Ocular Injuries From Terrorism Often Catastrophic

Neil Osterweil

April 09, 2014

TOKYO — Ocular trauma from warfare or terrorist attacks carries a high risk of devastating vision loss, according to retrospective review of ocular injuries from terrorist attacks.

"Unusual clinical presentations and devastating visual outcomes are common in terrorist warfare," said Güngör Sobacı, MD, professor of ophthalmology at Gülhane Military Medical Academy in Ankara, Turkey.

In fact, 80% of the eyes assessed had open-globe injuries, including rupture, penetrating wounds, and intraocular foreign bodies, he reported.

Dr. Sobacı presented the study results here at the World Ophthalmology Congress 2014.

Severe Visual Loss Common

The research team evaluated 130 eyes from 112 patients treated at the Gülhane Military Medical Academy from 2003 to 2013. Only patients with at least 6 months of follow-up data were included in the analysis.

Of the 112 patients, 109 were men in the military; the other 3 patients were women. None of the patients were wearing protective eyewear when their injuries occurred.

Of the 130 eyes, 104 had open-globe injuries, 80 of which were caused by foreign bodies, and 26 had closed-globe injuries — 20 contusions and 6 lamellar lacerations.

At initial presentation, visual loss was severe; 68 of the eyes with open-globe injuries had a visual acuity score of 4/200 with light perception, and 29 had no light perception at all.

Of the eyes with closed-globe injuries at presentation, 10 had a visual acuity score ranging from 19/200 to 5/200. Four of the eyes had 4/200 vision with light perception; only 1 had no light perception.

Six eyes developed traumatic endophthalmitis.

There were 284 operations — a mean of 2.8 per eye. More than a quarter of the eyes (26.9%) were enucleated or eviscerated.

In all, of the 87 eyes that underwent vitreoretinal surgery, 16 involved scleral buckling and 22 involved retinectomy. Thirteen eyes underwent an anterior segment procedure.

Of the 130 eyes, 75 had unfavorable visual outcomes, defined as a final visual acuity score below 5/200 or enucleation. Of the 55 eyes that developed proliferative vitreoretinopathies, 41 had bad visual outcomes, Dr. Sobacı reported.

Risk factors for worse visual outcomes were blast injuries and injuries requiring at least 2 surgeries. Eyes that underwent vitrectomy were more likely to be spared from enucleation.

The presence of an intraocular foreign body is not an indication for immediate vitrectomy, except when the penetrating body is toxic or the wound is infected, Dr. Sobacı noted. He emphasized that even in eyes with no light perception, everything possible should be done to salvage the eye for the sake of the patient's appearance.

It is often possible to spare the eyeball, if not the vision, said Yoshihiro Yonekawa, MD, ophthalmology resident at the Massachusetts Eye and Ear Infirmary and Harvard Medical School in Boston. He treated victims of the 2013 Boston Marathon bombings and was not involved with the study.

"Even if you have an open-globe injury, with today's surgical techniques and instrumentation, we're usually able to fix the open globe. A few decades ago, everybody with an open globe would have been enucleated," he said.

In fact, "in Korea and Vietnam, soldiers sustaining these kinds of injuries would have died," he noted.

Although modern protective equipment for soldiers protects their bodies very well, faces are not well protected. "In Iraq and Afghanistan, people are surviving, but with severe ocular and traumatic brain injuries," Dr. Yonekawa explained.

Israeli physicians are all too familiar with ocular trauma, said session comoderator Daniel Briscoe, MD, from the Department of Ophthalmology at Emek Medical Center in Afula, Israel.

"From 2000 to 2005, we had many instances where civilians were sitting on a bus and the bus would explode," he said. "Of course, they weren't wearing protective goggles; they were just sitting on a bus. We would have 60 people descending on a hospital with catastrophic injuries. Treating them demands a lot of skill."

Currently, "we have patients coming from Syria with these same kinds of injury, and we have treated several hundred of them. It's very, very difficult," Dr. Briscoe said.

The study was supported by the GATA. Dr. Sobacı, Dr. Yonekawa, and Dr. Briscoe have disclosed no relevant financial relationships.

World Ophthalmology Congress (WOC) 2014: Abstract FP-TH-03-7. Presented April 3, 2014.

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