Anaesthesia, 1976, Volume 3 1, pages 433-438
Thoughts on immediate care Anaesthetists are being increasingly called upon to give immediate treatment for various conditions in casualty departments and elsewhere. Thisfeature of short papers by invited experts is designed to describe the proper management of patients who require immediate care before the opinion of specialists in a particular field can be obtained.
The immediate care of eye injuries T. R. E L L I N G H A M
Eye injuries and the threat of visual loss that goes with them cause extreme anxiety in patients and doctors alike. There is often considerable disparity between the physical nature of the injury and the subsequent damage. Disrupted globes may, after treatment, regain a remarkable degree of function, whereas those unmarked eutwardly remain almost useless. The most important factor in the immediate care of eye injuries, is to recognise that an injury has been sustained. After this the correct action must be decided. The aim of this paper is to give some guidance on diagnosis, the immediate care which may be required and the urgency with which the injury must be referred to a specialist.
The history It is very important to listen to the description of the way in which the injury was sustained. Where ‘missiles’are involved, their size and speed give vital clues about the nature and extent of the lesion which may be expected. The globe is passively defended from large objects by the bony orbit. The protection afforded by the orbital rim is less from below and laterally. Cricket balls generally do not enter the orbit and damage the globe; this is in strict contrast to the havoc created by squash balls, which not only go between the margins but expand once they get there. The orbit is also actively defended by the lids which can be very speedily and tightly shut at the sight of an approaching threat. Anyone who complains of sudden discomfort or reduced vision after using a hammer on any form of steel or concrete must be suspected of having an intra-ocular foreign body until the contrary is proved. Unconscious victims of traffic accidents or some other severe trauma form a special group who need their eyes carefully examined. Injuries to the eyes are sometimes overlooked in the quite correct initial concern to establish stable respiratory and circulatory function. Anaesthetists have a special opportunity of looking at eyes when they are caring T. R.Ellingham, MB, ChB, FRACS, Senior Registrar in Ophthalmology, Royal Berkshire Hospital, Reading, and Moorfields Eye Hospital, London.
433
434
T. R. Ellingham
for traumatic cases and of ascertaining whether damage has been sustained or whether there are foreign bodies such as pieces of glass in the fornices or a flat anterior chamber indicating more profound damage. Method of examination First open the eye gently with the fingers while taking care not to push on the globe. Examine the cornea and conjunctiva and look into the fornices. Assess the visual acuity if the patient is conscious. A crude test such as looking at a newspaper or a watch may be used if a test chart is not available. Remember there are two eyes and always compare the two-this is more difficult where both are involved. Test the eye movements. Each eye should first be assessed separately and then both should be examined together. Restrictions of movement should be noted; these will give rise to diplopia if the vision in either eye is not affected. Look at thepupil to determine whether it is round and whether the anterior chamber is full or flat. Remember to compare the two eyes. A pear shaped pupil and a black spot at the limbus is highly suspicious of a perforating wound with iris prolapse; in some cases these eyes may have a re-formed anterior chamber because the iris is plugging the wound. Look for the red reflex in the pupil if you have an ophthalmoscope-if it is absent an explanation is needed. Look at the lids for marginal lacerations and perforations. Feel the orbital rim for fracture steps, localised tenderness and surgical emphysema. Compare the left with the riglit. Classification of injuries
Having listened to the history and looked at the eyes it should be possible to form some idea of the category of injury or injuries which must be dealt with (Table 1). The orbit Penetrating (or perforating) injuries. The importance of recognising this type of injury cannot be over emphasised. Where the wall of the globe has been breached there Table 1. A simple classification of injuries to the eye The globe Penetrating or perforating injuries Non-penetrating injuries Superficial wounds Internal derangements The lids Marginal lacerations Non-marginal lacerations The orbit 'Blow-out' Jiractures Malar fractures
Immediate care of eye injuries
435
is the risk of retained foreign bodies and the introduction of micro-organisms. The ocular contents make an excellent culture medium. The injury is often obvious but, on occasion, small high velocity metallic fragments can enter the globe and barely leave a mark. Steel and copper give rise to particularly toxic reactions in the eye, which can lead to total loss of function unless the metal is removed. All patients who complain of ocular discomfort after using a hammer must have their eye X-rayed. The aims of the first aid treatment of penetrating injuries is to prevent pressure on the eye prolapsing its contents and to prevent infection. Antibiotic drops, not ointment should be used if at all possible; the lids should be closed and the eye padded. If skilled help is more than 12 hours away systemic antibiotics are indicated. Intramuscular pencillin every 6 hours is satisfactory if the patient is not sensitive.
Non penetrating-superjcial
wounds
Corneal foreign bodies and corneal abrasions are very common injuries but it is fortunately true to say that abrasions under routine general anaesthesia are now rare. They belong to an era when corneal and conjunctival reflexes were frequently tested with the anaesthetist’s finger and deep ether and chloroform anaesthetics were administered by the open method. It is probably true that the abrasions were more likely to occur because of the drying up of the conjunctiva under deep general anaesthesia than because of the irritation of the vapours themselves. The lids are the best covers for the eyes under general anaesthesia and at other times; they should be closed during anaesthesia by non-irritant strips of adhesive paper or plastic tapedrops and ointments should not be instilled for protection as they are a potential source of infection if the bottle or tube is not changed between patients. Corneal abrasions and foreign bodies are comparatively easy to treat if they are approached logically. The two are considered together because, once a foreign body has been removed one is left with an abrasion. The lesion is basically a loss of corneal epithelium with usually a degree of damage to the underlying stroma. The discomfort is due to the stimulation of the exposed corneal nerve ends. This in turn leads to blepharospasm and profuse watering. A few drops of a topical analgesic solution (e.g. amethocaine) are instilled. This may need repeating after a few minutes. The patient lies flat, and, once he can open his eyes, the foreign body is removed with the tip of an hypodermic needle on a syringe. A drop of short acting mydriatic (hyoscine 0.25% or homatropine 2%) and some antibiotic ointment are instilled and the eye firmly padded for 24 hours. The aim is to prevent ciliary spasm by using the mydriatic, prevent infection with the antibiotic ointment, and prevent movement of the lids with the firm pad. Small lesions will be covered in 24 hours-larger ones may need 2-3 days of this treatment and daily dressing. The mydriatic is not essential in all cases, but the apparent failure of ointment and pad therapy is most likely due to the development of ciliary spasm or secondary iritis. This will be prevented in most instances by using a mydriatic at the outset. Injuries caused by acids, alkalis and toxic liquids. These are often splashed or thrown into eyes. The immediate care for this type of injury is lavage. This is not only the first treatment but the most important, and the speed with which it is done can be vital. Water is the best material and large amounts of it. Dilution of acids and alkali is the best way of reducing their potency.
436
T. R. Ellingham
The corneal epithelium presents no barrier to alkalis-nor does the stroma. The pH in the aqueous humour rises dramatically within seconds of strong alkali entering the conjunctival sac and nothing short of instant immersion in water can really prevent at least minimal damage from strong alkalis. Acids arenot quite as devastating, as the denatured protein of the superficial corneal stroma presents a barrier to further penetration. Treatment at the site of injury is vital and should be prolonged for ten to fifteen minutes if necessary-a fast ride to a Casualty Department is unlikely to alter the outcome if this has not been done. The eye should be washed out and antibiotic ointment or drops and a pad should be used before referral. A mydriatic should be used if there is to be delay in seeing a specialist. All alkali burns should be referred as the cornea may perforate. ‘Arc eye’ and ‘snow blindness’ are both due to excessive exposure of the corneal epithelium to ultra violet (uv) light. Snow reflects a vast amount of the uv light that falls upon it, unlike the normal background. The ‘arc’ used by welders emits a large amount of uv light. In both groups prolonged exposure is usually the keynote. Exposures over 24 hours are additive. Pain, photophobia and blepharospasm due to multiple small corneal ulcers are the symptoms. Local analgesic drops are used to relieve the pain, a short acting mydriatic is instilled, together with plenty of antibiotic ointment, and the eye is padded. Snow blindness is unfortunately often bilateral and double padding (i .e. both eyes covered) for 12 hours may be needed. Repeated doses of local analgesics are contraindicated and giving the patient a bottle to use as he feels is indefensible. This is because corneal epithelial loss is repaired basically by two mechanisms (epithelial slide from the edges of the ulcer and increased mitosis of cells around the edge); all local anaesthetics are anti-mitotic and inhibit healing and, in addition, they are toxic to living cells. Repeated use over a short period of time leads to tolerance which leads to more frequent use which can in turn lead to a total loss of corneal epithelium and permanent scarring with permanent visual loss. Internal derangement Hyphaema or blood in the anterior chamber may occur following blunt trauma to the eye. The bleeding usually comes from an iris vessel and is usually self-limiting. There is usually a history of a blow to the eye and subsequent cloudy vision to a greater or lesser extent; this is sometimes reported as being better after a sleep, but comes on again once the patient is up and about. The blood can be seen either as a small flat topped clot at the bottom of the anterior chamber, or filling it. The danger from hyphaemas is that they can bleed a second time, and the bleed then tends not to be self-limiting. This leads to a ‘total’ hyphaema where the anterior chamber is filled with blood and the intra-ocular pressure rises. This causes extreme pain, can force blood pigment into the cornea for all time and, if unrelieved, eventual blindness due to occlusion of blood vessels in the optic nerve. The treatment consists of rest-rest of the whole patient to avoid secondary
Immediate care of eye injuries
437
bleeding. This also allows absorption of the blood. Admission to hospital is probably the best way of achieving rest. Drops which will dilate or constrict the pupil should not be used. If there is pain and it is suspected that the pressure is elevated, acetazolamide (Diamox) 250 mg should be administered every 6 hours to adults-half the dose should be given to children. Hyphaemas are best referred to an expert. Vitreous haemorrhage may also follow blunt trauma. This will usually be described by the patient as a cloud across the vision but the anterior chamber will be seen to be clear. The danger is that a detached retina will develop following such an injury. These patients should always be sent for ophthalmic assessment, though this is not urgent. Traumatic cataract may be the cause of deteriorating vision some days after trauma. It is probably best seen in the red reflex as a ‘stellate’ or ‘sunflower’ pattern when viewed with an ophthalmoscope. There is no immediate treatment other than recognition and referral for assessment. Dislocated lens. This again may occur after blunt trauma and may be associated with hyphaema. The symptoms are of reduction in vision to a greater or lesser extent. The classic sign is of a ‘tremulous’ iris-the iris is seen to wobble on movement of the eye. These cases should be sent for immediate ophthalmic assessment as the intraocular pressure may be raised. The lids Marginal lacerations. If these are of full thickness or involve the inner canthus, where the tear drainage apparatus is located, they should be referred for surgical repair. An antibiotic ointment and a pad should be used in the interim. Non-marginal lacerations can be easily repaired, if fine sutures and suitable instruments are available; nothing very sophisticated is needed and lids heal very well. Puncture wounds should be viewed with some suspicion however. A small puncture wound has been known to have two inches of pencil behind it, residing comfortably in the orbit. The history of the injury is obviously an important clue in these cases. It is important to be very suspicious of a lid puncture wound which does not heal. The Orbit ‘Blow-out’fractures.This type of injury is often referred to as ‘a fracture of the orbital floor’, but the medial wall is usually involved as well. The bone of the floor and medial wall of the orbit is very thin and a sudden increase in intraorbital pressure can shatter these bony plates, and force orbital contents into the sinuses behind the walls. This type of injury is often not suspected until the accompanying ‘black eye’ has subsided and the patient complains of diplopia. The immediate care of these injuries is to prevent infection. Communication between the orbit and sinuses is not desirable, especially if there is blood clot as well. Most blow-out fractures do not need surgical intervention. Treatment with antibiotics is all that is required; oral tetracycline being commonly used. Surgery is seldom indicated in any case before 10 days, so referral after a week is all that is required if symptoms and signs are obviously nbt resolving. Malar fractures are very common. A fracture of the orbital floor may accompany
438
T. R. Ellingham
this injury and a not uncommon sign of this is surgical emphysema in the lower lid. Antibiotics are indicated if there is any question of communication between sinus and orbit. The case should be referred to a facio-maxillary surgeon. Padding the eye
Vaseline gauze should be used beneath the pad wherever possible. Pads should be applied separately over shut eyes after making sure the Vaseline gauze is stuck to the skin. Sellotape, Micropore or sticking plaster should not be crossed over the pad but all strips should be run in the same direction, starting on the forehead, downwards and outwards over the pad and pressed firmly onto the cheek, which has been lifted upwards-a jirm dressing is a comfortable dressing. Summary
The various types of injury which may occur to the eye are described. These may be easily missed altogether, or their extent not realised, unless great care and vigilance is exercised by those who first see the patient. Emphasis has been placed on the immediate care required and the urgency with which the different categories of injury must be referred to a specialist.
Thoughts on immediate care Anaesthetists are being increasingly called upon to give immediate treatment for various conditions in casualty departments and elsewhere. Thisfeature of short papers by invited experts is designed to describe the proper management of patients who require immediate care before the opinion of specialists in a particular field can be obtained.
The immediate care of eye injuries T. R. E L L I N G H A M
Eye injuries and the threat of visual loss that goes with them cause extreme anxiety in patients and doctors alike. There is often considerable disparity between the physical nature of the injury and the subsequent damage. Disrupted globes may, after treatment, regain a remarkable degree of function, whereas those unmarked eutwardly remain almost useless. The most important factor in the immediate care of eye injuries, is to recognise that an injury has been sustained. After this the correct action must be decided. The aim of this paper is to give some guidance on diagnosis, the immediate care which may be required and the urgency with which the injury must be referred to a specialist.
The history It is very important to listen to the description of the way in which the injury was sustained. Where ‘missiles’are involved, their size and speed give vital clues about the nature and extent of the lesion which may be expected. The globe is passively defended from large objects by the bony orbit. The protection afforded by the orbital rim is less from below and laterally. Cricket balls generally do not enter the orbit and damage the globe; this is in strict contrast to the havoc created by squash balls, which not only go between the margins but expand once they get there. The orbit is also actively defended by the lids which can be very speedily and tightly shut at the sight of an approaching threat. Anyone who complains of sudden discomfort or reduced vision after using a hammer on any form of steel or concrete must be suspected of having an intra-ocular foreign body until the contrary is proved. Unconscious victims of traffic accidents or some other severe trauma form a special group who need their eyes carefully examined. Injuries to the eyes are sometimes overlooked in the quite correct initial concern to establish stable respiratory and circulatory function. Anaesthetists have a special opportunity of looking at eyes when they are caring T. R.Ellingham, MB, ChB, FRACS, Senior Registrar in Ophthalmology, Royal Berkshire Hospital, Reading, and Moorfields Eye Hospital, London.
433
434
T. R. Ellingham
for traumatic cases and of ascertaining whether damage has been sustained or whether there are foreign bodies such as pieces of glass in the fornices or a flat anterior chamber indicating more profound damage. Method of examination First open the eye gently with the fingers while taking care not to push on the globe. Examine the cornea and conjunctiva and look into the fornices. Assess the visual acuity if the patient is conscious. A crude test such as looking at a newspaper or a watch may be used if a test chart is not available. Remember there are two eyes and always compare the two-this is more difficult where both are involved. Test the eye movements. Each eye should first be assessed separately and then both should be examined together. Restrictions of movement should be noted; these will give rise to diplopia if the vision in either eye is not affected. Look at thepupil to determine whether it is round and whether the anterior chamber is full or flat. Remember to compare the two eyes. A pear shaped pupil and a black spot at the limbus is highly suspicious of a perforating wound with iris prolapse; in some cases these eyes may have a re-formed anterior chamber because the iris is plugging the wound. Look for the red reflex in the pupil if you have an ophthalmoscope-if it is absent an explanation is needed. Look at the lids for marginal lacerations and perforations. Feel the orbital rim for fracture steps, localised tenderness and surgical emphysema. Compare the left with the riglit. Classification of injuries
Having listened to the history and looked at the eyes it should be possible to form some idea of the category of injury or injuries which must be dealt with (Table 1). The orbit Penetrating (or perforating) injuries. The importance of recognising this type of injury cannot be over emphasised. Where the wall of the globe has been breached there Table 1. A simple classification of injuries to the eye The globe Penetrating or perforating injuries Non-penetrating injuries Superficial wounds Internal derangements The lids Marginal lacerations Non-marginal lacerations The orbit 'Blow-out' Jiractures Malar fractures
Immediate care of eye injuries
435
is the risk of retained foreign bodies and the introduction of micro-organisms. The ocular contents make an excellent culture medium. The injury is often obvious but, on occasion, small high velocity metallic fragments can enter the globe and barely leave a mark. Steel and copper give rise to particularly toxic reactions in the eye, which can lead to total loss of function unless the metal is removed. All patients who complain of ocular discomfort after using a hammer must have their eye X-rayed. The aims of the first aid treatment of penetrating injuries is to prevent pressure on the eye prolapsing its contents and to prevent infection. Antibiotic drops, not ointment should be used if at all possible; the lids should be closed and the eye padded. If skilled help is more than 12 hours away systemic antibiotics are indicated. Intramuscular pencillin every 6 hours is satisfactory if the patient is not sensitive.
Non penetrating-superjcial
wounds
Corneal foreign bodies and corneal abrasions are very common injuries but it is fortunately true to say that abrasions under routine general anaesthesia are now rare. They belong to an era when corneal and conjunctival reflexes were frequently tested with the anaesthetist’s finger and deep ether and chloroform anaesthetics were administered by the open method. It is probably true that the abrasions were more likely to occur because of the drying up of the conjunctiva under deep general anaesthesia than because of the irritation of the vapours themselves. The lids are the best covers for the eyes under general anaesthesia and at other times; they should be closed during anaesthesia by non-irritant strips of adhesive paper or plastic tapedrops and ointments should not be instilled for protection as they are a potential source of infection if the bottle or tube is not changed between patients. Corneal abrasions and foreign bodies are comparatively easy to treat if they are approached logically. The two are considered together because, once a foreign body has been removed one is left with an abrasion. The lesion is basically a loss of corneal epithelium with usually a degree of damage to the underlying stroma. The discomfort is due to the stimulation of the exposed corneal nerve ends. This in turn leads to blepharospasm and profuse watering. A few drops of a topical analgesic solution (e.g. amethocaine) are instilled. This may need repeating after a few minutes. The patient lies flat, and, once he can open his eyes, the foreign body is removed with the tip of an hypodermic needle on a syringe. A drop of short acting mydriatic (hyoscine 0.25% or homatropine 2%) and some antibiotic ointment are instilled and the eye firmly padded for 24 hours. The aim is to prevent ciliary spasm by using the mydriatic, prevent infection with the antibiotic ointment, and prevent movement of the lids with the firm pad. Small lesions will be covered in 24 hours-larger ones may need 2-3 days of this treatment and daily dressing. The mydriatic is not essential in all cases, but the apparent failure of ointment and pad therapy is most likely due to the development of ciliary spasm or secondary iritis. This will be prevented in most instances by using a mydriatic at the outset. Injuries caused by acids, alkalis and toxic liquids. These are often splashed or thrown into eyes. The immediate care for this type of injury is lavage. This is not only the first treatment but the most important, and the speed with which it is done can be vital. Water is the best material and large amounts of it. Dilution of acids and alkali is the best way of reducing their potency.
436
T. R. Ellingham
The corneal epithelium presents no barrier to alkalis-nor does the stroma. The pH in the aqueous humour rises dramatically within seconds of strong alkali entering the conjunctival sac and nothing short of instant immersion in water can really prevent at least minimal damage from strong alkalis. Acids arenot quite as devastating, as the denatured protein of the superficial corneal stroma presents a barrier to further penetration. Treatment at the site of injury is vital and should be prolonged for ten to fifteen minutes if necessary-a fast ride to a Casualty Department is unlikely to alter the outcome if this has not been done. The eye should be washed out and antibiotic ointment or drops and a pad should be used before referral. A mydriatic should be used if there is to be delay in seeing a specialist. All alkali burns should be referred as the cornea may perforate. ‘Arc eye’ and ‘snow blindness’ are both due to excessive exposure of the corneal epithelium to ultra violet (uv) light. Snow reflects a vast amount of the uv light that falls upon it, unlike the normal background. The ‘arc’ used by welders emits a large amount of uv light. In both groups prolonged exposure is usually the keynote. Exposures over 24 hours are additive. Pain, photophobia and blepharospasm due to multiple small corneal ulcers are the symptoms. Local analgesic drops are used to relieve the pain, a short acting mydriatic is instilled, together with plenty of antibiotic ointment, and the eye is padded. Snow blindness is unfortunately often bilateral and double padding (i .e. both eyes covered) for 12 hours may be needed. Repeated doses of local analgesics are contraindicated and giving the patient a bottle to use as he feels is indefensible. This is because corneal epithelial loss is repaired basically by two mechanisms (epithelial slide from the edges of the ulcer and increased mitosis of cells around the edge); all local anaesthetics are anti-mitotic and inhibit healing and, in addition, they are toxic to living cells. Repeated use over a short period of time leads to tolerance which leads to more frequent use which can in turn lead to a total loss of corneal epithelium and permanent scarring with permanent visual loss. Internal derangement Hyphaema or blood in the anterior chamber may occur following blunt trauma to the eye. The bleeding usually comes from an iris vessel and is usually self-limiting. There is usually a history of a blow to the eye and subsequent cloudy vision to a greater or lesser extent; this is sometimes reported as being better after a sleep, but comes on again once the patient is up and about. The blood can be seen either as a small flat topped clot at the bottom of the anterior chamber, or filling it. The danger from hyphaemas is that they can bleed a second time, and the bleed then tends not to be self-limiting. This leads to a ‘total’ hyphaema where the anterior chamber is filled with blood and the intra-ocular pressure rises. This causes extreme pain, can force blood pigment into the cornea for all time and, if unrelieved, eventual blindness due to occlusion of blood vessels in the optic nerve. The treatment consists of rest-rest of the whole patient to avoid secondary
Immediate care of eye injuries
437
bleeding. This also allows absorption of the blood. Admission to hospital is probably the best way of achieving rest. Drops which will dilate or constrict the pupil should not be used. If there is pain and it is suspected that the pressure is elevated, acetazolamide (Diamox) 250 mg should be administered every 6 hours to adults-half the dose should be given to children. Hyphaemas are best referred to an expert. Vitreous haemorrhage may also follow blunt trauma. This will usually be described by the patient as a cloud across the vision but the anterior chamber will be seen to be clear. The danger is that a detached retina will develop following such an injury. These patients should always be sent for ophthalmic assessment, though this is not urgent. Traumatic cataract may be the cause of deteriorating vision some days after trauma. It is probably best seen in the red reflex as a ‘stellate’ or ‘sunflower’ pattern when viewed with an ophthalmoscope. There is no immediate treatment other than recognition and referral for assessment. Dislocated lens. This again may occur after blunt trauma and may be associated with hyphaema. The symptoms are of reduction in vision to a greater or lesser extent. The classic sign is of a ‘tremulous’ iris-the iris is seen to wobble on movement of the eye. These cases should be sent for immediate ophthalmic assessment as the intraocular pressure may be raised. The lids Marginal lacerations. If these are of full thickness or involve the inner canthus, where the tear drainage apparatus is located, they should be referred for surgical repair. An antibiotic ointment and a pad should be used in the interim. Non-marginal lacerations can be easily repaired, if fine sutures and suitable instruments are available; nothing very sophisticated is needed and lids heal very well. Puncture wounds should be viewed with some suspicion however. A small puncture wound has been known to have two inches of pencil behind it, residing comfortably in the orbit. The history of the injury is obviously an important clue in these cases. It is important to be very suspicious of a lid puncture wound which does not heal. The Orbit ‘Blow-out’fractures.This type of injury is often referred to as ‘a fracture of the orbital floor’, but the medial wall is usually involved as well. The bone of the floor and medial wall of the orbit is very thin and a sudden increase in intraorbital pressure can shatter these bony plates, and force orbital contents into the sinuses behind the walls. This type of injury is often not suspected until the accompanying ‘black eye’ has subsided and the patient complains of diplopia. The immediate care of these injuries is to prevent infection. Communication between the orbit and sinuses is not desirable, especially if there is blood clot as well. Most blow-out fractures do not need surgical intervention. Treatment with antibiotics is all that is required; oral tetracycline being commonly used. Surgery is seldom indicated in any case before 10 days, so referral after a week is all that is required if symptoms and signs are obviously nbt resolving. Malar fractures are very common. A fracture of the orbital floor may accompany
438
T. R. Ellingham
this injury and a not uncommon sign of this is surgical emphysema in the lower lid. Antibiotics are indicated if there is any question of communication between sinus and orbit. The case should be referred to a facio-maxillary surgeon. Padding the eye
Vaseline gauze should be used beneath the pad wherever possible. Pads should be applied separately over shut eyes after making sure the Vaseline gauze is stuck to the skin. Sellotape, Micropore or sticking plaster should not be crossed over the pad but all strips should be run in the same direction, starting on the forehead, downwards and outwards over the pad and pressed firmly onto the cheek, which has been lifted upwards-a jirm dressing is a comfortable dressing. Summary
The various types of injury which may occur to the eye are described. These may be easily missed altogether, or their extent not realised, unless great care and vigilance is exercised by those who first see the patient. Emphasis has been placed on the immediate care required and the urgency with which the different categories of injury must be referred to a specialist.
