ha,' is that injuries in patients with glasses tend to be more serious: in the Australian series one case was associated with a choroidal tear, two patients had penetrating. injuries and one patient sustained a penetrating injury with a traumatic cataract. Several of these patients with glasses raised the question of their hardenedglass warranty. The warranty says specifically that in cases of any injury to the eyeball $5000 will be paid only if such injury results in permanent total loss of vision - that is, no light perception. As well however, the warranty will cover up to $5000 for any medical or surgical expenses in excess of the expenses paid by provincial or private health plans in cases of any such permanent and total injury to the eye. What type of protection is available? For those who have to wear spectacles a nylon sports frame with a rubber bridge (Fig. 7) gives good protection and would prevent a brow laceration as seen in case 17 (Fig. I). Because the frame will collapse on impact, the chance of a temple snapping into the eye is certainly reduced. As this study demonstrated, hardened-glass lenses

may shatter; therefore the player should insist that the optician insert 3 mm centre thickness plastic in these nylon frames.6 Most opticians retail these frames and plastic lenses for less than $50. For those who do not wear glasses there are two basic types of protection on the market, metal and plastic. The metal frame (Fig. 8) certainly gives adequate protection but it is somewhat uncomfortable and many players have rejected it for plastic frames. One type of plastic protection, the Solari eye guard, is shown in Fig. 9. The inside can be padded, and it certainly is comfortable. Another protection available is the Protec, which also can be padded (Fig. 10). It is light and appears to be the eye guard that is most comfortable and acceptable to squash players I have spoken to. These metal and plastic squash guards cost $13 to $15 at optical and sports stores in Canada. In summary, over 2½ years I saw 23 cases of significant eye injury, 11 of which required hospitalization. Of these cases, 5 had some decrease in vision; 3 of the 5 players wearing glasses or hard contact lenses sustained

an injury with permanent reduction in vision. Only 2 of the 17 nonspectacle wearers lost any permanent vision. There appears at present to be adequate eye protection; it is the responsibility of the medical profession to encourage players to wear this protection at all times; as well, we must encourage clubs to provide such protection outside each court. Only in this way will we reduce the incidence of these significant eye injuries. I wish to acknowledge with thanks the generous help of the medical photography department of The Wellesley Hospital and the assistance of Anne Marie Malone in the preparation of this paper. References 1. NORTH IM: Ocular hazards of squash. Med I Australia 1: 165, 1973

2. INGRAM DV, LEWKONIA I: Ocular hazards of playing squash racquets. BrIt .7 Ophihal 57: 434, 1973 3. BRONSTEIN JL: Eye injuries in sport. Practitioner 215: 208, 1975

4. MOORE MC, woRTHLEY DA: Ocular injury

in squash players. Australian .7 Ophth 5: 46, 1977 5. SCRIVENER AR: Impact-resistant lenses. Brit I

Physiol Optics 28: 26, 1973

6. CHRIsTIANsoN MD, PARKER JA: Material and thickness: important parameters in spectacle lens impact resistance. Presented at the annual meeting of the Canadian Ophthalmological Society, Calgary, June 1977

Primary management of ocular trauma J. DONALD MORIN, FRCS[C]

Ocular trauma is common, and unfortunately in recent years the incidence of eye injuries has not substantially decreased. This is despite preventive measures such as public education, industrial safety programs and eye protection devices. In one year alone 30 000 eye claims were submitted to the Ontario Workmen's Compensation Board. In 1975, 12 children lost eyes in hockey. Fortunately only a few eyes are completely lost; nevertheless ocular trauma of varying extent is a frequent emergency problem. Early correct diagnosis and treatment will avoid making the eye injury worse and help relieve patient and doctor from the terrifying expectation of blindness. In the management of a patient with ocular trauma, the first step is to record the visual acuity. The visual acuity should be determined with a Snellen chart, if possible, but if the patient canReprint requests to: Dr. J.D. Morin, St. Michael's Hospital, 30 Bond St., Toronto M5B 1W8

not read the Snellen chart the physician should determine at what distance the patient is able to count fingers, see hand movements or determine accurate light projection. Vision should be measured with spectacle correction if available, but if the patient's spectacles are broken the doctor should record the vision as the patient looks through a pinhole held before his eye while he reads the Snellen chart. Immediately after an eye injury, there is a great tendency to squeeze the eye shut and blink vigorously. This can be overc6me by a drop or two of local anesthetic, such as tetracaine or cocaine. Once the patient has relaxed and opened his lids, it is possible to measure the visual acuity and inspect the anterior ocular structure. If the lids still will not open, one may need a lid retractor to hold them apart. This can be improvised by bending paper clips over a snap. Gently retract the lids to see whether the cornea is clear and intact; if not, patch gently and send the patient directly to hospital for an ophthalmologist's care. Once the cornea has been found satisfactory, check the red reflex with an ophthal-

moscope to determine whether there is a cataract, foreign body or intraocular hemorrhage. If a foreign body has struck the eye, details of what the foreign body is, when it struck the eye and what has occurred since the injury should be ascertained. It is important to locate the foreign body or the site at which the foreign body struck the eye. It is easy to see a foreign body on the limbus, but on the cornea this is more difficult and it may be seen only with oblique light or with fluorescein staining. If beneath a lid, it may be seen only after the lid is flipped over. Once located, the corneal foreign body should be irrigated free or lifted free with a swab. If this fails, use a #25 disposable needle, which is the most readily available corneal spud. While removing the corneal foreign body, as much rust ring as possible should be removed. If this is difficult, rather than persist, patch the eye and remove the remainder the next day after the inflammatory process has loosened the residual rust ring. As long as there is rust present on the cornea, a foreign body sensation will persist, a larger



TLAGYSTATIN. CREAM effective topical treatment for vaginitis due to both major vaginal pathogens corneal scar will form and the possibility of future complications remains. Fragments of metal may enter the eye and leave only a subtle entrance wound that can be difficult to see, and a dangerous intraocular foreign body may be overlooked. If there is any doubt even after a good view with an ophthalmoscope, an ocular x-ray should be taken to make sure there is no intraocular foreign body present. A retained intraocular foreign body is dangerous.

-Pouienc If it is ferrous metal, the eye will degenerate due to the destructive effect of the metal (siderosis) on the ocular tissue. If it is copper, the ocular tissue reaction is even more severe. Intraocular foreign bodies are often best removed in the operating room where they can be accurately located electronically and removed by magnetic techniques. Contusion eye injuries are common, especially on Saturday nights and in

racquet sports. When one sees ecchymosis of the lids, one should suspect more than just a black eye is present, for the traumatic shock wave as it passes through the eye and the orbit can lead to multiple injuries. Subconjunctival hemorrhage, which may be obvious, will reabsorb without treatment. Much more serious is blood in the anterior chamber (hyphema). Hyphemas interfere with vision but will reabsorb in 5 days if the patient re-


4 .

FIG. 1-Hyphema 306 CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118

FIG 2-Lid laceration


ceives complete bed rest with a bino- X-ray of the sinus will show an antrum enables one readily to detect the epithelial defects with an ultraviolet light. cular eye patch. If there is a secondary full of blood. Tree branches, fingernails, paper Lacerations of the eyelid deserve hemorrhage into the anterior chamber, which may occur in the high-risk special consideration. If the lid margins edges and contact lenses are all comperiod of 3 to 5 days after the initial are involved, particular attention to ac- mon causes of corneal abrasion. All injury, severe sequelae, such as glauco- curate alignment of the margin is im- abrasions should be patched to relieve ma, corneal scarring or both may de- portant to avoid deformity, which pain, and if necessary supplemental sysvelop. The red reflex may be obliter- will cause tearing. Figure-eight sutures temic analgesics should be used but not ated due to the hemorrhage, and if it through the margin, splinting the lid local anesthetics. The patch should be spreads into the vitreous body it may margin against its fellow, will properly left on until no epithelial defect is seen take months to clear and for vision to position the tissue for healing. If the and the eye is comfortable. Recurrent return. Careful care of the patient with canaliculus, particularly the lower ca- corneal erosion can be prevented by hyphema is needed to avoid these com- naliculus, is interrupted by the lacera- using ointment such as Lacrilube in the tion, every effort should be made to injured eye before retiring. plications. Chemical agents when in contact Retinal edema can develop following prevent tearing and avoid the need for blunt trauma. The retina will be elev- secondary repair. Often this is best with the eye can lead to conjunctivitis, ated at the posterior pole and the vision done by placing a fine silicone tube keratitis, uveitis, cataract, glaucoma distorted and decreased. A rupture of through the severed ends of the canal- and obstruction of the lacrimal tract. Alkalis are the worst as they continue the retina in the macula may leave iculus. Corneal lacerations are serious ocular to damage the eye for weeks after the permanent loss of vision. A choroidal rupture deep to the retina leaving an injuries. Once recognized such cases injury. All chemicals should be washed irregular white arcuate scar is easily should be transferred quickly to avoid out with water and not antidotes, as further injury. Early definitive ophthal- looking for the proper antidote will recognized by ophthalmology. An orbital fracture may occur due mological treatment is needed to save lead to unnecessary delay. The most important treatment is preto a force striking the eye and pushing the eye and avoid glaucoma and cavention, and the most important methit forcibly against one of the orbital taract. Corneal abrasion, whether due to od is by awareness. The doctor, induswalls. This generally involves the orbital floor and leads to entrapment of direct trauma or exogenous agents, al- trial safety officer, parent, teacher and the inferior rectus ocular muscle, pre- though very painful, can be difficult child should be made aware of hazardventing ocular elevation and causing to detect until fluorescein is used. An ous circumstances. And as a physician, diplopia. Also there may be damage arc welder's corneal flash burn is al- one should always take the opportunity to the inferior orbital nerve leading most impossible to see until the eye is to initiate or reinforce preventive proto a numbness of the lower face. stained by a drop of fluorescein. This grams against eye injuries.E


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INDICATIONS: Mixed vaginal infection due to Trichomonas vaginalis and Candida albicans. CONTRAl NDICATIONS: Hypersensitivity to one of the components. Combined treatment with oral Flagyl should be avoided in cases ot active neurological disorders or a hetory of blood dyscrasia, hypothyroidism or hypoadrenalism unless in the opinion ot the phyrecian the benefits outweigh the poss.le hazard to the patient. WARNINGS: Nystatin possesses little or no antibacterial activity while metronidazole is selective against certain anaerobic bacteria, therefore, Flagystatin may not be effective in bacterial vaginal infections. Flagystatin should not be prescribed unless there is direct evidence of trichomonal infestation. PRECAUTIONS: Where there is evidence of trichomonal infestation in the sexual partner, he should be treated concomitantly with oral Flagyl to avoid reinfestation It is possible that adveme effects normally associated with oral administration of metronidazofe may occur following the vaginal administration of Flagystatin. When administering oral Plagyf (see Flagyl Product Monograph) the following precautions must be borne in mind:

Patients should be warned against consuming alcohol, because ot a possible deultiram-like reaction. Although no persistent hematologic abnormalities have been observed in clinical studies, total and differential leukocyte counts should be made betore and atter treatment especially it a second course ot oral Flagyl therapy is needed. Metronidazole passes the placental barrier. Although it has been given to pregnant women without apparent complication, it is advinaBe that oral use be avoided in pregnant patients and the drug be withheld during the tirslt trimester ot pregnancy. Oral treatment should be discontinued it atania or any other symptom ot CNS involvement occum. ADVERSE REACTIONS: They are intrequent and minor: vaginal burning and granular sensation Bitter taste. nausea and vomiting, already known to occur with Flagyl, were mainly seen when oral Flagyl was administered concomitantly with Flagystatin bcal treatment In the course ot clinical trials with Flagystatre. reactions. not necessarily related to the product. were observed. spots on the skin around the knees, welts all over the body. aching and swelling 01 wrists and ankles, pruritis. headache, coated tongue and tatigue.

OVERDOSAGE: There is no specific antidote. Treatment should be symptomatic after gastric lavage. DOSAGE AND ADMINISTRATION: One vaginal insert or one applicatortul of Flagystatirt cream daily, inserted deep into the vagina, for tO consecutive days. It after tO days of treatment a cure has not been achieved a second tO-day course of treatment should be given. It Trichomonas naginails has not been completely eliminated, oral Flagyl 250 mg b.i.d. should be administered for tO days. SUPPLY: Vaginal inserts containing 500 mg metronidazole and tOO,OOO U. nystatin. bones of 10 with applicator. Vaginal Cream delinerang 500 mg metronidazole and tOO.OOO U. nystatin per applicatorful. tubes of 55 g with applicator.

I .


-Poulenc ip CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118 307

Primary management of ocular trauma.

ha,' is that injuries in patients with glasses tend to be more serious: in the Australian series one case was associated with a choroidal tear, two pa...
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