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October 2009

Clinical Update: Wounds of War
Military Ophthalmologists Help Soldiers Rebuild Lives
By Denny Smith, Senior Editor

(PDF 819 KB)

The conflicts in Afghanistan and Iraq make news every day. But that news does not often explore the monumental work of military physicians who treat seriously wounded troops and who are expected, somehow, to put broken bodies—and lives—back together.

Care in the Combat Zone

Lt. Col. Mark L. Nelson, MD, served in Iraq during some of the most intense violence in 2006 and is now stationed at Madigan Army Medical Center in Ft. Lewis, Wash. Just as he now welcomes wounded troops home to embark on long-term rehabilitation, he once treated them minutes after they sustained a combat injury. “The majority of wounds are secondary to blasts from improvised explosive devices (IEDs), but there’s a lot of chaos in a combat environment so the injuries can come from almost everything,” he said.

The injuries range from corneal abrasions and intraocular foreign bodies (IOFBs) to traumatic cataracts, retinal detachments and open globe devastation. “Treatment in Iraq is essential life support—and eye trauma is better managed comprehensively by shipping the soldier stateside. So we close open globes, make them watertight, make sure potentially infectious material is removed and antibiotics administered.” Wounded troops are then evacuated immediately to a U.S. Army base in Landstuhl, Germany, where they are evaluated for stability and transferred again to Walter Reed Army Medical Center.

Delayed surgery not deleterious. Despite the several-day delay in treatment between the combat theater in Iraq or Afghanistan and hospital care stateside, outcomes are not affected, said Lt. Col. Eric D. Weichel, MD, former director of the retina service at Walter Reed and now in private practice in Washington, D.C. Thanks to certain measures, Dr. Weichel said, the time lapse between primary repair and more definitive care has not increased the rates of post-traumatic endophthalmitis. “As a standard, the ophthalmologists in the combat theater proceed with very quick globe closure—no waiting six to eight hours after the patient is NPO, as we do in civilian care. The patients are also started immediately on systemic levofloxacin. We’ve found that intravitreal concentrations of levofloxacin are higher than what’s needed for most organisms to prevent endophthalmitis. Injured eyes also get a subconjunctival antibiotic injection and a topical fourth-generation fluoroquinolone following primary globe closure.”

The results of a retrospective study he conducted are reassuring, Dr. Weichel said. “We looked at 250 consecutive open-globe injuries, more than 100 of which had retained IOFBs, and found that delayed removal of IOFBs did not lead to a single case of posttraumatic endophthalmitis. I’ve also communicated with Navy and Air Force ophthalmologists who have not seen a single culture-positive case of post-traumatic endophthalmitis from the wars in Iraq and Afghanistan. And the rates of vitreoretinopathy as well as final visual acuity are comparable to what you see in the literature.”

Explosive sterilization? Dr. Nelson offered an intriguing possibility that might explain the low rate of infection and inflammation: the mechanism of the injury. “It’s very interesting—the fragments from IEDs may become nearly sterile from the heat and velocity created by explosions. And by passing through the eye wall, a foreign body traverses tissue that’s much less laden with microbes than elsewhere on the body, such as the abdomen.”

More reasons for treatment at home. The delay in surgical repairs means quicker reunions with loved ones. “Getting the wounded soldiers home first means that they get to see their family much sooner than if they were kept in Iraq or Landstuhl for weeks or months of surgeries and recovery,” Dr. Weichel said.

And for retinal injuries, there are medical rationales to send patients home for treatment. “Most of these soldiers are injured by IEDs and have lost consciousness. So it’s not possible right then to assess their visual acuity and perform secondary vitreoretinal surgery until they regain consciousness,” said Dr. Weichel. “And even if we wanted to do a retina repair in the combat zone, we can’t use a gas tamponade and then transfer the patient by flight because the gas will expand. We would have to wait until the gas resorbs. So it’s just more practical to do secondary repairs back home.”


Care in the Tertiary Setting

Even after arrival at Walter Reed, eye repairs may have to wait while other injuries are stabilized, Dr. Weichel said. “Frequently these patients need gas or oil tamponade and then positioning on the side or stomach. But that may not be an option if they are missing limbs or are immobilized by external fixation devices. And they are often very sick, are intubated and sometimes febrile or dealing with pulmonary emboli. Of 387 soldiers we recently looked at, three died during tertiary care. So we have to weigh the risk of life-threatening events, like strokes or MIs, before proceeding with a secondary repair of ocular trauma. In fact, we wait an average of 10 to 14 days for patients to be stable enough orthopedically before IOFB removal. We might try something sooner in the case of retinal detachments, especially if they’re macula-on detachments. Once we perform a vitrectomy for a retained IOFB, we send the vitreous for gram staining and bacterial cultures.”

Special concern for brain injuries. Dr. Weichel noted that in troops treated for eye trauma, 44 percent also have extremity wounds, and 12 percent have had amputations. And a full 66 percent have suffered a traumatic brain injury (TBI). “Fortunately, TBI does not independently appear to affect final visual acuity. We were worried about that because it can actually affect other physiologic processes. But TBI patients with ocular trauma do need extra attention. They have a hard time remembering, so it’s difficult for them to be compliant with drops or other meds. It’s also very difficult for them to follow commands and they can get severely agitated, so eye surgeries that might ordinarily be done on a conscious patient become a general anesthesia procedure. Community reintegration is the goal for everyone who has suffered a life-changing injury, but TBI patients have a harder time getting a job, and relearning how to socially interact.”


Care in the Community

Depending on their injuries, some wounded service members can recover reasonably well and even return to active duty, said Dr. Weichel, but others need to be discharged. Of those, many will require ongoing care and have the option of enrolling in the VA system or assuming private insurance.

Heads-up to community providers. About 50 percent of injured veterans seek private care, he said, partly because it’s convenient to where their families live. “That’s where community ophthalmologists may see these patients. The most obvious injuries will be stabilized by that time, but traumatic optic neuropathy continues to affect about 20 percent of wounded veterans. Residual macular edema can also be a problem for anyone who was near a blast wave, and lid and facial lacerations may need additional reconstruction.”

Dr. Nelson said that blunt trauma from blast waves suffered by soldiers can leave torsional or concussive injuries such as commotio retinae. He said that community ophthalmologists who treat veterans may likely be seeing some late traumatic cataracts, or blast wave-related angle recession, which can result in glaucoma. “And they may see injuries that were repaired and from which the patient recovered a remarkable amount of vision, but still need life-long, yearly follow-ups.” He added that it’s possible for a soldier to have a retinal injury with no evidence of anterior segment damage at all, especially if an IOFB penetrated the sclera rather than the cornea.

Attention to TBIs. Dr. Weichel called for particular regard for veterans with TBIs. “Be patient with them—they may need longer appointments, and you should be sure to write down any instructions and follow-up appointment details.”


Care for the Future—and for the Past

Dr. Weichel outlined four areas of ophthalmic research into trauma that he thinks deserve more attention:

  • Management of corneal scarring, well as corneal neovascularization.
  • Progress on treating proliferative vitreoretinopathy.
  • Minimizing primary enucleation and establishing criteria for enucleation for eyes with pain or no light perception. Currently, about 13 percent of severely injured eyes are enucleated in the combat theater, Dr. Weichel said, and for soldiers who return home with bilateral NLP, it's another 2 percent. Oculoplastics surgeons generally recommend enucleation of NLP eyes within 14 days to avoid the risk of sympathetic ophthalmia. “In the case of an eye with NPL, we bring up the topic of enucleation and some will readily consider it. Others are willing to chance the sympathetic ophthalmia. Sometimes an NLP eye can look cosmetically normal and isn’t painful, such as when an orbital foreign body transects the optic nerve but leaves the globe intact. Many NLP injuries, however, are cosmetically disfiguring or else patients are in pain from a disorganized globe. Secondary enucleation, in our experience, has resolved the severe eye pain associated with NLP vision following primary repair.”

Honoring the soldier, and doctor. Dr. Nelson remembers well the dedication of both patients and colleagues in Iraq. “I was so impressed with the soldiers and Marines I took care of in Iraq, many of whom had very severe injuries. There were times I was exhausted from doing surgeries for several days on end, but I could never feel sorry for myself while soldiers were putting their lives on the line every day. I was equally amazed by the skills of the providers—nurses, corpsmen, medics or physicians. I would have felt completely comfortable with their care had I incurred an injury over there.”


A Surgeon for Children of War

Pediatric ophthalmologist Col. Kevin Winkle, MD, served in Balad from 2006 to 2007, during which he treated hundreds of injured Iraqi children and adults as well as U.S. troops. His surgical team saw profound trauma almost every day, he said, and the experience was physically and emotionally searing. “You’d never know when you’d be in the operating room for eight hours on case after case, all of it devastating trauma, with faces absolutely shredded, and extensive eye and orbit trauma. Sometimes we just tried to put the jigsaw pieces together. I’m still sort of recovering. I’ve done Ironman Triathlons and they took every bit of willpower to finish. But they were nothing compared to a six-month tour of being on call 24 hours/ seven days a week just hanging in there.”

Save a life, then limbs and eyes. When Dr. Winkle first arrived in Balad, the medical corps did not have a fixed facility. “We had three ORs, with two beds each, in a tent hospital. Iraq was as bad as it got when I was there, but the staff did a phenomenal job of triage. Some soldiers were essentially dead when they came in, but the ER physicians and trauma surgeons would crack the chest anyway in heroic efforts to save them. Generally, if the wounded survived as far as the hospital it was rare that they didn’t live to get into the OR. We’d stabilize them and then follow the ‘life, limb and eyes’ rule: If someone was bleeding out or their brain was swelling, measures were taken that could save a life. But after that, it was a judgment call. I would sometimes have to remind orthopedic guys that eyes are just as important as limbs. The exception was when blood flow to a distal extremity was compromised, which would warrant holding off on the eye injury. An hour or two will not make a big difference in outcomes for open-globe injuries.”

Suturing the shreds of violence. Dr. Winkle treated more Iraqis than U.S. troops. “About 20 to 25 percent of surgical cases were our active duty men and women, and the rest were local Iraqis. We saw faces and eyes that had just been blown apart. Of about 450 surgeries I did, I had to remove at least 73 eyes. The kids we saw were usually injured by projectile trauma from suicide bombers or IEDs. Very rarely was it crossfire involving our soldiers.”

Dr. Winkle described scenes that do not reach the newspapers and that few physicians will confront in an entire career. “The trauma from IEDs could be devastating—in some patients much of the face appeared to be missing. But often it was actually filleted apart and, amazingly, there was a fair amount of tissue remaining that could be reapproximated with rotation flaps. For our troops, we’d do primary repairs and then ship them out so they could get definitive oculoplastic treatment stateside. But for Iraqis, the primary repairs we gave were quite possibly all they were ever going to get. Fortunately, I worked with some great oromaxillofacial and ENT surgeons. If there was massive tissue loss, we did grafting, such as with muscle flaps. We also did a lot of plating for decimated bone on civilians. For the kids, unfortunately, there were usually no parents or relatives around. So after we did what we could they were shipped to local Iraqi hospitals. We never saw them again.”

Idealism burnished by life—and death. Dr. Winkle, who is now in Anchorage, hoping to build a pediatric ophthalmology service that would be shared between the Department of Defense and the Alaska native community, had originally begun a pediatrics residency before embarking on his ophthalmology training. He had looked forward to improving the vision of kids or return sight to the blind.

“One of the reasons I chose ophthalmology is that it’s a very rewarding specialty. People who were once blind could have a new gleam in their eye. I wanted to ensure the visual development of children, to see eyes straightened by a strabismus correction. In Iraq I didn’t do a lot of salvaging vision—I did a lot of putting eyes back together, eyes that were probably never going to see again. My first enucleation in Iraq was on a child. And through all of my training and previous work I never pronounced anyone dead, until Iraq—and it was a child. It was sobering. You can acquire, in six months, more experience than you might in a lifetime.”