.5.5.1 Indications for Removal of Foreign Bodies
9.5.5.2 Patient Consent
9.5.5.3 Surgical Procedure
9.5.5.4 A Word for Eyes with No Perception of Light
9.5.5.5 Do’s and Don’t’s for Intraocular Foreign Bodies (Fig. 9.16)
Prevention
9.6 Summary
References
10: Traumatic Uveitis and Sympathetic Ophthalmia
10.1 Traumatic Uveitis
10.1.1 Pathogenesis
10.1.2 Signs and Symptoms
10.1.3 Ancillary Testing
10.1.4 Differential Diagnosis
10.1.5 Treatment
10.1.6 Cycloplegics
10.1.7 Corticosteroids
10.1.8 Follow-up
10.1.9 Complications
10.2 Phacoanaphylaxis/Phacoantigenic Uveitis
10.2.1 Pathogenesis
10.2.2 Signs and Symptoms
10.2.3 Ancillary Testing
10.2.4 Differential Diagnosis
10.2.5 Treatment
10.2.6 Complications
10.3 Sympathetic Ophthalmia
10.3.1 Pathogenesis
10.3.2 Signs and Symptoms
10.3.3 Diagnosis
10.3.4 Histopathology
10.3.5 Differential Diagnosis
10.3.6 Prevention
10.3.7 Management
10.4 Conclusion
References
11: Endophthalmitis Following Ocular Trauma in Armed Conflicts
11.1 Introduction
11.2 Etiopathogenesis
11.3 Clinical Features
11.3.1 Symptoms
11.3.2 Signs
11.4 Diagnosis
11.5 Management
11.5.1 Management at Forward Medical Center
11.5.2 Management at an Eye Center of Civil/Military Hospital by Ophthalmologist
11.5.2.1 Diagnostic
11.5.2.2 Preventive
11.5.2.3 Therapeutic
11.5.3 Management at Advanced Ophthalmic Center
11.5.4 Vitrectomy in Post-Traumatic Endophthalmitis
11.5.5 Steps of Vitrectomy
11.6 Concurrent Associations
11.6.1 Endophthalmitis with Cornea Involvement
11.6.2 Endophthalmitis with Scleral Tear
11.6.3 Endophthalmitis with Retinal Detachment
11.6.4 Endophthalmitis with Retained IOFB
11.6.5 Hypotony
11.7 Conclusion
References
12: Stem Cell Transplantation for Ocular Surface Chemical Injuries: Techniques and Outcomes
12.1 Anatomic Location and Limbal Stem Cell Characteristics
12.2 Etiological Subtypes and Demography of Limbal Stem Cell Deficiency (LSCD) Secondary to Injury
12.3 Mechanism of Development of LSCD
12.4 Classification of LSCD
12.5 Clinical Features
12.5.1 Symptoms
12.5.2 Signs
12.6 Laboratory Work Up and Role of Investigational Modalities
12.7 Strategy of Managing LSCD
12.8 Simple Limbal Epithelial Transplantation (SLET)
12.8.1 Pre-operative Considerations
12.8.2 Surgical Technique of SLET
12.8.3 Post Operative Management
12.9 Complications
12.10 Outcomes
12.11 Future Directions
12.12 Conclusion
References
13: Unsalvageable Eye: Cosmetic Rehabilitation
13.1 Surgical Techniques
13.1.1 Pre-operative Investigations
13.1.1.1 B Scan Ultrasonography
13.1.1.2 Computed Tomography (CT)/Magnetic Resonance Imaging (MRI) Scan
13.1.2 Pre-operative Counseling
13.1.3 Enucleation
13.1.3.1 Indications
13.1.3.2 Contraindications
13.1.3.3 Surgical Techniques
Principle
Method
Enucleation with Placement of a Simple Sphere Implant
Enucleation with Placement of a Donor Sclera-Covered Porous Implant
Post-operative Care
Complications
Evisceration
Indications
Contraindications
13.1.3.4 Surgical Techniques
Principle
Method
Sclerotomy Techniques for Evisceration
Post-operative Care
Complications
13.2 Orbital Implants
13.2.1 Complications [14]
13.3 Ocular Prosthesis
13.3.1 Indications of Ocular Prosthesis
13.3.2 Types of Ocular Prosthesis
13.3.3 Conformer or Clear Shell
13.3.4 Scleral Shell
13.3.5 Full Thickness Prosthesis
13.3.6 Stock Prosthesis
13.3.6.1 Advantages
13.3.6.2 Disadvantages
13.3.7 Custom-Made Prosthesis
13.3.7.1 Advantages
13.3.7.2 Disadvantages
13.3.8 Method of fabrication [16]
13.3.8.1 Impression Tray Selection
13.3.8.2 Impression
13.3.8.3 Making a Wax Pattern
13.3.8.4 Iris Painting
13.3.8.5 Acrylic Capping of the Iris
13.3.8.6 Fabrication of Base Sclera Shell
13.3.8.7 Positioning of the Iris
13.3.8.8 Attachment of the Iris
13.3.8.9 Coloring of the Sclera Shell and Veining
13.3.8.10 Clear Resin Coating and Finishing
13.3.9 Patient Education Regarding Prosthesis Care
References
14: Orbital and Maxillofacial Injuries
14.1 Introduction
14.2 Modes of Trauma
14.3 Presentation
14.3.1 Clinical Divisions of Face
14.3.2 Upper Third Injuries
14.3.3 Middle Third Injuries
14.3.4 Nasoorbital Fractures
14.3.5 Maxillary Fractures
14.3.6 Zygomatic Complex Fractures
14.3.7 Orbital Blowout Fractures
14.3.8 Lower Third Injuries
14.4 Management
14.4.1 Primary Management and Resuscitation
14.4.2 Imaging
14.4.3 Definitive Management
14.4.4 Soft Tissue Repair
14.4.5 Hard Tissue
14.4.6 Approaches to the Facial Skeleton
14.4.7 Upper Third Fractures
14.4.8 Middle Third Fractures
14.4.9 Lower Third Fractures
14.4.10 Panfacial Fractures
14.4.11 Blast Injuries and GSW
14.5 Rehabilitation
14.6 Conclusion
References
15: Injuries of the Nasolacrimal Drainage System
15.1 Introduction
15.2 Anatomy of the Lacrimal Drainage Pathway
15.2.1 Osteology
15.2.2 Soft Tissue Anatomy
15.3 Lacrimal System Injuries
15.3.1 Etiology
15.3.2 Mechanism of Injury
15.4 Clinical Manifestations
15.5 Diagnosis
15.5.1 Clinical Assessment
15.5.2 Role of Imaging
15.6 Management
15.6.1 Canalicular Trauma
15.6.2 Lacrimal Sac and Duct Trauma
15.6.3 Concurrent Facial Trauma
15.6.4 Secondary Repair
15.7 Complications and Sequelae
References
16: Neuro-ophthalmology of Head Trauma
16.1 Introduction
16.2 Neuro-ophthalmic Features of Head Trauma Can Be Considered
16.3 Optic Nerve Injury/Traumatic Optic Neuropathy (TON)
16.4 Papilledema
16.5 Optic Chiasmal Injury
16.6 Cortical Visual Loss
16.7 Motor Visual Pathway Injury Includes
16.8 Ocular Motor Nerve Palsy
16.9 Fourth Nerve Palsy
16.10 Sixth Nerve Palsy
16.11 Treatment
16.12 Orbital Apex Injury
16.13 Cavernous Sinus Injury
16.14 Facial Nerve Palsy
16.15 Convergence and Accommodative Insufficiency and Spasm
16.15.1 Convergence Insufficiency
16.15.2 Divergence Insufficiency
16.15.3 Spasm of Accommodation and Convergence
16.16 Brainstem Injury
16.16.1 Internuclear Ophthalmoplegia (INO)
16.16.2 Dorsal Mid Brain Syndrome
16.17 Supranuclear Disorders in TBI
16.18 Saccadic Eye Movements
16.19 Pursuit Eye Movements
16.20 Vestibulo-Ocular Reflex (VOR)
16.21 Conclusion
References
17: Reconstruction of Eyelid Injuries in Military Trauma
17.1 Introduction
17.2 Anatomy
17.2.1 Skin
17.2.2 Orbicularis Oculi
17.2.3 Tarsal Plate
17.2.4 Medial and Lateral Canthal Tendon
17.2.5 Levator Palpebrae Superioris
17.2.6 Blood and Lymphatic Supply
17.3 Evaluation of Eyelid Defect
17.4 General Consideration for Lid Reconstruction
17.5 Eyelid Reconstruction of Full-Thickness Lid Defects Involving Margin
17.6 Small Defect (Up to 25–50% of Lid Length)
17.7 Medium Defect (50–75% of Lid Length)
17.7.1 McGregor Flap
17.8 Large Defects(>75% of Lid Length)
17.8.1 Upper Lid
17.8.2 Cutler–Beard Bridge Flap
17.8.3 Mustarde Lid Switch Flap
17.8.4 Glabellar Flap
17.9 Lower Lid
17.9.1 Hughes Tarsoconjunctival Flap
17.9.2 Mustarde Cheek Rotation Flap
17.9.3 Fricke’s Flap
17.9.4 Median Forehead Flap
17.9.5 Tripier Flap
17.10 Eyelid Reconstruction in Anterior Lamellar Defects
17.10.1 Primary Closure with or Without Undermining
17.10.2 Laissez Faire
17.10.3 Skin Grafts
17.10.4 Flaps
17.10.4.1 Special Transposition Flaps
17.10.5 Lateral Canthal Defects
17.10.6 Medial Canthal Defects
17.10.7 Canalicular Repair
References
18: Ocular Trauma in Armed Conflicts: Manifestations, Management, and Outcomes—Complex Case Scenarios
18.1 Introduction
18.1.1 Representative Cases
18.2 Sankara Nethralaya (SN) Experience
18.2.1 Surgery Outcome
18.3 Discussion
18.3.1 Anesthesia-Related Issues and Management
18.3.2 Vitreoretinal Issues in Acute Trauma Settings and Its Management
18.3.2.1 Timing of the VR Surgery
18.3.2.2 Intraocular Foreign Body (IOFB) Related Issues
18.3.2.3 Endophthalmitis-Related Issues
18.3.3 Glaucoma Issues and Management
18.3.4 Corneal Issues and Management
18.3.5 Oculoplasty-Related Issues and Management
18.4 Conclusive Remarks
References
19: Ocular Manifestations and Management Strategies in CBRN Warfare
19.1 Introduction
19.2 Chemical Warfare and Eye Injuries
19.3 Classification of Chemical Warfare Agents
19.3.1 Types
19.3.2 Common Properties and Clinical Presentation of Exposure of Chemical Warfare Agents to Human Body
19.3.3 Nerve Agents
19.3.4 Vesicants or Blister Agents
19.3.5 Arsenical Vesicants
19.3.5.1 Lewisite: BAL (Dimercaprol)
19.3.6 Mustard Agents (Sulfur Mustard (H) and Nitrogen Mustard (HN)
19.3.7 The Most Common Ocular Presentations
19.4 General Guidelines for Initial Management
19.5 Choking Agents (Asphyxiants). Phosgene (CG), Diphosgene (DP), Chloropicrin (PS)
19.5.1 Halogenated Oximes
19.5.2 Tear Gas
19.5.3 Systemic Adverse Effects of RCA
19.5.4 Ocular Effects of Tear Gas Substances
19.5.5 Ocular Management
19.6 General Guidelines to Be Followed by Mass Population in Case of Chemical Strike
19.6.1 When Protective Equipment Is Available
19.6.2 When Protective Equipments Are Not Available
19.7 Biological Warfare: Ophthalmic Manifestations, Prevention and Management
19.8 Biological Weapons: Classification and Methods of Delivery of Biological Agents
19.8.1 Classification of Biological Agents (Microorganisms or their Toxic Products)
19.8.2 These Agents Can Be Transmitted from One Man to Another Causing Large Number of Casualties
19.8.2.1 Methods of Delivery
19.8.2.2 Systemic Involvements of Biologics
19.8.2.3 Ophthalmic Manifestations
19.8.2.4 Specific Ophthalmic Manifestations
Botulism
Ocular Manifestations
Management
Anthrax
Ocular Manifestations
Management
Smallpox
Ocular Manifestations
Management
19.8.2.5 Tularaemia
Ocular Manifestations
Management
19.8.2.6 Early Detection and Prevention of Effects of Biological Agents
19.8.2.7 Early Detection and Warning
Challenges
19.9 Radiological Warfare
19.9.1 Effects of Radiation on Ocular Tissue of Humans and Animals
19.9.2 Ocular Radiation Injuries
19.9.3 Acute Onset of Radiation Induced Manifestations
19.9.4 Intermediate and Delayed Onset Post Radiation Ocular Changes
19.10 Nuclear Warfare and Its Impact on Health Status
19.10.1 Basic Effects of Nuclear Explosion
19.10.2 Effects of Nuclear Radiation on Human
19.10.3 Long-Term Effects of Nuclear Explosion on Human Body
19.10.4 Ocular Injuries in Blast and Thermal Effects
19.11 Conclusion
References
20: Classification Systems for Ocular Trauma
20.1 Introduction
20.2 Birmingham Eye Trauma Terminology
20.3 Classification of Ocular Trauma
References
21: Imaging in Eye Injury
21.1 Various Imaging Modalities
21.1.1 Ultrasonography
21.1.1.1 Ultrasound with Tissue Harmonic Imaging
21.1.2 Ultrasound Biomicroscopy (UBM)
21.1.2.1 Conventional Ophthalmic B-Scanner (10 MHz) Versus Ultrasound Biomicroscopy (UBM)
21.1.3 Scheimpflug Imaging
21.1.4 Optical Coherence Tomography (OCT)
21.1.5 Fundus Autofluorescence (FAF)
21.1.6 Fluorescein and Indocyanine Green Angiography
21.1.7 Electrophysiological Tests
21.1.8 Radiographic Imaging
21.1.8.1 Plain x-Ray
21.1.8.2 Computerized Tomography (CT Scan)
21.1.8.3 Magnetic Resonance Imaging (MRI)
21.2 Imaging in Specific Conditions
21.2.1 Anterior Segment Trauma
21.2.1.1 Ultrasound Evaluation of the Anterior Segment
21.2.1.2 Ultrasound Biomicroscopy (UBM)
21.2.1.3 Anterior Segment Optical Coherence Tomography (ASOCT)
Anterior Segment Optical Coherence Tomography (ASOCT) Versus Ultrasound Biomicroscopy
21.2.1.4 Scheimpflug Imaging
21.2.2 Posterior Segment Trauma
21.2.2.1 Ultrasound of the Posterior Segment
Posterior Vitreous Detachment (PVD)
Vitreous Traction Band and Track
Vitreous Base Avulsion
Retina and Choroid
Retinal Detachment (RD) Versus Posterior Vitreous Detachment (PVD)
Choroidal Detachment (CD)
21.2.2.2 OCT in Posterior Segment Trauma
21.2.2.3 Angiography in Posterior Segment Trauma
21.2.2.4 Fundus Autofluorescence in Posterior Segment Trauma
21.2.3 Evaluation of Intraocular Foreign Body
21.2.3.1 Ultrasound
21.2.3.2 Radioimaging for Foreign Body
21.2.3.3 Electrophysiological Tests
21.2.4 Globe Integrity
21.2.4.1 Ultrasound
21.2.4.2 Radioimaging
21.2.5 Optic Nerve Injury
21.2.5.1 Optic Nerve Avulsion
21.2.5.2 Traumatic Optic Neuropathy (TON)
VEP in TON
Radioimaging in TON
21.2.6 Orbital Imaging
21.2.6.1 Orbital Hemorrhage
21.2.6.2 Orbital Fracture
21.2.6.3 Orbital Emphysema
21.2.6.4 Orbital Compartment Syndrome
21.2.6.5 Extraocular Muscle Injury
21.2.6.6 Carotid Cavernous Fistula
21.3 Conclusion
References
22: Prevention of Ocular Injuries in the Armed Forces and Rehabilitation of the Visually Impaired
22.1 Prevention of Ocular Injuries
22.2 Classification of Ocular Protective Devices
22.3 Low Vision Assessment
22.4 Low Vision Assessment
22.5 Examination
22.5.1 History
22.5.2 Visual Acuity
22.6 Treatment
22.6.1 Optical Devices
22.6.1.1 Low Vision Devices for Distance
22.6.1.2 Low Vision Devices for Near Vision
22.6.2 Nonoptical Devices
22.6.2.1 Relative Size Devices
22.6.2.2 Light and Illumination Controls
22.6.2.3 Writing and Communication Devices
22.6.2.4 Mobility Devices
22.6.2.5 Sensory Substitution Devices
22.6.2.6 Electronic Devices
22.7 Rehabilitation
References