Penetrating Eye Trauma

#### PENETRATING EYE TRAUMA

J Emerg Med. 2019 Mar;56(3):294-297

# Ocular Compartment Syndrome and Lateral Canthotomy Procedure.

Amer E, El-Rahman Abbas A

BACKGROUND: Ocular compartment syndrome (OCS) is a serious ophthalmological emergency that should be diagnosed and treated immediately to prevent permanent loss of vision. It is usually caused by a retro-orbital bleed that will subsequently increase intra-orbital pressure and threaten the patient's vision. Lateral canthotomy and cantholysis is a minor bedside procedure using simple equipment that is readily available in emergency departments, and the aim of such a procedure is to free the eye globe from its lateral attachment to the bony orbital wall and allow more eye protrusion and hence reduce intra-orbital pressure and save the patient's sight. The case we present describes a 42-year-old man who presented with facial injuries following an alleged assault and in whom a computed tomography scan of the head showed a retro-orbital hemorrhage. The patient had subtle signs of increased intra-orbital pressure for which lateral canthotomy and cantholysis was indicated.

DISCUSSION: OCS is an ophthalmological emergency that can present with subtle signs of increased intraocular pressure that can lead to irreversible loss of vision if not treated with a simple bedside operation called lateral canthotomy and cantholysis within a specific time frame. We explore the pathophysiology and presentation of OCS and how to perform the lateral canthotomy with cantholysis procedure.

CONCLUSIONS: The aim of this case presentation is to highlight the importance of diagnosing OCS as an ophthalmological emergency and discuss how to perform the sight-saving procedure.

Acta Ophthalmol. 2019; Epub ahead of print

# E ye Injuries across history and the evolution of eye protection.

Hoskin A, Mackey D, Keay L, Agrawal R, Watson S

PURPOSE: To describe the history of eye injuries and the consequent evolution of eye protection.

METHODS: A comprehensive search of Medline and the grey literature using the terms 'ocular trauma' and 'eye protection' or 'injury prevention' and 'history'. References were used to identify other relevant publications. Publications were classified according to the setting of eye injury: occupational, recreational or combat-related.

RESULTS: Eye protection has been described in a wide range of sources, including in literature and art. With advances in eye protection material and design, as well as government and societal promotion of appropriate eye protection usage in the workplace, the epidemiology of ocular trauma has changed over time. In developed countries, the use of eye protection in the workplace has reduced the proportion of occupation-related eye injuries over the last century, with a higher proportion occurring during sports or at home. New protection devices and policies have evolved to meet this change.

CONCLUSION: Vision loss has broad implications for the individual and for society and despite available prevention strategies, ocular trauma is a significant cause of preventable monocular and bilateral vision loss. The use of appropriate eye protection has reduced the burden of ocular trauma. History provides lessons for informing current eye protection and eye injury prevention strategies.

Mil Med. 2019 Mar 1;184(Suppl 1):335-341

# Using Simulation to Address a Training Gap in Battlefield Ocular Trauma: A Lateral Canthotomy and Cantholysis (LCC) Prototype Training System.

Sotomayor T, Bailey M, Dorton S

Over the past 15 years of conflict, eye injuries have ocurred at a steady rate of 5-10% of combat casualties, attributed to the enemy's use of improvised explosive devices. Many of these injuries result in a compartment syndrome of the orbit, easily decompressed through the use of a simple procedure called a Lateral Canthotomy and Cantholysis (LCC). Current training curricula at the U.S. Army Center for Pre-Hospital Medicine at Fort Sam Houston, Texas incorporates LCC training presented in lectures and taught using cadavers and goats (resources permitting), but lacks a LCC training device for the development of psychomotor skills. Requirements analysis, iterative design and development, and testing were performed for a simulation-based training system that may be used to practice the LCC procedure. Subject matter experts have conducted numerous reviews of the prototype system, where feedback is used to drive subsequent designs. Further work, including formal analysis of training effectiveness, will be performed to validate the training system. This will benefit will benefit military and civilian training programs by training psychomotor skills to enhance competency in the LCC procedure for preserving eyesight.

Ophthalmic Plast Reconstr Surg. 2019 Sep 25;Epub ahead of print

# Orbital Fractures and Associated Ocular Injuries in Operation Iraqi Freedom and Operation Enduring Freedom Referred to a Tertiary Care Military Hospital and the Effect on Final Visual Acuity.

Justin G, Turnage W, Brooks DI, Davies B, Ryan D, Eiseman A, Weichel E, Colyer M

PURPOSE: To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom.

METHODS: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity.

RESULTS: Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%).

CONCLUSIONS: Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.