Eye Injuries at Sea

© 2020 Jeffrey E. Isaac, PA-C

There’s nothing like a stick in the eye to make you remember the meaning of pain. This negative feedback serves us well by ensuring that we will do almost anything to protect our eyes from trauma. The high degree of pain experienced is in direct proportion to the eye’s value to survival. It also makes examination and treatment quite a challenge when the protection fails and an eye does suffer injury.

Fortunately, the eye is pretty tough. It can absorb a lot of force without damage, and repair itself quickly when superficial damage does occur. The field treatment for eye injuries usually involves protection and pain relief rather than trying to fix anything on the spot.

A pair of sunglasses is an acceptable bandage. We rarely patch eyes anymore. When the tail of the jib sheet snaps across the cornea of your favorite tactician during your Sunday club race, think protection and pain relief. Take her out of the action, put her sunglasses on, offer some motrin or Tylenol, and head for shore. Whether that happens before or after the finish line will have to be negotiated. The ER doc or optometrist with the proper equipment and anesthetics is going to get a much better exam than you are on a sailboat on the race course.

Offshore you need a better plan. Eye injuries are usually minor and self-limiting, but they can be serious and lead to permanent loss of vision. You have to be able to tell the difference and affect some form of treatment on board. This will require some of the tools and tricks used in the ED. Anesthetic, irrigation fluid, and a good light are required. 

Healthy eyes move left, right, up, and down, together. This is called extra-ocular movement. The pupils constrict together in response to light, and dilate in the dark. Pupils are round. The cornea is clear, and covers the colored iris with clear fluid in between. The healthy eye sees what it’s looking at without blurring or double vision.

The first step in your evaluation is to see if the injured eye is doing what its supposed to do. A magnifying lens and flashlight (an otoscope is both in one device) will help. If the patient is in significant discomfort, a drop or two of tetracaine or lidocaine in the eye will make this much easier.  Have your patient follow your finger or flashlight with their eyes: up, down, left, right. Check the pupil’s response to light in both eyes. Look at the cornea and the space over the colored iris. Is it clear? Is the space behind the cornea free of blood? Finally, can the patient see OK (with allowances for the blurring caused by tears)?

If the eye performs its normal functions without too much difficulty, it’s probably going to be OK. You may see a corneal abrasion, especially if you shine your light from the side while looking straight at the eye. It looks like a smudge or shallow scrape on the clear part of the eye. As long as the eye checks out OK otherwise, this is no big deal. It can be painful, however.

Corneal abrasions are treated symptomatically. That is, make the patient feel better while the cornea heals – usually within 48 hours. Dark glasses seem to help, as do lubricating eye drops applied frequently. A patch is no longer used. The patient will probably need pain medication for the first day or so. Sometimes we use antibiotic eye drops or ointment, but his is not necessary unless you had to flush a lot of dirt out of the eye.

You might encounter a conjunctival hematoma (don’t you love these terms?). These look horrible. The white of the eye is covered with a swollen collection of blood. However, it is rarely painful. Sometimes the victim doesn’t even know its there until people start screaming and fainting. Check the extra ocular movement, pupils, cornea, and vision. It will probably check out just fine. No treatment is required. In this case, the dark glasses are for the benefit of the onlookers.

A foreign body in the eye is another common occurrence. Tears are the best form of removal. If a good cry doesn’t work, you can irrigate the eye with clean water or saline solution. My favorite technique is to have the patient immerse the face in a basin of water and open their eyes. Be sure to remind them to hold their breath or use a snorkel.

After irrigation, gently pull the lids away from the eye while the patient looks up, down, left, and right. If you see something still in there, gently wipe it out with a wet q-tip. If you can’t find anything but the patient is still complaining of a foreign body sensation, this is probably a scratch on the cornea or conjunctiva. Have them use antibiotic or lubricating eye drops frequently. The sensation will usually resolve in a few hours.

Examining an injured eye, or searching for the piece of sawdust can be nearly impossible due to pain and apprehension. A couple of drops of ophthalmic anesthetic like tetracaine can be invaluable. This is a prescription drug, which numbs the eye for a short time allowing for examination and foreign body removal. There are, of course, instructions and precautions for its use that you will need to discuss with the medical practitioner who prescribes it.

An eye in trouble is one that is not performing as it is supposed to. The movements are not normal, the pupil is not round or doesn’t react, you see blood behind the cornea, or the patient cannot see. Also, be very worried about an eye problem accompanied by a severe headache, fever, or purulent discharge.

A foreign body imbedded in the cornea or conjunctiva is an urgent problem that should see a doctor within 48 hours or so, or treated under medical advice. A foreign body that penetrates the globe of the eye is a true emergency. Leave it in place, protect the eye, treat for pain, and evacuate expeditiously.

Your offshore medical kit should include the following tools for dealing with eyes. Prescription items require instructions from your medical consultant:
 

• Flashlight or otoscope
• Ophthalmic anesthetic (e.g. tetracaine or lidocaine) (Rx)
• Lubricating eye drops (e.g. Natural Tears)
• Antibiotic eye drops or ointment (e.g. erythromycin ophthalmic ointment) (Rx)
• Magnifying lens
• Sunglasses
• Q-tips