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Combat-related ocular trauma requires unique care
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 Col. Mark L. Nelson |
PHILADELPHIA — Damage control surgery is essential to managing open-globe injuries sustained in combat situations, according to a speaker here.
"One of the hardest decisions you make in this situation is, 'Do I enucleate the eye, or do I repair it?'" Col. Mark L. Nelson, MD, said at Macula 2011. "The bottom line is you want to close the globe ... and get the patient back to the States."
Dr. Nelson was the only eye surgeon at the Theater Evacuation Hospital in Balad, Iraq, from July to October 2006. He repaired 114 major ophthalmic injuries, of which 63 were open globe and about half required primary enucleation.
Shrapnel from improvised explosive devices are particularly destructive to the eye, Dr. Nelson said. He added that CT scans are an invaluable tool for identifying intraocular foreign bodies, which should be removed after the patient is evacuated to the United States.
In addition, complex vitreoretinal procedures should be performed in the United States, he said. While some patients have successful outcomes, many eyes cannot be restored due to the severity of the injuries.
"You just have to come to the acceptance that some of the eyes are not salvageable," Dr. Nelson said.
- Disclosure: No products or companies are mentioned that would require financial disclosure. The ideas, opinions and material presented by Dr. Nelson do not reflect the official policy of the Department of the Army, Department of Defense or the U.S. government.
Practicing in a remote location requires consideration of factors that we fortunately do not have to consider when caring for patients in the community. Col. Nelson indicated that no attempt was made to remove foreign bodies from the eye at triage. Any ruptured globe with a retained intraocular foreign body was primarily closed, and surgical removal of the foreign body was performed later in a more favorable environment. Traditionally, it is taught that intraocular foreign bodies require urgent removal to prevent infection, and in clinical practice, these cases constitute one of the rare, truly urgent surgical procedures that ophthalmologists perform. Except when the foreign body is considered dirty (eg, farm implements), Col. Nelson’s experiences impact my practice in that the urgency of these surgical cases may not be as high as previously thought.
Col. Nelson’s study indicated that, in combat conditions, about half of the open-globe injuries required primary enucleation, a staggeringly high percentage. In clinical, non-combat conditions, patients with open-globe injuries would undergo primary closure of the open globe and in the ensuing 10 to 14 days, the decision whether to enucleate would be made based on the visual acuity and other clinical criteria. In these cases I consider not only the clinical findings, but also psychological ramifications. For open-globe injuries encountered in the local community, primary enucleation will likely continue to be a rare procedure.
– Mitchell S. Fineman, MD
Associate
Surgeon, Retina Service of Wills Eye Institute, Philadelphia
Disclosure:
No products or companies are mentioned that would require financial disclosure.