October 2018


Reporting from the 33rd Triservice Ocular Trauma Skills Laboratory

by Liz Hillman EyeWorld Senior Staff Writer

Residents work on suture skills during a wet lab at the Ocular Trauma Workshop.

A pig eye with blue dye to track damage is placed in a 3-D printed eye socket and exposed to a “pure blast” in an effort to simulate blast trauma on the eye.

The eye is examined post-blast and shows no obvious signs of injury, but Dr. Rex notes that research is ongoing on the effect of such a blast on retinal structures and the optic nerve.
Source (all): EyeWorld


Annual program focuses on injuries physicians may see when treating service members

Thirty-six residents (some military and some local civilian), four military staff physicians in potentially deployable units, and 60 faculty members gathered for the 33rd Triservice Ocular Trauma Skills Laboratory at Uniformed Services University (USU) in Bethesda, Maryland, a 4-day, annual program that prepares physicians for the types of injuries they might see in our nation’s service members, both at home and abroad.
“In my mind, this is the only course like it that exists,” said Army Lieutenant Colonel Marcus Colyer, MD, director of the ocular trauma course at the Uniformed Services University of the Health Sciences, and a vitreoretinal surgeon at Walter Reed National Military Medical Center, Bethesda, Maryland. “It’s tied to the expectation that the military has to treat wounded service members,” he continued, noting that he and the other faculty are trying to tie all readiness aspects to this course.
Attendees of the workshop, which took place in May, received lectures and intensive wet lab training in oculoplastics, anterior and posterior segment injury, ocular pathology, and advanced anterior segment surgical maneuvers. Dr. Colyer, who has been part of the course since 2005, led the way from room to room where attendees were working on everything from penetrating trauma and suture basics to simple laceration repair to more advanced suture techniques and laceration management.
Each hands-on block surgical experience began with a 20- to 30-minute crash course lecture, aimed to give the attendee the most important synopsis related to the diagnosis and management of injuries they might see in the field and how to handle them surgically.
If a corneal foreign body appears superficial in a blunt trauma case it should be removed said, Won Kim, MD, Walter Reed National Military Medical Center, but deeply embedded foreign bodies should be left alone as attempts to remove them can cause further damage and scarring of the corneal stroma. He added that these foreign bodies will often migrate more anteriorly over time making them safer to remove. Non-penetrating trauma can cause damage to seven rings of intraocular tissues resulting in iris sphincter tears and traumatic mydriasis, iridodialysis, angle recession, cyclodialysis, trabecular meshwork tears, zonular rupture, and retinal dialysis. Non-penetrating trauma can also cause damage to the lens (contusion cataract, capsule rupture, and lens involution, to name a few) and hyphema.
James Karesh, MD, Krieger Eye Institute, Baltimore, discussed chemical injury. “If you don’t do something about it right now, you’ve missed the boat,” he said, explaining that eyes exposed to a chemical injury need to be flushed immediately onsite before bringing the patient to a more formal medical setting. An eye exposed to acid or alkaline might need to be irrigated for up to 2 hours to ensure all the chemical is removed. In addition, the person’s clothes, if exposed, should be taken off and their face and body washed as well. The medic helping this person should take measures to protect their own eyes.
Alkaline chemical injuries are the worst, Dr. Karesh said, explaining that ammonia is the worst of the worst, eating through the cornea and causing ciliary body damage. Acids might not be as bad as alkaline solutions because they create their own barrier to deep penetration. Dr. Karesh called hydrochloric acid the worst in this category due to its propensity to cause systemic injuries.
After copious irrigation, Dr. Karesh said treatment can include anti-inflammatory agents, anterior chamber washout, symblepharon rings, autologous serum, and umbilical cord serum. Surgical treatments, depending on the case, can include stem cell transplants, a keratoprosthesis, penetrating keratoplasty or lamellar keratoplasty, or a graft.
In addition to training the next generation of military ophthalmologists and staff physicians in units that could soon deploy, and thus could be facing these injuries sooner than others, Dr. Colyer sees the course as an opportunity to test the application of new equipment for physicians in the armed services. One example is the 3-D NGENUITY system (Alcon, Fort Worth, Texas), which uses TrueVision (Santa Barbara, California) technology, to see if it can provide a more ergonomic, comfortable experience for physicians who might otherwise spend 12+ hours craning their necks at an operating microscope.
The course is also a place where a few key industry players can meet and discuss potential collaborative opportunities that could benefit military ophthalmologists. Three Army logistics personnel were on hand to help take and provide feedback on what military ophthalmologists need, the current state of technology, and if new technology is “hardened enough” for the military’s purposes (i.e., can withstand conditions like heat, sand/dust, and drop delivery).
Down a few floors into the belly of Uniformed Services University is a room with a blast tube, a device that could mimic a “pure blast” situation, without all the other factors one might associate with an explosion, such as shrapnel.
“The blast is an injury separate from objects that hit the eye or heat generated,” Dr. Colyer said. “There is some sort of injury in the blast itself.”
That’s what Tonia Rex, PhD, associate professor of ophthalmology, Vanderbilt Eye Institute, Nashville, Tennessee, is researching. Dr. Rex was on hand to show how the eye can look after a pure blast. Wearing ear protection and behind a closed door, looking through the small window that showed a pig eye in a 3-D-printed artificial eye socket, a short countdown proceeded the brief blast. The eye looked normal. This was a teaching tool to convey to residents what the blast can do to the eye, Dr. Rex said. It could result in hyphema or a ruptured globe, but that often doesn’t happen, she said. Rather, subclinical damage can worsen over time and result in vision loss.
“Letting residents know what [a pure blast] looks like, hear that sound, and see that the eye doesn’t have to appear damaged” drives home the point that if it’s known a patient has been exposed to a blast, they need a different level of follow-up to monitor how their posterior structures might respond over time, even if everything looks normal in the anterior segment, Dr. Rex said.
Shannon McCole, MD, chairman and program director, Eastern Virginia Medical School, Norfolk, Virginia, who has been involved as an instructor at the course for 3 years, said that the course is invaluable to military ophthalmologists and residents who might face deployment, but the inclusion of civilian ophthalmology residents has important applications also.
“To my knowledge, there is no course like this. … We’re also serving the needs of injured civilians and injured U.S. citizens here. All around in ophthalmology we need to be competent in dealing with traumatic eye injuries,” said Dr. McCole, who sees a fair share of ocular trauma injuries at Sentara Norfolk General’s level 1 trauma center serving the entire Hampton Roads area.
Michael Ullman, MD, a third-year ophthalmology resident at Georgetown University/Washington Hospital Center, Washington, D.C., is one such civilian resident.
“I will be pursuing a corneal fellowship at the end of this year,” Dr. Ullman said. “The trauma course was extremely applicable to my education. After 1 week, I felt more confident in my ability to assess and treat ocular trauma. I have attended several surgical courses and nothing comes close to the ocular trauma course. There are extremely realistic surgical models and one-on-one teaching with experts. I can’t think of a more educational week in my entire residency.”
“This type of extensive course is important,” Dr. Ullman continued. “Unfortunately, most eye trauma occurs sporadically and often at inopportune times. With a condensed, content heavy course filled with realistic surgical scenarios, I was able to rapidly pick up skills that I currently rely on. I was also able to learn from military experts who ‘wrote the book’ on ocular trauma and have unparalleled real-world experience with trauma.”

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

: marcus.h.colyer.mil@mail.mil
Karesh: jkaresh@lifebridgehealth.org
Kim: wonkim74@hotmail.com
McCole: MccoleSM@EVMS.EDU
Ullman: mullman@gmail.com
Rex: tonia.rex@vanderbilt.edu

Reporting from the 33rd Triservice Ocular Trauma Skills Laboratory Reporting from the 33rd Triservice Ocular Trauma Skills Laboratory
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