There is no branch of surgery which the non-specialist is more afraid to enter than ophthalmology. All operations inside a patient’s eye are work for an expert, but you should be able to repair most injuries to his lids. If you cannot refer him, you may have to suture his cornea, or his sclera. Even if his eye seems to be hopelessly injured, there is much that you can do to preserve some useful sight in it.
As with the skull, the chest, and the abdomen, there are two main kinds of injury—blunt ones which leave his cornea and his sclera intact, and penetrating ones which go through them.
A blunt injury, such as that from a fist, resembles a head injury. It can cause serious internal lesions, including bleeding, with few external signs.
Penetrating eye injuries are always serious and differ geographically. In rural areas many of them are caused by thorns striking the eyes of people walking in the bush, or by young children pushing things into one another’s eyes. Injuries of this kind are difficult to prevent, but you should try to make sure that: (1) goggles are worn by everyone whose work might injure their eyes, and (2) seat belts are always worn in cars.
The purpose of an eye is to see with, so always start by testing (and recording) a patient’s visual acuity. An eye injury can be terrifying. If he cannot see, make sure he knows what has hap- pened, understands any treatment you give him, and is told the prognosis for his sight.
An injured eye is always an emergency, but it is not quite so urgent as a ruptured spleen, or an extradural haematoma. After the necessary emergency treatment, you usually have 2 or 3 days in which to refer him. If you do have to operate, make sure you go to the theatre having made the diagnosis and knowing exactly what you are going to do. You will need fine instruments and sutures and a magnifying loupe. These are listed in Section 23.1.
JAMES (8 years) was referred with a swollen eye and a diagnosis of rupture of the globe. His visual acuity was tested and found to be normal. Examination of his upper conjunctival fornix showed a piece of wood. LESSON Always test the visual acuity. In this patient it made the original diagnosis of rupture of the globe impossible.