Open eye injuries: Neurologic considerations

O pen eye injuries in war have been occurring in ever-increasing numbers. After serving in Pleiku, Vietnam, for the 71st Evacuation Hospital, a concerned ophthalmologist, Albert Hornblass, MD, compared eye injury rates in American and other military conflicts. He noted that during the American Civil War, eye injuries were 0.5% of all casualties, but in the Vietnam War, eye injuries occurred at a rate between 5% and 9%. During Desert Shield and Desert Storm (Kuwait), the rate climbed even higher, to 13%. The eye injury rate is expected to increase significantly in future military conflicts. The number of civilians injured by military conflict increased during the 20th century. The civilian injuries during war have reached 90% internationally of the total injuries per military conflict. Fragmentation weapons are predominantly the cause of increased eye injuries in these conflicts. Overseas, the number of civilian patients treated during war by the US military field hospitals also has been on a dramatic rise since World War II. Between 1980 and 1990 there were 12,216 incidents of bombing in the United States, most of them involving pipe bombs. Domestically in the United States, assault and violent crimes have escalated the number of penetrating eye injuries, as well as firearm-related deaths. In addition, motor vehicles crashes continue to account for a substantial portion of penetrating ocular trauma in the United States. For the anesthetist, the management of open eye injury for trauma patients has been controversial for more than 40 years. There is also an inherent legal significance for patients with penetrating eye injury. The literature contains about 20 articles favoring the use of succinylcholine and about 20 against its use. More important, for a patient with an open eye injury, there are unique considerations that need to be made before ophthalmic surgery. From the perspective of teaching trauma, the penetrating eye injury scenario portrays how to manage complex patients with serious “coincidental” problems. This article addresses such problems and suggests evaluations to assist the anesthetist in the decisionmaking process before and during ophthalmic surgery. In the United States, one fourth of all preventable trauma death occurs in the operating room. In trauma centers, preventable deaths are related primarily to errors in judgment. In nontrauma hospitals, virtually all preventable deaths are the result of failure to understand the severity or multiplicity of the injuries.