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Clinical Update: Cataract
Wounds of War: Part One: Eye Surgeons in Iraq and Afghanistan
By Denny Smith, Senior Editor
 
 

The cost of war is often counted in fallen soldiers. But war’s survivors, both soldier and civilian, may also pay a tremendous price, by enduring traumatic, disfiguring and life-altering injuries. Ophthalmologists, like many other physicians and medical workers, have been tending the wounded in Afghanistan and Iraq for over three years now. More than 17,000 American servicemen and women have been wounded since the U.S.-led invasions began.1

“The survivors often have very bad injuries, and there’s no way to completely repair many of them,” said Thomas H. Mader, MD, a retired U.S. Army colonel who served in Iraq in 2004 and who is the primary author of a recent report in Ophthalmology describing ocular and adnexal injuries treated by U.S. Army ophthalmologists.2 “Occasionally you treat a patient with a relatively minor injury, which can be repaired in 10 minutes and the prognosis is excellent. But then there are explosive globe injuries, and other terribly mutilating trauma, where there is absolutely no chance at all of salvaging the eye.” Dr. Mader is now practicing ophthalmology at the Alaska Native Medical Center in Anchorage.

Eye and brain injuries appear to be more frequent in Afghanistan and Iraq compared with previous U.S. conflicts, even though the number of deaths per injured troops has decreased. This apparent spike in head injuries is partly a statistical illusion: The body armor of troops in Iraq and Afghanistan, much improved over what soldiers had in World War II, Korea and Vietnam, protects internal organs but not faces and limbs. So, ironically, doctors now confront profoundly injured troops who once would have died of massive thoracic or abdominal wounds before nonfatal injuries to eyes and extremities got medical attention.

For Every War, a Dread Weapon

Many of the injuries logged in Iraq result from disastrously effective improvised explosive devices (IEDs). These are simple, homemade bombs, such as artillery shells filled with glass or rocks, that are detonated remotely as troop convoys pass by. The sheer concussive force of IEDs is dangerous in itself, but most injuries are related to debris propelled by the blast. “These fragments can range in size from a grain of sand to something the size of your fist,” said Dr. Mader.

Sean M. Blaydon, MD, is a former lieutenant colonel who commanded the Army’s first eye surgical team to be deployed in the Iraq conflict, in 2003 and 2004. “Roadside bombs became more common as the conflict dragged on,” said Dr. Blaydon. “Many of the injuries were devastating, including large areas of the face or both eyes. It’s very troubling to see young kids with both eyes missing. I don’t know anybody who didn’t get personally affected by it.” Prior to his service in Iraq, Dr. Blaydon was director of ophthalmic plastic, orbital and reconstructive surgery and the ocular trauma service at Brooke Army Medical Center in San Antonio. He is now a clinical assistant professor at the University of Texas, San Antonio, and in private practice in Austin.

A different, but just as troubling, injury profile was described by Lt. Col. Mark F. Torres, MD, who served in Afghanistan in 2003 at Bagram Air Base, north of Kabul. “In Afghanistan there are fewer IED-related injuries and more wounds related to land mines. This is a country with 20 years of recent war, and so there are many, many land mines planted throughout the country. Now, thanks to better armor, they cause fewer injuries to the thorax or abdomen. But that doesn’t save the extremities, head and neck. And the majority of victims are children, who often approach the mines out of curiosity, like they would a toy. These typically cause a lot of damage to the face and limbs.” Dr. Torres is now assistant chief of ophthalmology at Madigan Army Medical Center in Tacoma.

Care for the Globe

Physicians witnessing modern warfare are standing at a frontier of visually appalling and medically daunting trauma. But the goal for treating a battle-related ocular wound is the same as it would be for any big-city ER trauma: Save the globe and preserve vision.

“We always erred on the side of attempting to preserve badly damaged globes,” said Dr. Mader. “Even when it looked like an injury was so severe that the chance of the eye’s survival was minimal, we always brought them into the OR and tried to do the best repair possible. There are times when an injury is so drastic that you just cannot anatomically put the eye back together. When that happens you have to know when to call it quits. But we always tried to salvage the eye even if the prognosis for useful vision seemed poor.”

Dr. Blaydon concurred. “The philosophy of my team was to do as much as we could to salvage the globe. No matter how severe the injury, if we could put the globe together somehow, we did. We knew that in a good 50 percent of severely injured eyes there was little chance that vision was going to be saved, and very likely the eyes would eventually be enucleated. But these soldiers were badly injured, and sedated, and not able to give consent. If they were enucleated right then, they might later second-guess what was done. They may wonder, ‘I came in with 10 other guys and maybe they just didn’t have time to save my eye.’ We wanted them to be able, later on, to understand how serious the injury was and how every effort was made to save the eye. After that, psychologically, they do better if they have an enucleation.”

Working shoulder to shoulder. The care given in the first minutes and hours after an injury must be intensely organized even in the middle of chaos. Dr. Mader described a typical scene. “Our team worked in Baghdad in the heavily fortified Green Zone. We had a general ophthalmologist, an oculoplastics specialist, neurosurgeons and maxillofacial surgeons. We all worked together, often on the same patients, because so many troops with eye injuries had other wounds of the face and brain.”

Dr. Blaydon shared a similar picture. “These soldiers often had multiple injuries. On top of a wounded eye, a guy could have had traumatic amputation below the knee on one side, lost a foot on the other, and they’re still trying to save one arm. Many times we had to delay our surgery because the orthopedic surgeons were trying to save arms and legs.”

When assessing a newly injured soldier, Dr. Mader hoped to be able to communicate with him or her. “Some were unconscious, suffering from horrible head wounds. For others, it was helpful if they were still conscious, because you could question them, assess their visual loss, ask if they could see light or moving fingers.” Sometimes, grimly, the prognosis was obvious, even to the patient. “One young fellow who had lost both eyes in a blast came in fully conscious and was talking clearly to me. He knew what had happened to him.”

Dr. Blaydon described wounds that seemed almost impossible to approach. “You may see ruptured globes in civilian practice, but in combat trauma it could be hard even to distinguish pieces of sclera. In everyday urban trauma, a bad rupture is usually stellate, with sharp edges, and it’s straightforward to repair. In combat-related, high-velocity injuries, not only do you have complex cornea and sclera lacerations and intraocular contents coming out, but the edges are so necrotic it’s hard to even sew them back together.”

Neither bombs nor balm discriminated. Army ophthalmologists have been treating soldiers and civilians in almost equal numbers. “We treated both American and allied troops, as well as Afghan military and enemy combatants. The majority of casualties we saw were actually Afghan civilians,” said Dr. Torres.

The same was true for Dr. Mader. “An injured person could randomly be an American or an Iraqi, soldier or civilian. When someone was brought into the hospital, we treated everybody the same, whether a civilian, a child or enemy combatant.”

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1 www.dior.whs.mil/mmid/casualty/castop.htm.

2 Mader, T. H. et al. Ophthalmology 2006; 113(1):97–104.

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EDITOR'S NOTE: As the conflict in Iraq enters its fourth year, Army ophthalmologists continue treating wounded troops there and in Afghanistan. EyeNet presents the first of two reports on the experiences of Eye M.D.s confronting combat-related ocular injuries. NEXT MONTH: Soldiers Journey Home for Recovery.