Ocular trauma in the Global War on Terrorism

Lessons learned from Iraq and Afghanistan

By Col. Raymond I. Cho, MD, FACS

Since the Global War on Terrorism began in 2001, more than 50,000 American service members have sustained combat-related injuries in Iraq and Afghanistan, with additional coalition and civilian casualties many times that number. Ocular trauma represents a significant proportion of wartime injuries — including 10% to 15% of combat-related injuries during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). The task of treating these injuries has fallen to several dozen military ophthalmologists who have deployed to the combat theater over the past 13 years, including myself, and hundreds more who serve stateside in the Department of Defense, Veterans’ Administration and civilian sector. The lessons we’ve learned from these experiences can be divided into several categories: prevention, preparedness, treatment and rehabilitation.

PREVENTION

There is simply no substitute

Many groups that routinely engage in high-risk activities such as construction and sports have long recognized the value of eye protection. During the early days of OIF, the military noted a significant number of serious but potentially preventable eye injuries,¹ leading to a large-scale push to issue Combat Eye Protection (CEP) to all deployed troops. Subsequent studies demonstrated a significant decrease in the rate of eye injuries,² as well as injuries to the face.³ A notable factor in the success of this program was the adoption of an Authorized Protective Eyewear List (APEL) that allowed for the wear of commercially available ballistic eye protection (Figure 1). Soldiers and Marines have found the appearance of these glasses far preferable to those previously developed by the military.

Figure 1a & 1b. Soldier wearing the eye protection that prevented a piece of shrapnel from damaging his right eye in an improvised explosive device attack.

PREPAREDNESS

Conditions are beyond demanding

The success of combat casualty care relies on complex systems of casualty evacuation and the organization of medical assets at multiple levels on the battlefield and beyond. From the combat medic on the ground, to the battalion aid station, combat support hospital, critical care air transport team (CCATT), regional medical center, and tertiary care center, every provider and support personnel involved must understand his vital role in the echelons of care. Ophthalmologists deployed to the combat theater must be both physically and mentally prepared to deal with some of the most challenging cases they will ever face. Equipment is often less than optimal — sometimes even unavailable, testing the limits of one’s creativity and adaptability. If the operating microscope goes down or a mass casualty situation occurs, performing an open globe repair under loupes may be the only viable option. If a particular suture or implant is unavailable, the surgeon must choose or create an alternative. Ophthalmologists must often deal with patient movement during surgery caused by various influences, such as incoming mortar rounds, nearby helicopters, or other surgical specialists operating simultaneously. Decisiveness, persistence, patience, technical prowess and optimism are all job requirements.

Know your part

Training is a critical component of preparedness. All providers along the evacuation and treatment chain must be aware of the warning signs of serious ocular injury and take appropriate action to mitigate against further complications. For instance, first responders should be able to recognize the signs of an open globe injury, and know that the eye should never be pressure-patched, but protected with a Fox shield or other rigid device.

Another important factor to consider when planning for combat trauma or mass casualties caused by explosives⁴ is the high association of ocular trauma with concomitant injuries to the head, face and neck, and other parts of the body. Reports from OIF showed that patients with operative eye injuries had a 62% incidence of cranial, facial or neck injuries,¹ and a 22% incidence of open brain injuries.⁵ Therefore, it is imperative to co-locate specialists who deal with these injuries (neurosurgeons, otolaryngologists, ophthalmologists, and oral maxillofacial surgeons) in locations where high casualty flow is expected. This lesson has been applied by the U.S. military in the development of multidisciplinary head and neck surgery teams that are deployed to critical locations in the theater of operations.

TREATMENT LESSONS

Open globe injuries

Ophthalmologists primarily encounter open globe injuries.⁶ The surgeon must explore all suspected open cases, and achieve a watertight closure whenever possible. The presence of stellate lacerations, tissue maceration, or tissue loss often calls for adjunctive maneuvers such as tissue adhesives, patch grafts and contact lenses. In cases of severe corneoscleral lacerations in which visual potential is minimal, it’s often difficult to choose between primary repair and enucleation (Figure 2a).

Figure 2a and b. Severe bilateral globe ruptures caused by a mortar attack in Iraq. The unrepairable right globe was enucleated and the left globe was repaired with the aid of a Tutoplast corneal patch graft. Vision remains no light perception.

In general, the surgeon should give preference to primary repair in all cases in which closure can in any way be achieved, regardless of visual potential (Figure 2b). This rule of thumb is predicated upon the availability of subsequent ophthalmic care. When a patient is unlikely to have access to an ophthalmologist, such as a local national in a country with no reliable health care system, the better decision may be to primarily enucleate an unsalvageable globe to prevent sympathetic ophthalmia or a blind painful eye.

Intraocular foreign bodies

A large percentage of combat-related open globe injuries involve an intraocular foreign body (IOFB), with a 26% incidence reported during OIF.⁶ In most cases, IOFBs are left in place during the initial globe repair in theater; a surgeon removes them once the patient returns stateside. This delayed approach has proven effective for war injuries: in a series involving 63 eyes of patients who had been in OIF, no one had endophthalmitis. The average time to IOFB removal was 21 days.⁷

Periocular lacerations

It is extremely common for soft tissue lacerations sustained in combat, particularly those caused by improvised explosive devices (IEDs), to be grossly contaminated. In most surgical specialties, the usual guidance is to avoid primary closure in such cases and to debride wound edges when tissue appears devitalized. However, military ophthalmologists recommend another approach to periocular lacerations. Due to the rich vascular supply of the eyelids and periocular region, it is unusual for these wounds to become infected, so the surgeon can safely perform primary closure following careful irrigation of very contaminated material.

Tissue debridement in the eyelids is also discouraged, as this can cause anterior lamellar shortening leading to lid retraction, ectropion and lagophthalmos.

Orbital fractures

Most internal orbital fractures do not require immediate repair, so (save for cases with extraocular muscle entrapment) it is often advisable to defer treatment until after the patient is evacuated stateside. The surgeon must decide case by case the appropriate course of action based on the fracture’ severity, the patient’s overall condition, the presence of concomitant injuries, the potential for surgical morbidity, and the availability of appropriate equipment, supplies and expertise.

Complex orbitofacial reconstruction can be particularly challenging. In many war injuries, severe tissue damage or loss leads to poor vascularity, potentially compromising reconstructive outcomes. Using alloplastic implants in such cases can be problematic, as many military surgeons have noted an unacceptable incidence of implant infection and extrusion. When reconstruction of a missing anatomic structure is required (such as the orbital rim or facial buttresses), the surgeon should consider using autogenous materials (such as calvarial bone or vascularized free flaps) in lieu of alloplastic implants (Figure 3).

Figure 3. Soldier injured by suicide bomber in Afghanistan with severe orbitofacial trauma.

REHABILITATION

Additional care is often required

Many ocular trauma patients require numerous procedures and close follow-up care. Given the frequent need for multiple ophthalmic subspecialists, it is ideal for this care to be delivered at a tertiary referral center where broad subspecialty expertise is available. Continuity of care is particularly important in light of the very complex nature of many of these cases. When transfer of care is required by relocation or transition, careful physician-to-physician coordination is essential.

Visual rehabilitation can greatly aid in the recovery and return to society of individuals with significant vision loss. Low-vision services, life skills training, computer access, mobility aids and occupational assistance are all available through the VA’s Vision Rehabilitation Clinics located around the country. Patients who have sustained traumatic brain injury are also at risk for visual complications, and should be screened by an ophthalmologist regardless of whether they have sustained direct ocular trauma.⁸

The lessons don’t end here

Our nation’s service members have sacrificed much to defend our freedoms. It is our obligation to provide them the best possible care, and to apply the lessons we have learned from their injuries to better the lives of those who follow. These lessons are relevant not only to wartime trauma, but also to preventing, preparing for and treating ocular trauma in any environment. OM

The views expressed in this article are those of the author, and do not represent the official policies of the U.S. Army, U.S. Navy, U.S. Air Force, Department of Defense or U.S. Government.

REFERENCES

About the Author

Col. Raymond I. Cho, MD, FACS, is the Director of Oculoplastic and Orbital Surgery at Walter Reed National Military Medical Center and Associate Professor of Surgery at the Uniformed Services University of the Health Sciences in Bethesda, Md. He deployed to Balad Air Base, Iraq, from 2005 to 2006, where he served as Chief of Ophthalmology at the 332nd Air Force Theater Hospital and Ophthalmology Consultant for the Iraqi theater of operations. His e-mail address is raymond.i.cho.mil@mail.mil.