War Surgery and Medicine
In North Africa men with ocular wounds were sent back as soon as possible to base hospital in Egypt, where they remained under continuity of observation and treatment until all inflammation had subsided and any risk of sympathetic inflammation had passed.
This ideal was not always practicable in Italy, where we had hospitals as it were in series from Naples to Helwan. It may be imperative for the forward one to move patients back quickly to keep beds empty for further convoys. Ophthalmic casualties could pass through several hospitals while their wounds were still in a dangerous state, and we learned from experience that a convoy by train or road or sea could be directed or diverted to a hospital where there was no ophthalmologist. There can be little doubt that once an ophthalmic casualty reaches a hospital where an equipped ophthalmologist is available it is better that he should not be transferred while any danger remains.
To give an idea of the relative proportions of different types of wounds the following analysis has been prepared of a series of 239 page 436 major battle casualties seen at 1 NZ General Hospital up to January 1945. The cases are of serious wounding and do not include functional or blast disturbances, subcutaneous foreign bodies, or head injuries not involving the orbit. In this connection it should be mentioned that, unless the precise type is stated, figures for ocular wounds can be misleading. Amongst the casualties admitted to hospital, Lieutenant-Colonel Coverdale's estimate of the proportion with ocular wounds is about 3 per cent with serious and 3 per cent with minor wounds, a fairly high percentage for the ophthalmologist when it is remembered that he is also called to see many men with subjective difficulties, but with no signs of injury.
The wounds were mostly due to shell, mortar, or mine fragments, and were often multiple and dirty with lacerations of the skin, lids, or conjunctiva.
|Right eye wounded||75||39||114|
|Left eye wounded||57||28||85|
|Both eyes wounded||22||18||40|
|Men with other wounds elsewhere, 120.|
|(1) Penetrating or perforating wounds of the globe of one or both eyes||67||30||97|
|(2) Penetrating or lacerating wounds of the lids or orbit—|
|(a) With contusion of the globe and intra-ocular injury||44||19||63|
|(b) Without injury to globe||8||3||11|
|(3) Contusion of the globe without injury to the lids or orbit||11||6||17|
|(4) Superficial penetrating or lacerating wounds of the globe of one or both eyes||23||27||50|
|(5) Burns of the globe||1||1|
|Both eyes lost or blinded||7||0||7|
|One eye lost or blinded and the other seriously injured||5||2||7|
|Both eyes seriously injured||0||1||1|
|One eye lost or blinded||68||21||89|
|One eye seriously injured||20||21||41|
|Men with one or both eyes removed||49||16||65|
|Men presumed on clinical grounds to have small retained intra-ocular foreign bodies after disposal||9||6||15|
These figures cover patients treated at 1 General Hospital in Egypt and Italy up to and including January 1945, and are not complete for 2 NZEF although they probably include the great majority of cases.
Of 67 men with penetrating or perforating wounds of the globe in Egypt, 51 (76 per cent) eyes were removed—usually farther forward than the base hospital. Of 29 such cases in Italy, 16 (55 per cent) eyes were removed. The number of cases with one eye seriously injured (but not removed) was therefore proportionately higher in Italy. This may have been due, at least in part, to evacuation difficulties in the desert, but it is also evidence of the value of penicillin and albucid soluble which were not available to ophthalmologists before about April 1944. All those with contracted sockets after enucleation or evisceration in forward areas (10 in all) arrived at Helwan with fibrosis already established. The condition of the sockets was a salutary reminder that in ophthalmology there is no substitute for the day-to-day watchfulness and care of the ophthalmic surgeon. Many of these men were in transit for two weeks and the consequences could not have been avoided. A feature of interest present in about 30 per cent of wounds was the severity of the retinal and vitreous haemorrhages from foreign bodies which were either disproportionately small in size and extra-ocular, or which caused tangential or penetrating wounds of the brow or cheek not directly involving the orbit. This was commented on in the First World War, and was due, no doubt, to the velocity of the fragments.
Intra-ocular foreign bodies so frequently consisted of non-magnetic alloys, stone, or bakelite that the giant magnet was not often of value. Many eyes had retained foreign bodies of very small size, and these will need to be watched over long periods. In some situations, stone and bakelite may remain stable and cause no reaction. Time alone will show. (Six years after the war Coverdale had seen no late harmful effects.) The element of uncertainty was increased by the fact that no radiological method of exact localisation was available in the Middle East.
Problems of special importance were the penetrating injuries of the eye and the injuries to the cornea produced by small particles following mine explosions, and to a lesser extent explosions of shells and mortars. Ophthalmological specialists were attached to the CCS after the Alamein period and electro-magnets were available then, but not of sufficient power to be efficient in the majority of cases.
Minimal treatment was recommended in the forward areas before cases were seen by an ophthalmologist. Excision of the eye was page 438 restricted to completely disorganised eyes, the removal of which was necessitated by the general treatment of a face wound. A simple pad and bandage was then applied, no packing being inserted. In wounds of the globe, atropine was instilled, and if a penetrating wound was present a pad and bandage was applied, the lids being stitched together if damaged and the case evacuated lying.
At a forward ophthalmic unit the only treatment advised was that urgently necessary for the conservation of vision. Excision was carried out only for extensive rupture of one blind eye, this being done within ten days of injury. Excision of any prolapsed uvea or lens capsule was done, wounds of the sclera sutured, and wounds of the cornea covered by conjunctival flaps. Foreign bodies were removed only if easily extracted when the magnet was applied to an existing wound of the sclera, or when they could be brought forward from the anterior chamber for anterior extraction. Foreign bodies spattering the cornea were difficult to remove and were generally left alone unless causing irritation. General sulphonamide or penicillin treatment was instituted early in all perforating wounds of the eye and orbit. Corneal exposure was prevented, when necessary, by suturing the lids together. Moderate delay in the removal of foreign bodies did not prove harmful, so that patients could be evacuated to base for major operative procedure. At the Base useless eyes were removed when any danger of sympathetic ophthalmia arose. Foreign bodies were removed by the anterior or posterior route with the use of the magnet if possible. Forty per cent were magnetisable.