appendix: suturing 101

257© Springer Nature Switzerland AG 2019 C. J. Calvano et al. (eds.), Ophthalmology in Military and Civilian Casualty Care, https://doi.org/10.1007/978-3-030-14437-1

Appendix: Suturing 101

Introduction

During times of conflict and in the event of natu-ral or man-made disasters, many with unique skills, especially physicians, are called to assist in the treatment of the wounded. In these situa-tions, it is not uncommon for an ophthalmologist whose clinical practice does not involve the trau-matic closure of globe injuries to find themselves having to close ruptured globes. Additionally, if resources are especially limited, a surgeon who has never sutured under a microscope, or never closed an ophthalmic wound may find them-selves having to do so for the first time.

Unlike other adnexal tissue, the lamellar struc-ture of the cornea imparts a natural stiffness that requires special techniques in order to achieve a watertight, prolate-shaped closure. Below you will find the general principles for suturing globe/cornea injury under a microscope.

Goals

1. Suture equally long and consistent with each suture position, for prolate-shape, peripheral corneal sutures are longer than the central ones.

2. When resuturing a corneal transplant the sutures are placed in a radial fashion – point to the center of the cornea in PKPs.

3. Trauma closure – all sutures placed perpen-dicular to the laceration.

4. Suture passes, 80–90% depth, and centered on the posterior aspect of the laceration.

5. Suture passes on opposite side of a laceration should be at the same depth, flat and parallel to descemet’s.

6. Sutures should achieve good opposition, with-out excessive compression.

7. For the sake of efficiency, and not compro-mising the strength of the suture material, try to grab each suture only once for every pass.

Steps

1. Visualize radial line from center of cornea. (a) Entry and exit point of needle ~0.7 mm

on each side of the interface. 2. Place needle along radial line, or perpendic-

ular to the laceration (Fig. A.1). 3. Place forceps tips along this radial line (Fig.

A.2). (a) Approach tissue at 45° angle. (b) Walk inferior tip down tissue to just

above descemet’s. 4. Rotate tissue 45° (Figs. A.3, A.4, and A.5).

(a) Angle needle 45° to the tissue surface. (b) Pass needle straight at 45°, first placing

tip right behind the forceps. (c) Straight line drive, no hand wrist rotation

needed (exception: if one of the tissue is significantly swollen) – whole wrist moves horizontally, parallel to floor.

https://doi.org/10.1007/978-3-030-14437-1

258

5. Release tissue with forceps (Fig. A.6). 6. Grab and stabilize host tissue, approaching

at 45° angle. 7. Gently lower the needle until it is (Fig. A.7)

(d) Radial to center cornea. (e) Flat. (f) Parallel to host descemet’s. (g) If blood in the interface rotate needle

up 45°, pull tissues apart, allow your assistant to vigorously irrigate between the tissues, visualize des-cemet’s during irrigation, then rotate needle forward to flat position, lower to level of descemet’s.

8. Enter host tissue flat just above descemet’s (Fig. A.8)

(h) As the needle engages tissue, it creates a visual clue “V” at the level of descemet’s.

9. Immediately rotate the wrist and needle tip, sharply to abruptly change the needle direc-tion so it exits tissue 90° to the surface `0.7 mm from the laceration (Fig. A.9). If you feel tissue resistance to needle passage, such that you need to provide counterforce with your forceps: – Pull the needle back a fraction and turn

your wrist more. – Needle passing perpendicular to the sur-

face meets little resistance, then you can gently lift needle thru cornea with upward wrist movement (Fig. A.10).

10. Grab the needle below the tip with needle drivers and rotate the needle out of the tissue trying to drag the base of the needle through the precise path as the tip (a) Once tissue is cleared bring the needle

straight to you (A) (b) Until the suture tip is visible at the edge

of your surgical field (switch to low power) (B).

(c) Preposition your typing forceps at posi-tion © and grab/stabilize the suture when the tip is visible (C).

(d) Release the needle while continuing to hold the suture at position C.

(e) Bring needle driver back into the field over the wound in a wide arching motion (this maneuver prevents inadvertent pulling of the suture through the wound if the needle is caught in the needle driver hinge or if the needle is magne-tized and attached to the needle driver.

Fig. A.1 Place needle along radial line, or perpendicular to the laceration

Fig. A.2 Place forceps tips along this radial line


259

11. Utilizing the forceps at position C pull the suture tip 50% of the distance between the edge of the visible surgical field and the wound. Then raise in preparation for tying.

12. Bring the needle driver back into the field and over the wound (do not release the suture), pointing toward the suture end (Fig. A.11).

3:1:1 or Slip Knot (Fig. A.12) 1. When initiating the tying maneuver, the

suture, needle driver, and suture tip need to be on the same side of the wound. (a) In this configuration the suture tension

keeps the suture on the needle driver (Fig. A.13).

(b) If the needle driver and the suture tip are on opposite sides of the wound, point the needle driver toward the suture tip (if curved needle driver you can twist the needle driver, turning it over). Ask your

assistant to put a drop of BSS onto the field to float the suture (Fig. A.14).

2. Wrap the suture around the needle driver with the forceps – this is facilitated if the suture and long axis of the needle driver are parallel.

3. Advance the needle driver, grasp the suture tip (change hands) and lay the suture across the wound with the correct appositional force (Fig. A.15).

4. Now the needle driver and tip are on the same side of the wound again (leave it there).

5. Rotate the needle driver slightly to the side, keeping the tip pointing at the tip of the suture (Fig. A.16) and wrap once with the suture, grab the tip by advancing the needle driver, and pull the suture through the loop.

6. Pull at 90°, equal tension, just above the tissue plane: Do not let the suture tension across the wound change (do not let the looped suture move to either side, the knot should just col-

Same

Equals 90˚entry

Figs. A.3, A.4, and A.5 Rotate tissue 45°


260

a

α

β

γ

b

Needle behindforceps

Needle adjacentto forceps

Lays to side hard to pick up

a

Figs. A.3, A.4, and A.5 (continued)


261

b

c

Figs. A.3, A.4, and A.5 (continued)

Fig. A.7 Gently lower the needle

Fig. A.6 Release tissue with forceps


262

Fig. A.8 Enter host tissue flat just above descemet’s

Fig. A.9 Immediately rotate the wrist and needle tip, sharply to abruptly change the needle direction so it exits tissue 90° to the surface `0.7 mm from the laceration

Fig. A.10 Needle passing perpendicular to the surface meets little resistance, then you can gently lift needle through cornea with upward wrist movement

Surgicalfield

Type caseof field

Pointing towardthe suture end

Needletowards you

Fig. A.11 Bring the needle driver back into the field and over the wound (do not release the suture), pointing toward the suture end


263

Fig. A.12 Slip knot

Fig. A.13 In this configuration the suture tension keeps the suture on the needle driver

Fig. A.14 If the needle driver and the suture tip are on opposite sides of the wound the suture tension pulls the suture off the needle driver


264

Fig. A.15 Advance the needle driver, grasp the suture tip (change hands) and lay the suture across the wound with the correct appositional force

Fig. A.16 Rotate the needle driver slightly to the side, keeping the tip pointing at the tip of the suture

lapse (Fig. A.17). The tension across the wound is set! One more approximation loop is added by repeating the above steps.

Alternate:

1. Once the correct appositional force is achieved across the wound, keep the suture tension steady in the forceps (At this point you should already have the tip of the suture in your nee-dle driver) (Figs. A.18 and A.19).

2. You can now release the sutures and test the wound for leaking:• If you like the tension:

– Lay the short suture end on the cornea. – Lift the needle drivers slightly, keeping

the tips pointed at the tip of the suture, – wrap once, and again tighten at 90° in

the plane just above the suture.• If you don’t like the tension:

– Bring the tip back to the opposite side of the wound, pull equally with both hands and reestablish tension at the desired levels, then repeat the above procedure.


265

Backhand Suturing 1. The mechanism of backhand suturing is the

same. 2. Passing the needle through the tissue is the

same except the needle is away from you. 3. In the initial pass, evert the tissue 45°. 4. The needle approaches the tissue at 45° (no

need to turn the wrist) (Fig. A.20). 5. After the needle exits the tissue, bring it toward

you just like a standard suture pass, creating an inverted “V” configuration (Fig. A.21).

6. The suture is still stabilized when the tip is at the edge of your view. Then you let go of the needle and make a wide sweep with the nee-dle driver back onto the field.

7. The needle driver is placed across the cornea, and points back into the center. Wrap the suture around the forceps, normally for the initial throw (subsequent directions are unchanged) (Fig. A.22).

Don’t let suturemove

90˚

Fig. A.17 Pull at 90°, equal tension, just above the tissue plane: Do not let the suture tension across the wound change (do not let the looped suture move to either side, the knot should just collapse

Figs. A.18 and A.19 Without letting go of the suture tip, while keeping tension with the nondominant hand, advance the tip of the suture to the same side of the

wound, and create a small knot with a slight jerking motion when the knot has fully collapsed


266

α

β

a

b

Fig. A.20 All needles should enter the tissue at 90 degrees. This can be accomplished with a no touch technique (a), or be everting the tissue at 45 degrees and entering the tissue at 45 degrees to achieve an equivalent 90 degree entry


267

Fig. A.22 The needle driver is placed across the cornea, and points back into the center. Wrap the suture around the forceps normally for the initial throw (subsequent directions are unchanged)

Field of view

Fig. A.21 After the needle exits the tissue, bring it toward you just like a standard suture pass, creating an inverted “V” configuration


269© Springer Nature Switzerland AG 2019 C. J. Calvano et al. (eds.), Ophthalmology in Military and Civilian Casualty Care, https://doi.org/10.1007/978-3-030-14437-1

AAcceleration/deceleration injury, 106Acetylcholinesterase (AChE), 191, 192Adamsite (DM), 198Adult-onset binocular diplopia, 105Advance Party (ADVON), 250Afferent visual disease, 107Afghanistan freedom, 6Airbag-associated alkaline burns, 117Akkin method, 60Alkali injuries, 17All Army Activities message (ALARACT), 166American Academy of Ophthalmology and

Otolaryngology (AAOO), 3American Civil War, 4Amniotic membrane transplantation (AMT), 177Angle recession glaucoma, 78, 79Anterior chamber exam, 25, 26Anterior segment trauma

chemical injury, 121corneal abrasion, 120, 121hyphema, 121–123traumatic cataracts, 123–125

Anterior vitrectomy system, 77Anti-tumor necrosis factor alpha (TNF-a) antibodies, 177Aphakia, 123Arachnid-inflicted trauma, 117Area Operating Base (AOB), 216Aschner–Dagnini reflex, 40Aschner phenomenon, 40Atraumatic vision disturbance, 19Authorized Protective Eyewear List (APEL), 236, 237Autologous limbal stem cell transplantation (ALT), 177

BBacillus cereus, 139, 158Ballistic and laser protective spectacle (BLPS), 236Ballistic eye protection, 166–168Ballistic lenses, 108Ballistic spectacles, 108Bilateral injury, 116Binocular diplopia, 19Binocular painful vision disturbance, 19

Binocular painless vision disturbance, 19Binocular single vision, 107Bird related injuries, 118Birmingham Eye Trauma Terminology

System (BETTS), 35Birmingham original publication, 10Blast-anterior segment trauma

anesthesia, 55, 56general suturing principles, 56–58incarcerated iris, 57–59initial evaluation, 54, 55post procedure, 61prehospital, 53scleral lacerations, 59–61stellate lacerations, 59, 60superficial foreign bodies, 55

Blast-induced ocular and orbital trauma, 104Blunt trauma, 121Brown Recluse bites, 117

CCanalicular system, 93Canalicular tears, 120Carotid-cavernous fistula (CCF), 98Central retinal artery occlusion (CRAO), 28Certified Registered Nurse Anesthetists (CRNAs), 249Chemical injury, 116, 121Chemical warfare (CW) agents, 176, 182

carbonyl dichloride/phosgene, 190, 191chlorine gas, 189, 190classification, 186customary laws of war, 185, 186fentanyl, 194lewisite (agent L), 188, 189nerve agents

AChE, 191, 192atropine, 193classification, 191miosis, decreased vision, and eye pain, 192nicotinic symptoms, 193organophosphates (OP), 191oxime drug, 193public safety, 191

Index

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270

Chemical warfare (CW) agents (cont.)sarin (GB), 191soman (GD), 191tabun (GA), 191V agents, 191

nitrogen mustards, 187, 188standard Iraqi chemical agents, 186sulfur mustard

chronic keratopathy, 186, 187cold climate, 186delayed keratopathy, 187inhalation injury, 186interventions, 187LSC, 187median incapacitating dose, 186NAC, 187phosgene, 185severe keratoconjunctivitis, 186sulfhydryl, carbonyl, and amino groups, 186triage and immediate decontamination, 187warm climate, 186

Chloroacetophenone (CN), 1952-Chlorobenzalmalononitrile, 195, 196Chloropicrin (PS), 197, 198Choroidal rupture, 66Closed globe injuries, 10

choroidal rupture, 66commotio retinae, 65, 66giant retinal tears, 68macular hole, 66, 67retinal dialysis, 67retinitis sclopeteria, 67traumatic brain injury, 103vitreous base avulsion, 67vitreous hemorrhage, 64, 65

Clostridium perfringens, 139Combat blast, 101Combat Support Hospital (CSH), 215, 216Commotio retinae, 65, 66Complete retinal artery occlusion (CRAO), 17Conjunctival injection, 20Corneal abrasion, 120, 121, 165Corneal endothelial cells (CEC), 188Counterinsurgency (COIN)

aid resources, 214American Expeditionary Forces, 210Army Air Force units, 211Army National Guard, 216Brooke Army Medical Center, 216civilian medical care, 211clinical ophthalmology, 211Colonel Homas catalogues, 214competence and judgment, 210counter-insurgency operations, 215diagnostic and curative medical care, 217European Theater of Operations, 210evidence, 214eye casualties, 210Fitzsimons Army Medical Center, 216formal directive, 210

guerilla forces, 209, 210“high impact” surgical procedures, 212indigenous patients, 213Korean War veteran ophthalmologist, 211local population risks, 217low intensity conflict, 211MAAG study, 211, 212MEDCAP members, 212, 213medical engagement, 218, 219

Afghan National Army, 220blind right eye, 221CT scan, 220elective strabismus case, 222Enzenauer Volunteer Medical Center, 219host nation patient, 218leprosarium patient, 218MEDCAPs, 220with Montagnard patients, 218Noor Eye Hospital, 222orbital tumor patient, 219post-op child, 220post-op esotropia patient, 221, 222pre-op child, 220pre-op esotropia patient, 221pre-op oculoplastic patient, 219sterile marble, 220strabismus surgery, 222

NATO, 217Noor Eye Hospital, 216ocular misalignment, 216ocular wounds and injuries, 210operations, 215ophthalmologic activities, 210Physician Assistants, 217political and media sensitivity, 210political factors, 214SF battalion, 215, 216Special Operations Forces in Afghanistan, 217Table of Organization and Equipment, 210trained personnel, 211trusted networks, 214type of eye care, 212U.S. Air Forces Special Operations, 217US Army FM 3-07, 213US Army’s 2006 FM Field Manual 3-24, 213Vietnam War, 211WHAM ophthalmology activities, 215

Cranial nerve palsy, 106Cranial nerve paresis, 106Craniofacial injuries, 106

DDamage control ophthalmology

anatomy, 33Birmingham Eye Trauma Terminology System, 35blast-anterior segment trauma

anesthesia, 55, 56general suturing principles, 56–58incarcerated iris, 57–59

Index

271

initial evaluation, 54, 55post procedure, 61prehospital, 53scleral lacerations, 59–61stellate lacerations, 59, 60superficial foreign bodies, 55

cardinal complaints, 15diagnostic imaging

computed tomography, 46–49magnetic resonance imaging, 49, 50ultrasound, 45, 46X-ray/plain film, 46

differential diagnosisatraumatic vision disturbance, 19binocular painful vision disturbance, 19binocular painless vision disturbance, 19monocular painful vision disturbance, 19monocular painless vision disturbance, 19

emergence, 16, 41final visual acuity, 11, 12general endotracheal anesthesia, 38general principles, 12, 13history, 18induction agents, 38initial approach, 16intraocular pressure, 34local anesthetics, 36monitoring and maintenance, 40, 41muscle relaxation, 38–40non-urgent conditions, 16ocular trauma score, 11oculocardiac reflex, 40ophthalmologic exam

anterior chamber exam, 25, 26external ocular exam, 19–21intraocular pressure measurement, 26, 27ocular motility, 24, 25ocular ultrasound, 28–30posterior chamber, 27, 28pupil exam, 21, 22visual acuity exam, 22, 23visual field testing, 25, 26

peribulbar block, 37physiology, 34premedication, 38preoperative assessment, 35, 36retrobulbar block, 36, 37sub-tenon nerve block, 37, 38topical anesthesia, 36triaging eye injuries, 11, 12urgent conditions, 16

Defense Health Agency (DHA), 254Descemet’s membrane, 187Diaton transpalpebral tonometer, 82Dibenzoxazepine (CR), 197Diethyl S-[2-(diethylamino)ethyl] phosphorothioate

(Amiton), 1912,3-Dimercaptopropanol (BAL), 189Dimethyl sulfoxide (DMSO), 179Diphenylaminochloroarsine, 198

Diphoterine rinsing solution (DRS), 182Diplopia, 19, 105–108, 119Dog bite injury, 93

EEfferent visual disturbances, 107Eight-ball hyphema, 76Eisner method, 60Elective surgeries, 36Electroocculograms (EOG), 185Electroretinography (ERG), 184, 185Endophthalmitis, 47, 128Endoscopic cyclophotocoagulation (ECP), 84Enucleation, 98Escalation of force (EOF), 161External ocular exam, 19–21Extraocular movement (EOM), 24, 25Extraocular muscle entrapment, 114Extraocular muscles, 24Eye armor

body armor, 229combat support hospital, 229development of, 228eye injuries

automatic weapons, 228example, 228eye protection, 228incidence of, 227military training exercise, 228modern battlefield, 227, 228wound globe, 227, 228

eye-hazardous laser, 229eye protection, 229injection-moldable optical-grade polycarbonate, 230Korean War, 232, 233missions of infantryman, 228, 229modern development

American Optical eye armor, 236ametropia, 235BLPS, 236Combat Ocular Problems, 234, 235DOD, 234Gargoyles, 235Hirschberg’s observation, 234laser wavelengths, 237low-energy lasers, 235, 236MCEP program, 236, 237medium-power laser systems, 235MEPS, 236polycarbonate, 234Postoperative Eye Guard, 234private industry, 234

personnel equipment, 229polycarbonate, 230pre-Colombian America, 230scratch-resistant coatings, 230senior officers, 229, 230soldier-acceptable eye armor, 230Vietnam war, 233, 234

Index

272

Eye armor (cont.)World War I, 230, 231World War II, 231, 232

Eyelid lacerations, 159Eyelid trauma

burns, 91, 92full thickness lacerations, 90partial thickness lacerations, 89periocular tissue loss, 90, 91

Eye wall, 10

FFamilial exudative vitreoretinopathy (FEVR), 125Federal Aviation Administration (FAA) reports, 162Firework injuries, 116Fly larva ophthalmomyiasis, 117

GGeneral anesthesia endotracheal anesthesia (GETA), 38Geneva Gas Protocol, 171Ghost cell glaucoma, 78Giant retinal tears, 68Glaucoma drainage devices (GDD), 85Globe removal

enucleation, 98eviscerations, 99exenteration, 99

Goggles, 108Goldmann perimeter, 107Goldmann test, 107“Greenstick” blow-out fracture, 119

HHawaiian Eye Foundation, 254Hemolytic glaucoma, 78Hemorrhage’s amblyogenic effects, 125Hemorrhagic chemosis, 114Hemosiderotic glaucoma, 78High order (HE) explosives, 175Hordeolum, 20Humanitarian missions

bilateral blinding cataract, 241clinical and military experiences, 243corneal-fellowship training, 245execution phase

ADVON, 250capacity building, 253complication management, 253general anesthesia, 250locations and diverse backgrounds, 250Medical Liaison Officer, 250military ophthalmology residents, 251–253orientation briefing, 250phacoemulsification, 254postoperative team, 251role-specific real-world training, 251surgical campaign, 250

surgical patient screening, 250team and individual training, 250, 251team cohesion, competence, and

confidence, 250, 251U.S./Partner Nation knowledge exchange, 253

issues, 243leadership, 243MEDCAP exercises, 241military ophthalmic surgical missions, 245, 246mission funding, 245MOST, 242MSICS technique, 242, 244, 245ophthalmic surgical mission, 246, 247Partner-Nation capacity, 243, 244post-deployment phase, 254pre-deployment phase

deploying personnel, 249, 250logistics issues, 249mission supplies, 249mission tasking sequence, 247MSICS surgeons, 249OHASIS, 248overall requirements, 247PDSS, 248, 249SSC, 248U.S. Embassy, 247, 248

USAR personnel assets, 243Hydrofluoric acid (HFA), 177Hyphema

advantages and disadvantages, 122angle recession, 78anterior segment after trauma, 75anterior vitrectomy system, 77causes, 121corneal blood staining, 76, 77eight-ball hyphema, 76elevated IOP, 77grading, 76, 122initial evaluation, 76intraocular pressure, 122medical management, 122patient’s pupil reactivity, 122potential complications, 76rebleeding, 76, 122surgical intervention, 122total hyphema, 76tranexamic acid, 76

Hypoxic-ischemic brain injury (HII) patterns, 129, 130

Iicare® tonometers, 27Improvised explosive device (IED), 33, 53, 175, 214Indirect traumatic optic neuropathy (ITON), 105Infracilliary approach, 120Internal carotid artery (ICA), 174Intracanalicular optic nerve, 104Intranuclear ophthalmoplegia (INO), 24–25Intraocular foreign body (IOFB), 10, 70, 127, 128Intraocular hemorrhage, 122

Index

273

Intraocular lens (IOL) power, 123, 124Intraocular pressure (IOP), 26, 27, 34, 75, 122, 185Intraorbital hemorrhage, 104Intraretinal hemorrhage (IRH), 68, 128, 129Intrascleral hemorrhage, 130Iraq freedom, 6

KKing-Devick test, 106Korean War, 5

LLaceration, 10, 121Lacrimal trauma, 93Lamellar laceration, 10Laser iridectomy, 83Laser trabeculoplasty (LTP), 84Lateral canthotomy with cantholysis, 16Lens-induced uveitis (LIU)

anterior chamber, 137complications, 138corneal abrasions/hyphema, 137etiology, 137pathogenesis, 137perforating/penetrating injuries, 137treatment of, 137, 138

Limbal stem cell deficiency (LSCD), 173Limbal stem cells, 187Local anesthetics (LAs), 36Low order (LE) explosives, 175

MMacular hole, 66, 67Manual Small Incision Cataract Surgery

(MSICS), 242, 249Matrix metalloproteinase (MMP) activity, 187Medial longitudinal fasciculus (MLF), 24Medial wall fracture, 95Medical Civic Action Programs

(MEDCAPs), 213, 241Medical readiness training exercises

(MEDRETES), 213Memorandum of Agreement (MOA), 249Methanol, 201Micro-invasive glaucoma surgery (MIGS), 85Military Combat Eye Protection (MCEP)

program, 236, 237Military Eye Protection System (MEPS), 236Military ophthalmologists, 7Military physicians, 4Military residency programs, 3Minimally invasive glaucoma surgery, 85, 86Mobile Ophthalmic Surgery Team (MOST), 242Monocular painful vision disturbance, 19Monocular painless vision, 19Morgan Lens, 17Muscle relaxation, 38–40

NN-acetyl L-cysteine (NAC), 187Nasolacrimal duct injury, 93Naso-orbital-ethmoid (NOE) fractures, 97National Fire Protection Association (NFPA), 181Necrotic/trauma-associated retinal breaks, 68Nitrochloroform, 197, 198Nominal Ocular Hazard Distance (NOHD), 162, 163Non-accidental trauma (NAT), 117, 129Non-Commissioned Officer in Charge (NCOIC), 249Nondepolarizing muscle relaxants (NDMRs), 39Nonpowder guns, 116

OO-chlorobenzylidene malononitrile (CS), 195, 196Ocular disturbances, 18Ocular motility, 24, 25Ocular motor dysfunction, 106Ocular polytrauma, 64Ocular surgery, 4Ocular toxicology

acids, 176, 177adamsite, 198adjacent endothelial cells, 173, 174alkalis

anterior structures, 177anti-TNF-a antibodies, 177base solutions, 177broad-spectrum antibiotics, 178corneal sensation and damage, 179corrosive damage, 177cycloplegics, 178dexamethasone, 178doxycycline, 178Draize test, 179Dua classification, 178early re-epithelialization, 178grade 2 injuries, 178grade 3 injuries, 178grade 4 injuries, 178inflammatory response, 178normal stromal function, 179ongoing inflammation, 179permanent visual loss, 177pH neutralization and screening, 177postoperative glaucomatous changes, 177Roper-Hall classification, 177, 178secondary glaucoma, 177silibinin, 178surgical evaluation, 179surgical intervention, 179treatment options, 177xenobiotic-induced skin irritation, 179

BZ, 193, 194chemical injuries

CW agents, 176occupational hazards, 176ophthalmic emergency, 176RCA, 176

Index

274

Ocular toxicology (cont.)timing and efficiency, 176

Chemical Weapons Convention, 171chloroacetophenone, 195chloropicrin, 197, 198choroidal and retinal vessels, 174components, 171, 172corneal epithelium, 172, 173CW agents (see Chemical warfare agents)damage and penetration, 172decontamination

CW agents, 182DRS, 182emergency/trauma physicians, 181exposure scenarios, 181mass casualty events, 181potential forensic analysis, 181recommendations, 181, 182superior decontamination solutions, 182timely decontamination, 181toxic substance, 181vision threatening injuries, 182

Descemet’s membrane, 173dibenzoxazepine, 197EOG, 185ERG, 184, 185fentanyl, 194ICA, 174injury patterns

colorimetric blast dosimeters, 175corneal scarring, 176enhanced vehicle shielding, 175gross contaminants, 175high order explosives, 175low order explosives, 175mustard gas casualties, 176negative phase, 175positive phase, 175prehospital management, 175protective eye wear, 175thermal burn injuries, 175TON, 175victim locations, 175

IOP, 185LSCD, 173melanin, 174O-chlorobenzylidene malononitrile, 195, 196oleoresin capsicum, 196, 197ophthalmic artery, 174optic disc, 174organic solvents, 179passive leak, 173patient evaluation, 183, 184PPE (see Personal protective equipment)RCA, 194, 195retina, 174rods and cones, 174RPE, 174skunk musk, 198, 199surfactants, 179, 180

systemic (vascular) absorption, 172systemic xenobiotics, 200, 201ultraviolet radiation, 199, 200VEPs, 184xenobiotic-induced retinal injury, 174xenobiotics, 175

Ocular Trauma Score (OTS), 11Ocular ultrasound, 28–30Ocular wounds, 4Oculocardiac reflex, 40, 119Oleoresin capsicum (OC), 196, 197Open globe injuries (OGI), 10, 126–128

intraocular foreign body removal, 70–72lacerations, 68, 121mixed, 68ruptures, 68, 121traumatic brain injury, 102, 103vitrectomy for retinal detachment, 73vitreoretinal surgery, 70zone 1 injuries, 68zone 2 injuries, 68zone 3 injuries, 68

Operations Enduring Freedom (OEF), 101Operations Iraqi Freedom (OIF), 101Ophthalmia nodosa, 117Ophthalmic artery (OA), 174Ophthalmic Microsurgical suturing techniques, 57Optic nerve sheath diameter (ONSD), 29Orbital and ocular adnexal trauma, 118, 119Orbital bone fractures, 114Orbital cellulitis, 47Orbital compartment syndrome (OCS), 16, 94, 165–167Orbital floor fracture, 95, 96Orbital hemorrhage, 81Orbital roof fracture, 96, 119Orbital trauma

carotid-cavernous fistula, 98floor and medial wall fracture, 95, 96NOE fractures, 97orbital compartment syndrome, 94orbital foreign bodies, 94, 95orbital roof, 96ZMC fractures, 97

Orbital wall fracture, 20Organization for the Prohibition of Chemical Weapons

(OPCW), 171Overseas Humanitarian Assistance Shared Information

System (OHASIS), 248

PPanOpticTM ophthalmoscope, 27, 28Papilledema, 28Partner-Nation a Pre-Deployment Site Survey (PDSS),

248, 249Pediatric ophthalmology

anterior segment traumachemical injury, 121corneal abrasion, 120, 121hyphema, 121–123

Index

275

traumatic cataracts, 123–125clinical findings, 114dilated examination, 115epidemiology, 112estimation, 111evaluation, 112head trauma complications

shaken-baby (impact) syndrome, 128–130traumatic cranial nerve injury, 128

history, 113initial evaluation, 111injury types

arachnid-inflicted trauma, 117bee stings, 117bird related injuries, 118Brown Recluse bites, 117cats, 118chemical injuries, 116dogs, 118firework injuries, 116fly larva ophthalmomyiasis, 117non-accidental trauma, 117nonpowder guns, 116polytrauma, 117sports injuries, 115thrown projectiles, 115

open globe injuries, 126–128orbital and ocular adnexal trauma, 118, 119posterior segment trauma

rhegmatogenous retinal detachment, 125, 126vitreous hemorrhage, 125

prevention, 118suspected open globe, 113tetanus vaccination status, 113ultrasound, 115

Penetrating injury, 10Penetrating keratoprosthesis (PKP), 177Perforating injury, 10Peribulbar block (PBB), 37Periocular tissue loss, 90, 91Periorbital burns, 91, 92Persian Gulf War, 6Personal protective equipment (PPE)

CBRNE terrorist incidents, 181chemical, radiological/biologic hazards, 180HAZWOPER standard, 180NIOSH-approved equipment, 180, 181

Photophobia, 19Pneumatonometer, 82Point of injury (POI), 149Polycarbonate lenses, 108Polytrauma, 117Polytraumatic injury, 63Porcelain eye fracture, 119Posterior chamber, 27, 28Posterior segment

antimicrobial prophylaxis, 64closed globe injuries

choroidal rupture, 66commotio retinae, 65, 66

giant retinal tears, 68retinal dialysis, 67retinitis sclopeteria, 67vitreous base avulsion, 67vitreous hemorrhage, 64, 65

diagnostic equipment, 64immediate posterior segment interventions, 63open globe injuries

intraocular foreign body removal, 70–72lacerations, 68mixed, 68ruptures, 68vitrectomy for retinal detachment, 73vitreoretinal surgery, 70zone 1 injuries, 68zone 2 injuries, 68zone 3 injuries, 68

polytraumatic injury, 63rhegmatogenous retinal detachment, 125, 126vitreous hemorrhage, 125

Postoperative proliferative vitreoretinopathy (PVR), 70Post traumatic glaucoma, 75

chemical burns, 82lens trauma

aphakia, 80–81lens particles, 80pseudophakia, 80–81pupillary block, 80

orbit, 81penetrating ocular injury, 81posterior segment, 81uveitis, 81

Pre-hospital careadvanced ocular diagnostic techniques, 157, 158ballistic eye armor, 157ballistic eye protection, 166–168ballistic eyewear, 149Battalion Aid Station, 156blast fragments, 150chemical injury

commercial-grade agents, 164copious irrigation, 164industrial detergents, 164Lactated Ringers, 164munitions, 164normal saline/Plasma-Lyte A IV fluid, 164petroleum products, 164

closed-globe injuries, 160, 161combat casualties, 149, 157conjunctival foreign body, 164, 165corneal abrasions, 165direct/indirect pressure, 150examples, 150, 152explosions, 156eye injuries from blast

corneal abrasions, 160fluorescein staining, 160gunshot wounds, 159high index of suspicion, 160injury patterns, 160

Index

276

Pre-hospital care (cont.)ophthalmic evaluation, 160post-traumatic inflammation, 160protective eyewear, 159visual dysfunction, 160

eyelid lacerations, 159final visual outcome, 149first responder care, 1564th generation fluoroquinolone, 157Fox shield, 151, 156high-explosive environments, 150laser eye injury

Amsler grid, 163illumination/bright light event, 161indirect viewing methods, 163international laws of combat, 161intraocular/retinal hemorrhage, 163invisible lasers, 161, 162laser threat, 162lens coloration, 162military devices, 161nighttime exposures, 162Operation Desert Storm, 162operational toll laser exposures, 162optical sighting devices, 163photoflash blindness, 161psychological impact, 162suspected laser injuries, 163temporary dazzling effect, 162unit training, 162, 163visible-light lasers, 161, 162visual acuity, 163

Medic, 156non-ophthalmic care, 157non-ophthalmologists, 149OCS, 165–167ocular injuries, 149open globe, 154, 155operational situation, 156ophthalmic surgical care, 149periocular wounding pattern, 150point-of-injury aid kits, 157post-traumatic endophthalmitis

evacuation and topical antibiotic drops, 158gram-negative organisms, 158gram-positive cocci, 158levofloxacin, 159moxifloxacin, 158, 159risk factors, 158third/fourth generation fluoroquinolones, 158visual outcomes, 158visual results, 158

potential ocular injury, 151, 153pressure dressings and patches, 157requirements, 157rigid eye shields, 150, 151swollen eyelids, 151, 154types, 150visual acuity, 151, 154

Pre-Ophthalmic Emergency Department Care, 113Preretinal hemorrhage (PRH), 128, 129Primary blast injury (PBI), 102, 108Public-private partnership (PPP) model, 254Pupil exam, 21, 22

QQuaternary blast injury, 1023-Quinuclidinyl benzilate (BZ), 193, 194

RRebound tonometer, 82Relative afferent pupillary defect (RAPD), 22Retinal detachment, 28Retinal dialysis, 67Retinal hemorrhage (RH), 128–130Retinal pigment epithelium (RPE), 174Retinal vein occlusion (RVO), 28Retinitis sclopeteria, 67Retinopathy of prematurity (ROP), 125Retrobulbar block (RBB), 36, 37Retrobulbar hemorrhage, 16, 94Revolutionary War, 3Rhegmatogenous retinal detachment (RRD), 125, 126Riot control agents (RCAs), 171, 176, 194, 195Rupture, 10

SSaccadic deficiencies, 106Scleral lacerations, 59–61Scoville heat units (SHU), 196Secondary blast injury (SBI), 102, 108Seidel sign, 114Shafer sign, 115Shaken-baby (impact) syndrome (SBS), 117, 128–130Shiotz tonometer, 27Sickle cell anemia, 77Special Forces (SF) battalion, 215, 216Sports injuries, 115SSC, 248Staphylococcal epidermidis, 139Stellate lacerations, 59, 60Stereovision, 108Subconjunctival hemorrhage, 20Subretinal hemorrhage, 129Sub-tenon nerve block, 37, 38Superficial foreign bodies, 55Suprachoroidal and subconjunctival pathways, 86Surgical Eye Expeditions (SEE), 254

TTactical Combat Care Guidelines (TC3 Guidelines), 159Tarantula defense mechanism, 117Tertiary blast injury, 102Thrown projectiles, 115

Index

277

Tonopen® tonometers, 27Topical anesthesia, 36Trabeculectomy, 84, 85Traditional incisional glaucoma filtration surgery, 84, 85Transscleral cyclophotocoagulation (TSCPC), 84Traumatic brain injury (TBI), 160

afferent system, 102blast injury mechanism, 102blunt, penetrating/acceleration/deceleration

forces, 101causes, 101closed globe injury, 103cognitive impairment and disability, 101DoD, 101open globe injuries, 102, 103

Traumatic cataracts, 123–125Traumatic cranial nerve injury, 106, 128Traumatic endophthalmitis

bacteria, 139broad-spectrum antibiotics, 140, 141clinical manifestations, 138, 139endogenous, 138exogenous, 138fungi, 139, 140incidence of, 138intravenous antibiotics, 140, 141intravitreal antibiotics, 141medical management, 140morphology and staining patterns, 139prognosis, 138prophylactic subconjunctival antibiotics, 140Pseudomonas species, 139Sabouraud’s dextrose agar, 139stains, cultures, and antimicrobial sensitivities, 139subconjunctival antibiotics, 141topical antibiotics, 140, 141vitrectomy, 141, 142vitreous specimens, 139

Traumatic glaucomaangle recession, 78, 79ghost cell glaucoma, 78hemolytic glaucoma, 78hemosiderotic glaucoma, 78hyphema

angle recession, 78anterior segment after trauma, 75anterior vitrectomy system, 77corneal blood staining, 76, 77eight-ball hyphema, 76elevated IOP, 77grade, 76initial evaluation, 76potential complications, 76rebleeding, 76total hyphema, 76tranexamic acid, 76

intraocular pressure, 75medical management

apraclonidine, 82

beta adrenergic antagonists, 82betaxolol, 82brimonidine, 82hyperosmotics, 83miotics, 83systemic CAI, 83topical carbonic anhydrase inhibitors, 83

post traumatic glaucoma (see Post traumatic glaucoma)

surgical managementlaser iridectomy, 83laser trabeculoplasty, 84minimally invasive glaucoma surgery, 85, 86traditional incisional glaucoma filtration surgery,

84, 85TSCPC, 84

Traumatic optic neuropathy (TON), 175blast-induced ocular and orbital trauma, 104clinical diagnosis, 104indirect TON, 105testing, 104

Traumatic retrobulbar hemorrhage, 94Traumatic uveitis

anterior chamber, 136anti-inflammatory therapy, 135blunt trauma, 135combat and civilian casualty situations, 135complications, 136corneal endothelial rings, 135diagnosis and management, 136elevated intraocular pressure, 136etiology, 137glaucoma, 136globe trauma, 136initial treatment, 136intraocular pressure, 136magnetic resonance imaging, 136natural disasters, 135periocular triamcinolone acetonide injections, 136persistent inflammation, 136pigmented cells, 135posterior synechiae formation, 136primary blast injury, 135secondary blast injuries, 135symptoms, 135terror attacks, 135topical corticosteroids, 136topical cycloplegic, 136topical glaucoma therapy, 136ultrasound, 136war injuries, 135

Triaging eye injuries, 11, 12Tripod/trimalar fracture, 97

UUltraviolet radiation (UV), 199, 200Uniformed Services University (USU), 254Universal Prescription Lens Carrier (UPLC), 237

Index

278

US Army Reserve (USAR) personnel assets, 243USARPAC Commanding General, 214US Department of Defense (DOD), 101, 234Uveitis, 81

VVestibular dysfunction, 106Vietnam War, 5, 6Visual acuity (VA) exam, 22, 23, 113Visual-evoked potentials (VEP), 184Visual field testing, 25, 26Vitreoretinal surgery, 70Vitreous base avulsion, 67Vitreous hemorrhage (VH), 28, 64, 65, 125

WWar of 1812, 4Whiplash shaken infant syndrome, 128White eye fracture, 119World War I, 4, 5World War II, 5Wound Data and Munitions Effectiveness in Vietnam

(WDMEV) team, 228

ZZones of compression, 58Zygomaticomaxillary complex (ZMC) fracture, 97

Index

appendix: suturing 101

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