Changing nature of combat brings new set of ocular injuries

San Diego-When military personnel are injured in combat situations, the primary concern of saving lives supersedes saving sight, said Col. Anthony J. Johnson, MD, Fort Sam Houston, Antonio, TX.

In combat situations, the use of fragmentation weapons has been “the lion’s share” of damage to the ocular surface.

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In the past 12 years, the U.S. Army and its Coalition Partners have had more than 1.2 million soldiers entering combat operations. Of those soldiers, slightly fewer than 60,000 have been injured, and of those, 2,800 have suffered “significant ocular injuries,” said Dr. Johnson, speaking here during World Cornea Congress.

Consistent with other recent conflicts, during the peak of operations, ocular injuries accounted for more than 15% of all evacuations out of combat theater.

If a wounded soldier is still alive upon arrival at a level 3-combat hospital, there is a 98% chance of surviving, Dr. Johnson said.

The number of terrorist activities outside of combat situations has “skyrocketed” since 2010, with terrorists preferring large-scale blasts that will deliver the most devastating damage to the largest number of people.

In today’s world, terrorist attacks have been ballistic in nature, bringing with them a slew of additional ocular, brain, and skin injuries.

According to the National Consortium for the Study of Terrorism and Reponses to Terrorism, in 2012 there were more than 8,400 terrorist attacks worldwide and more than 15,400 casualties, with the incidence increasing monthly. By 2013, there was an average of over 900 attacks per month.

The Oklahoma City Bombing, Boston Marathon attack, and the West Texas Industrial Plant explosion have all recently illustrated the fact that traumatic explosive injuries are no longer purely a construct of war and are a growing experience for urban ophthalmic providers, and ballistic weapons are the preferred weapons of choice because of the amount of damage they can inflict, he explained.

Next: Understanding traumatic brain injury

Ballistic weapons have a rapid release of energy, but the blast wave and extent of injury depends on the primary blast, Dr. Johnson said.

Traumatic brain injury (TBI) from one of any of the primary blast, secondary blast, or sudden deceleration of the patient can result in ocular damage as much as a direct hit to the face. More than 200,000 soldiers have been exposed to TBI as a result of blast exposure, he said.

These blasts can result in endothelial cell count of less than 2,000 on that side of the body to the blast-and this will result in difficult future surgeries and vision problems considering the average age of soldiers is typically around 21, Dr. Johnson said.

In TBIs, more than 40% have presented with diminished endothelial cell counts.

Dirt, rocks, and other objects are typically found around the globe during the time of closure in triage, Dr. Johnson said, and extra caution is necessary.

“Going downrange [in the field] means every corneal-trained specialist becomes a comprehensive ophthalmology specialist,” he said, adding it was not unusual for him to be responsible for suturing wounds comprising a majority of a patient’s face post-blast.

Finally, he said, “quaternary blast effects can results in asphyxia through inhalation, but if you do survive, blast dust is common. If you take care of these patients, pigment will cause tattooing on the patient’s face and other dermatologic damage.”

Ophthalmologists are at the combat hospital, but not likely on the field, he said.

Once initial injuries are taken care of on the field, mass casualties arrive “in bulk,” with up to 70 patients arriving at once, he added.

Some of the lessons learned from the years of combat and experience in treating the military injuries: even at high outside temperatures, the patient can be hypothermic.

“Massive blood loss can lead to hypothermia, regardless of temperature,” he said.

Next: Conclusion

Thirty percent of intracranial injuries go through the orbit, so the U.S. military has now deployed ocular and neck specialists.

“In today’s world, we don’t need to eviscerate in severe eye trauma any longer,” he said. “The Joint Trauma Registry now includes its own ophthalmology subset,” to better evaluate ophthalmic response to military injuries.

“We still need to deal with pre-hospital care, and we need to improve helmet and eye protection to protect against ballistic injury,” he said.