William W. Forgey, MD
Body System Symptoms and Management - Eye
Updated: Oct 18, 2021
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Pain and irritation of the eye can be devastating. Many causes are listed in table 3-4.
Eye Patch and Bandaging Techniques
In case of evidence of infection, do not use an eye patch or splint, but have the patient wear dark glasses or a wide-brimmed hat, or take other measures to decrease light exposure. Wash the eye with clean water by dabbing with wet, clean cloth every 2 hours to remove pus and excess secretions. Apply antibiotics as indicated under Conjunctivitis, page 45.
Eye patch techniques must allow for gentle closure of the eyelid and retard blinking activity. Sometimes both eyes must be patched for this to succeed, but this obviously is a hardship for the patient. Simple strips of tape holding the eyelids shut may suffice. In case of trauma, an annular ring of cloth may be constructed to pad the eye without pressure over the eyeball. A simple eye patch with oversize gauze or cloth may work fine, as the bone of the orbital rim around the eye acts to protect the eyeball, which is recessed.
Serious injury requires patching both eyes, as movement in the injured eye will decrease if movement in the unaffected eye is also controlled. It generally helps to have the victim kept at rest with her head elevated 30 degrees. A severe blow to one eye may cause temporary blindness in both eyes, which can resolve in hours to days. Obviously, a person with loss of vision should be treated by a physician if possible. Eye dressings must be removed, or at least changed, in 24 hours.
If a foreign object has been removed from the eye or the victim has suffered a corneal abrasion, the best splint is the tension patch. Start by placing 2 gauze pads over the shut eye, requesting the patient keep his eyes closed until the bandaging is completed. The patient may help hold the gauze in place. Three pieces of 1-inch-wide tape are ideal, long enough to extend from the center of the forehead to just below the cheekbone. Fasten the first piece of tape to the center of the forehead, extending the tape diagonally downward across the eye patch. The second and third strips are applied parallel to the first strip, one above and the other below. This dressing will result in firm splinting of the bandaged eye.
Foreign Body Eye Injury
The most common eye problems outdoors are from a foreign body, abrasion, snow blindness, and infection (conjunctivitis). Therapy for these problems is virtually the same, except that it is very important to remove any foreign body that may be present.
The initial step in examining the painful eye is to remove the foreign object. One of the lessons drilled into medical students is to never ever write a prescription for eye anesthesia agents (such as the tetracaine ophthalmic solution that I recommend for the Rx Oral/ Topical Medication Module). The reason is the patient may use it, obtain relief, and then not have the eye carefully examined for a foreign body. Eventually this foreign body may cause an ulcer to form in the cornea, doing profound damage.
When using the tetracaine, remember that it is very important to find and remove any foreign body. Pull down on the lower lid and use 1 drop. If the patient is unable to open her eye due to pain, place 1 or 2 drops in the inner corner of the eye while she is lying face up. Have her blink once or twice to allow the liquid to cover the eyeball. This medication burns when initially placed in the eye. This will increase the level of pain for a brief period until the medication takes effect. After the patient has calmed down, have her open the eye and look straight ahead. Very carefully shine a pen light at the cornea from one side to see if a minute speck becomes visible. By moving the light back and forth, one might see movement of a shadow on the iris of the eye and thus confirm the presence of a foreign body. Mucus can give a gooey appearance to the cornea that may mimic a foreign body. Have the victim blink to move any mucus around. A point that consistently stays put with blinking is probably a foreign body.
In making the foreign body examination, also be sure to check under the eyelids. Evert the upper lid over a Q-tip stick, thus examining not only the eyeball but also the undersurface of the eyelid. This surface may be gently brushed with the cotton applicator to eliminate any minute particles. Always use a fresh Q-tip when touching the eye or eyelid each additional time. Some foreign bodies can be removed easily. Have the patient place his face under water and blink. Water turbulence from underwater blinking or from directing running water in a fast-moving stream or poured from a cup may wash the problem away.
When a foreign body has been found embedded in the cornea, take a sterile, or at least a clean, Q-tip and approach the foreign body from the side. Gently prod it with the Q-tip handle until it is loosened. The surface of the eye will indent under the pressure of this scraping action. Indeed, the surface of the cornea will be scratched in the maneuver, but it will quickly heal. Once the foreign body has been dislodged, if it does not stick to the wooden or plastic handle but slides loose along the corneal surface, use the cotton portion to touch it for removal.
A stoic individual, particularly one accustomed to contact lenses, might be able to undergo an uncomplicated foreign body removal without the use of tetracaine 0.5% ophthalmic drops, but using an anesthetic makes the patient more comfortable and cuts down on interference from the blink reflex.
Foreign bodies stuck in the cornea can be very stubborn and resist removal. At times it is necessary to pick them loose with the sharp point of a #11 scalpel blade or the tip of a needle (I frequently use an 18-gauge needle). Anesthesia with tetracaine will be necessary for this procedure. Scraping with these instruments will cause a more significant scratch to the corneal surface, but under these circumstances it may have to be accepted. I would leave stubborn foreign bodies for removal by a physician in all but the most desperate circumstances. If you have a difficult time removing an obvious foreign body from the surface of the cornea, waiting 2 to 3 days may allow the cornea to ulcerate slightly so that removal with the Q-tip stick may be much easier. Deeply lodged foreign bodies will have to be left for surgical removal.
A painless foreign body may not be a foreign body. It could be a rust ring left behind after a bit of ferrous, or iron-containing, material has fallen out of the eye after having been lodged for a short time. If what you see is painless, ignore it in the off-grid setting.
The history that involves striking an object should alert you to the fact that the injury may have penetrated much more deeply than you would expect from blowing debris hitting the eye. While blowing debris can lodge in the eye surface, a foreign body slamming into the eye due to someone striking an object (say, a hammer against a rock) might have penetrated very deeply into the eyeball. Penetrating injuries are a disaster!
A puncture wound of the eyelid mandates careful examination of the cornea surface for evidence of a penetrating foreign body. These injuries must be seen by a physician for surgical care. Evacuation is necessary. If this is impossible, the eye must be patched, examined for infection twice daily, and treated with antibiotics both orally and topically.'
After removal of a foreign body, or even after scraping the eye while attempting to remove one, apply some antibiotic. The prescription kit should contain Tobradex ophthalmic drops. There are no nonprescription eye antibiotics. Brand-name Neosporin and Polysporin ointments in 15-gram tubes are nonprescription antibiotics that can be used in the eye. However, the manufacturer cannot recommend the use of these over-the-counter products for this purpose.
While the tetracaine will provide local pain relief, its continued use may hinder the natural healing process and disguise a significant injury or the presence of an additional foreign body. Pain relief is best attempted by protecting the eye from sunlight using sunglasses, providing a damp cloth for evaporative cooling, and oral pain medication. There is no evidence that patching an eye with a corneal abrasion is useful. Percogesic or ibuprofen, 200 mg, from the Non-Rx Oral Medication Module, both given in a dose of 2 tablets every 4 to 6 hours, may be provided for pain. The prescription analgesic Norco 10/325, 1 tablet every 4 to 6 hours, would provide significant pain relief.
The increased popularity of contact lenses means that several problems associated with their use have also increased. The lenses are of two basic types: the hard or rigid lens, which generally is smaller and does not extend beyond the iris, and the soft lens, which does extend beyond the iris onto the white of the eye. Soft lenses have been designed for extended wear. Hard lens use requires frequent removal, as the delicate cornea of the eye obtains oxygen from the environment and nutrients from eye secretions. These lenses interfere with this process and therefore are detrimental to the cornea.
Examine the eyes of all unconscious persons for the existence of hard lenses and remove them if found. It is probably best to remove soft lenses as well, as some are not designed for extended use and may also damage the eye. If you expect that you may go off the grid for an extended time, you may want to rethink using contact lenses altogether. Also obtain the proper eyeglass prescription and keep a pair in your bug-out bag!
Leaving most hard contact lenses in the eyes longer than 12 hours can result in corneal ulceration. While not serious, this can be a very painful experience. At times, even iritis (see page 47) may result. This condition almost always resolves on its own within a day. The history is the major clue that the diagnosis is correct. If the condition fails to clear within 24 hours, other problems should be looked into, such as corneal laceration, foreign body, or eye infection.
After removal of the contact lenses, place cool cloths or ice packs on the eyes. The patient should be evaluated by a physician to confirm the diagnosis. Provide protection from sunlight, using sunglasses during the day. Give aspirin or other pain medication if available. The patient may have pain from the migration of the lens into one of the recesses of the under to upper or lower eyelid, or possibly note only a loss of refractive correction. At times the complaint is a sudden “I have lost my contact lens!” Never forget to look in the eye as the possible hiding spot for the lens. Examine the eye as described in the section on foreign bodies in the eye (see page 38). When dealing with a hard lens, use topical anesthesia as described, if necessary and available. If the lens is loose, slide it over the pupil and allow the patient to remove it as she usually does. If the lens is adherent, rinse with eye irrigation solution or clean water and try again. If a corneal abrasion exists, patch as indicated above after the lens is removed.
The soft lens may generally be squeezed between the fingers and literally “popped” off. A special rubber pincer is sold that can aid in this maneuver. Hard lenses may also be removed with a special rubber suction cup device.
If the patient is unconscious, the hard lenses will have to be removed. Lacking the suction cup device, two different maneuvers may be employed. One is the vertical technique. In this method, move the lens to the center of the eye over the pupil. Then press down on the lower lid, over the lower edge of the contact lens. Next squeeze the eyelids together, thus popping the lens out between them as indicated in figure 3-1. In the horizontal technique, slide the lens to the outside corner of the eye. Tug on the facial skin near the eye in a downward and outward direction; the lens can pop over the skin edge and be easily removed. See figure 3-2.
The unconscious patient should have antibiotic salve placed in her eye and the lids taped or patched shut to prevent drying. These patches should be removed when needed for neurological checks and certainly upon regaining consciousness.
If removal of the lenses must be prolonged, safe storage will have to be provided. Regarding hard lenses, the ideal would be marked containers that pad the lenses so that they do not rattle around or otherwise become scratched. Small vials, labeled R and L, filled with a fluff of clean material, taped together, and placed in a safe location, would be ideal. Soft contact lenses must be protected from dehydration. It is always proper to store them in normal saline. This solution can be prepared by adding 11/2 ounces of table salt to 1 pint of water. Of course, if the patient has a special solution for her lenses in her possession, use it.
Abrasions may be caused by a glancing blow from a wood chip, a swinging branch, or even from blowing dirt, embers, ice, or snow. The involved eye should be anesthetized with prescription tetracaine and protected with Tobradex ophthalmic drops. Make sure that a foreign body has not been overlooked.
In cold wind be sure to protect your eyes from the effects of both blowing particles of ice and the wind itself. Grey Owl, in his interesting book Tales of an Empty Cabin, tells how he was walking along a windswept frozen lake on one of his long trips through the backwoods when suddenly he lost sight of the tree line. He felt that he must be in a whiteout, so he turned perpendicular to the wind and hiked toward the shore. Suddenly he bumped into a tree and realized that he was blind! He saved himself only by digging a snow cave and staying put for three days. He wondered how many good woodsmen were lost on their trap lines by a similar incident, apparently, a temporary opacification of the cornea from the cold wind or ice crystal abrasions.
Snow Blindness or Ultraviolet Eye Injury
Snow blindness is a severely painful condition primarily caused by ultraviolet B rays of the sun, which are considerably reflected by snow (85%), water (10–100%), and sand (17%). Thin cloud layers allow the transmission of these rays, while filtering out infrared (heat) rays of the sun. Thus, it is possible on a rather cool, overcast day with bright snow conditions to become sunburned or snow blind.
Properly approved American National Standards Institute (ANSI) sunglasses will block 99.8% of the ultraviolet B rays. Suitable glasses should be tagged as meeting these standards. Nonprescription glasses must fit properly and ideally provide side protection. A suitable retention strap must be worn, as I finally learned while rafting on the Green River in Colorado. And for those of us who must learn these things more than once, a second pair of glasses—particularly if prescription lenses are worn—is essential. Lacking sunglasses, any field-expedient method of eliminating glare, such as slit glasses made from wood or any material at hand, including the ubiquitous bandanna, will help. An important characteristic of snow blindness is the delayed onset of symptoms. The pain and loss of vision may not be evident until after damaging exposure has been sustained.
Besides snow blindness, either direct or reflected ultraviolet exposure can result in headache or sometimes activate herpes simplex sores on the lips (see page 62). The headache can be treated with pain medication (see page 31), or look for other underlying causes (see page 165).
Snow blindness is a self-limiting affliction. However, not only is the loss of vision a problem, but so is the terrible pain, usually described as feeling like red hot pokers were massaging the eye sockets. Lacking any first aid supplies, the treatment would be gentle eye patches, avoiding pressure on the eyes, and the application of cold packs as needed for pain relief. Generally, both eyes are equally affected, with a virtual total loss of vision.
The prescription tetracaine ophthalmic drops will help ease the pain, but long-term use will delay eye surface healing. Oral pain medication will be helpful and should be used. The severe pain can last from hours to several days. In case a drainage of pus or crusting of the eyelids occurs, start antibiotic ophthalmic ointment applications as indicated in the following section on conjunctivitis.
Conjunctivitis, an infection or inflammation of the eye surface, will be heralded by a scratchy feeling, almost indistinguishable from a foreign body in the eye. The sclera (white of the eye) will be reddened.
Usually the eye will be matted shut in the morning with pus or granular matter.
Infections are generally caused by bacteria, but viral infections also occur. Viral infections tend to have a blotchy red appearance over the white of the eye, while bacterial infections have a generalized red appearance. The drainage in bacterial infections tends to be pus, while viral infections usually cause a watery discharge.
Allergic conjunctivitis will result in a faint pink coloration and a clear drainage. There are frequently other symptoms of allergy such as runny nose, no fever, and no lymph node enlargement. With either viral or bacterial conjunctivitis, look for fever and possibly lymph node enlargement in the neck. Runny nose and sinus infection are frequently present as well. Be sure that a foreign body is not the cause of the reddish eye and infection. If so, it must be removed (see page 38).
Rinse the eye with clean water frequently during the day. Eye infections such as common bacterial conjunctivitis, the most common infection, are self-limiting and will generally clear themselves within 2 weeks. They can become much worse, however, so medical attention should be sought. Do not patch the eyes but protect them from sunlight. When one eye is infected, treat both eyes, as the infection spreads easily to the uninfected eye.
There is no suitable nonprescription medication, but note the discussion concerning the use of non-Rx Neosporin or Polysporin in the section on foreign body eye injury (page 38). From the Rx supplies, one could use the Tobradex ophthalmic drops 3 times a day for 5 to 7 days. If the infection fails to show improvement within 48 hours, the antibiotic will probably not be effective. Reasons for antibiotic failure include a missed foreign body; allergy to the antibiotic or to something else, such as pollen; or resistance of an infectious germ to the antibiotic being used. Switch medications in the case of no improvement after 48 hours. When no other antibiotic ointment is available, use an oral antibiotic such as doxycycline 100 mg, 1 capsule twice daily, or the alternative antibiotics suggested for the Rx Oral/Topical Medication Module (page 284). If the eye is improving, continue use as indicated above, continuing for a full 24 hours after symptoms have ceased.
Iritis is an inflammatory disease of the eye having the general appearance of conjunctivitis, but while in the latter the reddish color fades to white near the iris of the eye (the colored part), with iritis the rim of sclera (white of the eye) around the iris is more inflamed or reddened than the white portion farther out. The pupil will not constrict when light is shined at it.
Provide sun protection. Give aspirin or other pain medication if available. This patient requires urgent evacuation to a specialist. The non-Rx treatment will consist of giving the patient ibuprofen, 800 mg every 6 hours, or meloxicam, 15 mg daily. Instill Tobradex ophthalmic drops 4 times a day.
As iritis progresses, the red blush near the iris will become more pronounced and a spasm of the muscle used in the operation of the iris will cause the pupil to become irregular. With further progression, it is possible for the pupil (anterior chamber) to become cloudy, for cataracts and glaucoma to develop, and for serious scarring of eye tissues to occur. Sometimes a profound conjunctivitis or corneal abrasion will cause an iritis that will clear as the problem resolves. Some cases of mild iritis can be cleared with agents that dilate the pupil without steroid use. All cases of iritis require treatment by an ophthalmologist.
Common causes of allergic conjunctivitis are sensitivity to inhaled pollens and irritation from wood smoke. This problem is usually associated with a runny nose (rhinitis) and at times swelling of the eyelids. Rarely there will be a generalized skin itching and the appearance of welts (urticaria). In severe cases there can be considerable swelling of the conjunctival covering of the white of the eye (sclera), forming what appears as fluid-filled sacs over the sclera of the eye (but not covering the cornea). This puffy tissue generally has a light pink tinge to it. While this can look terrible, it is not serious and will resolve on its own within 48 hours, after further exposure to the causative agent ceases.
From the non-Rx supplies give Percogesic, 1 tablet 4 times a day, and use the Opcon-A eye drops, 1 drop in each eye every 3 or 4 hours as needed. Percogesic is used for its decongestant actions, and it will also treat the itchy discomfort of this condition.
Sties and Chalazia
The infections of the eyelid called sties and chalazia can cause scratching of the cornea surface. Often the victim thinks that something is in the eye when, in fact, one of these small pimples is forming. The sty is an infection along a hair follicle on the eyelid margin.
The chalazion is an infection of an oil gland on the inner lid margin.
The patient will have redness, pain, and swelling along the edge of the upper or lower eyelid. At times the eye will be red with evidence of infection, or conjunctivitis. An eyelid may be swollen, without the pimple formation, when this problem first develops. There should not be extensive swelling around the eye. That could represent a periorbital cellulitis, which is a serious infection requiring treatment with injectable antibiotics and urgent evacuation.
Make sure that a foreign body is not causing the symptoms. Check the eye and eyelids as indicated (see page 38). While checking, ascertain if a pimple formation confirms the diagnosis. If it is on the upper lid and it is scratching the eye while blinking, patch the eye and send the patient to a physician for treatment. If no medical care is available, have the patient place warm compresses on the eye for 20 minutes every 2 hours to cause the sty to come to a head. When it does, it may spontaneously break and drain. If it does not drain within 2 days, open it with a flick of a sharp blade or needle that has been sterilized. Continue the warm compresses and provide medication as below.
If Rx supplies are available, instill Tobradex ophthalmic drops 3 times a day. (Also note discussion concerning the use of over-the-counter antibiotic ointment in the eye on page 41.) If the lid is quite swollen, give the patient doxycycline, 100 mg twice daily, or Levaquin, 500 mg once daily. Once the infection is localized and draining, the oral antibiotic will not be necessary.
Spontaneous Subconjunctival Hemorrhage
This condition, an amazingly common problem, presents as bright bleeding over a portion of the white of the eye. (Actually, a hemorrhage has occurred between the white of the eye and the mucous membrane covering it.) It spreads out over a period of 12 to 48 hours, then reabsorbs slowly over the next 7 to 21 days, next turning the conjunctiva yellowish as the blood is reabsorbed. There should not be any pain with this condition, although some people may report a vague “full” feeling in the eye. It normally occurs without cause, but can appear after blunt trauma or violent coughing, sneezing, or vomiting. No treatment is necessary. Evacuation is not required unless associated with trauma.
Blunt Trauma to the Eye
The immediate treatment is to immobilize the injured eye as soon as possible by patching both eyes and moving the patient only by litter. Double vision could mean that there has been a fracture of the skull near the eye or that a problem has developed within the central nervous system. Double vision is sometimes caused by swelling of tissue behind the eyelid. A hyphema, a collection of blood in the front or anterior chamber of the eye, may appear. The blood settles in front of the pupil and behind the cornea, and can develop a distinct blood fluid level easily noticed simply by looking carefully at the pupil and iris.
Patch as indicated in the section on eye patch and bandaging techniques (page 37). Patients with a hyphema and serious blunt trauma should be evacuated to a physician for care. Have the patient sit with head up from 45 to 90 degrees, to allow blood to pool at the lower edge of the anterior chamber. Check the eye twice daily for drainage, which might indicate infection. If infection develops, treat with an oral antibiotic such as the doxycycline 100 mg twice daily. The Tobradex ophthalmic drops may be instilled 3 times daily. Treat with oral pain medication. Give Atarax, 25 mg, 4 times daily as needed to potentiate the pain medication and help alleviate nausea, or 50 mg 4 times daily if required to calm the patient.
Provide the strongest pain medication required to prevent the injured patient from grimacing and squeezing the injured eye so as not to compromise the eye contents even more. Small corneal or scleral lacerations may require no treatment at all, but these should be seen and evaluated by a physician if at all possible. Note that severe injury to one eye may even cause blindness to develop in the other eye due to “sympathetic ophthalmia,” which is probably an allergic response to eye pigment from the injured eye entering the victim’s bloodstream.
Glaucoma is the rise of pressure within the eyeball (intraocular pressure increase). The most common form (open angle glaucoma) generally is not encountered before the age of 40. The patient notes halos around lights, mild headaches, loss of vision to the sides (peripheral field cuts), and loss of ability to see well at night. The external eye usually appears normal. Glaucoma frequently affects both eyes. This condition is generally of gradual onset, so the patient can consult a physician upon returning from the bush.
Initial treatment is with a prescription drug, 1 drop of 0.5% pilocarpine. It would not be necessary to carry this medication, except to treat this condition. This problem should be detected by the pre-trip physical examination. Everyone over the age of 40 should check their intraocular pressure periodically as part of their on-the-grid periodic health assessment.
Acute glaucoma (narrow angle glaucoma) is much less common than open angle glaucoma but is much more spectacular in onset. Acute glaucoma is characterized by a rapid rise in pressure of the fluid within the eyeball, causing blurred vision, severe pain in the eye, and even abdominal distress from vagal nerve stimulation. An acute attack can sometimes be broken with pilocarpine, but it often needs emergency surgery. A thorough eye examination should be done before the trip to discover those eyes with narrow angles that could result in acute glaucoma. In eyes likely to develop acute glaucoma, a laser iridectomy can be done as an outpatient to prevent an acute narrow angle glaucoma attack.
Events that might precipitate an acute glaucoma attack can include the use of certain medications, such as decongestants. If anyone develops severe eye pain while taking a decongestant or other nonessential medication, have them stop taking it immediately. Severe eye pain from any cause is a reason for urgent evacuation of the patient.