The U.S. military needs to improve its coordination of vision care and shore up its ophthalmic capabilities, which are threatened by a proposed steep reduction in personnel, said Robert A. Mazzoli, MD. He was speaking at the “Ophthalmologists During Wartime” symposium, which was cosponsored by the Truhlsen-Marmor Museum of the Eye and the Society of Military Ophthalmologists.
The rate of combat ocular injuries is increasing. Ocular injuries have accounted for an increasing proportion of combat injuries, increasing from 2% to 20% over the last century, with the proportion rising to over 25% during the early stages of the global war on terror (GWOT). The change since World War I has partly been due to the development of high-energy explosives, which produce many more shrapnel and explosive fragments. Mortality rates from ocular trauma have decreased because of increased use of antisepsis and specialty eye centers, resulting in greater numbers of injuries rather than deaths.
Ocular injuries during combat are unique. Dr. Mazzoli noted that combat injuries of the eye are worse than those seen during peacetime and that specific knowledge is needed to best treat these injuries.
Combat produces “complex ocular polytrauma.” This means that injuries can be extremely complex and chaotic, rather than merely complicated. Because many parts of the eye are affected, these injuries require the knowledge of multiple ophthalmic subspecialties (e.g., retina and cornea and oculoplastics).
Capabilities must keep up with needs of patients. To optimize outcomes,“it is critical to get the right patient to the right facility with the right ophthalmic capability for the right treatment at the right time,” said Dr. Mazzoli. The capability to provide that care depends on many factors, including medical personnel, facilities, and policy on care coordination.
Capabilities reset with every war. Historically, each time the nation has entered a war, its baseline capabilities for providing medical care have been insufficient. During wartime, those capabilities increase, only to rapidly deteriorate with the onset of peace, so that the nation enters each war with poorer medical capabilities than at the exit of the preceding one, said Dr. Mazzoli. Optimally, lessons learned during wartime will lead to some of those new capabilities becoming enduring capabilities so the new baseline is better than the old going into the next war.
Dr. Mazzoli gave examples of how during World War I, there was no ophthalmology capability and few “real” ophthalmologists in the military; by the GWOT, there were residency sites but no designated ophthalmic trauma centers or casualty policy. Worryingly, the Department of Defense has proposed a 40% to 60% reduction in uniformed ophthalmic strength, said Dr. Mazzoli. “This begs the question of whether they’ll reintroduce a doctor draft for the inevitable next war.”
Ways to improve treatment of combat ocular trauma. There is a need to send soldiers with ocular injuries to the appropriate capable facilities, which, according to Dr. Mazzoli, would involve both horizontal integration, with facilities communicating with one another, and vertical integration with the overarching trauma system. Underlining the need to improve integration, Dr. Mazzoli quoted a blind veteran who testified before Congress that, “Nobody is talking to each other, and you can’t get the care if nobody is talking to each other.”
New military vision centers. “There is hope on the horizon for military ocular combat casualty care,” said Dr. Mazzoli. This year, Congress has mandated the establishment of four regional ocular centers of excellence. Specialty vision care coordination must be an integral part of this system to ensure horizontal and vertical coordination, he said. Dr. Mazzoli noted that this upgraded system of military ocular combat casualty care could provide a template for a national civilian ocular trauma system. In addition, Dr. Mazzoli recommends collaboration between the Department of Defense and civilian organizations such as the Academy, the American Society of Ophthalmic Trauma (ASOT), and the American College of Surgeons Committee on Trauma (COT).
—Stephanie Leveene, ELS
Financial disclosures: Dr. Mazzoli: None.
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