War-related eye injuries require complex, unconventional management strategies

War shifts needs and priorities, and much of what is taken for granted in peacetime is no longer there.

More than 18 months since the beginning of the war in Ukraine, ophthalmologists there are working around the clock, dealing with overwhelming injuries that have no civilian parallel and require complex decisions in difficult conditions, fighting with time and with the consequences of delayed presentation.

“We always try to do everything possible and sometimes impossible, but results are often not as good as we would hope,” Nadiia Ulianova, MD, head of the department of post-traumatic eye pathology at the Filatov Institute of Eye Diseases and Tissue Therapy in Odesa, Ukraine, said.

The main focus of her department is the provision of highly specialized assistance to war victims in a regimen of continuous readiness, 24 hours a day, 7 days a week.

“I never thought that I would be dealing with such extremely difficult trauma. My career goals and my skills were focused on small incisions and mini-invasive surgery without sutures. Now this has dramatically changed, and it is large incisions, huge sutures and big, complex trauma,” Andrii Ruban, MD, PhD, said.

Ruban is a vitreoretinal specialist who since the start of the war has been serving as a surgeon at the military hospital and at the Center of Clinical Ophthalmology in Kyiv, Ukraine. Like many others, he has had to learn new skills and strategies.

The challenges of war-related ocular injuries are different from those in civilian practice, and it is imperative for ophthalmologists who serve in war zones to understand the complexities they may face.

“You may not be interested in war, but war is interested in you,” Ferenc Kuhn, MD, PhD, said, quoting Leon Trotsky. “We thought after the Second World War that these major conflicts were over. Unfortunately, that’s not true. The discussion on how to handle war-related trauma is very timely.”

Kuhn, a world-recognized authority in ocular traumatology, personally operated on some wounded soldiers from Ukraine, tragic cases that arrived on his operating table months after the primary injury.

“I remember a 50-year-old soldier who had already lost one eye. I did a very long surgery with extremely minimal hope, and when I saw him the next day, his only concern was not whether he could see again, but when he could go back fighting for his country,” he said.

Combat trauma unlike any other

The war in Ukraine is reminiscent of World War II, unrestricted in terms of the weapons used, the territory involved, and the military targets that include resources and infrastructures, disregarding the international laws of war.

“This tells you that the number of casualties, both general injuries and eye injuries, is much higher,” Kuhn said.

Injuring rather than killing the enemy is more strategic in this kind of war, he said.

“An injured soldier not only is removed from the battlefield but requires care, and this ties up large amounts of resources,” he said.

The eye is only 0.1% of the body surface but represents 10% to 15% of all injuries because 90% to 95% of the information reaches us through the eye, and the eye naturally turns toward the action. The typical pattern of war-related eye injuries is complex polytrauma associated with the head, face, neck and multiple other body regions.

“Combat injuries are worse than the worst trauma you see in peacetime, much higher in terms of devastation and severity than the worst trauma we see even in the worst train or car wrecks,” Robert A. Mazzoli, MD, former consultant to the Surgeon General of the U.S. Army and co-founder of the Defense Health Agency’s Vision Center of Excellence, said.

Modern warfare is characterized by high-energy explosives that detonate in close proximity to ground personnel. These include artillery shells, mortars, grenades, rockets, aircraft bombs and now, explosive drones.

“The archetypal injury is blast, which not only creates multiple high-velocity, high-energy fragments and shrapnel but also a concussive blast wave, which itself can cause significant injury and death. When it hits you, the energy content of the blast wave causes a huge blunt injury that results in a lot of internal damage without necessarily showing up as an anatomic injury,” Mazzoli said.

In World War I literature, the term used was “shell shock,” indicating people who were found dead and had no visible external wound.

“It was the concussive force. And this went hand in hand with what they called ‘war shock,’ now PTSD, post-traumatic stress disorder. There’s nothing novel. We saw this in World War I, we saw it again in World War II and then in the Gulf War. We are seeing it in the Middle East and, again, in Ukraine,” Mazzoli said.

Damage control ophthalmology

Blast injuries involve every part of the eye, from the surface to the retina and optic nerve, the muscles, the adnexa and the orbit, and are further complicated by the presence of multiple foreign bodies. Because other organs are also affected, the eye may not be the first priority for treatment.

“You have to make decisions, not only about how to triage the eye injury, but about which discipline of medicine will take care of the patient first. Life-threatening injuries push back the eye in the priority list, with negative consequences on what we can do when the time comes,” Kuhn said.

In addition, combat trauma is invariably mass casualty, with multiple patients presenting simultaneously with devastating, life-threatening injuries. Because of this, the time available to treat any single patient is significantly limited.

“You have to do the best you can for the most casualties, do what’s most key to set the foundation and go on to the next patient. That is what we call ‘damage control ophthalmology’: Do what’s most critical to stabilize the eye, make it watertight, ensuring the cornea has adequate coverage to prevent infection, and prepare it for later, more definitive procedures,” Mazzoli said.

A system under stress

The Ukrainian military medical system is based on the four-level NATO system of care, in which successive echelons have more sophisticated capabilities in terms of specialized personnel and technological equipment.

“At first and second levels, near the battlefield, it is very important to preserve the integrity of the eye and prevent further damage. Teleophthalmology could theoretically improve eye care in these war zones, but it is not widely available. It is our next step for the near future,” Ruban said.

Level three includes additional capabilities in terms of diagnostic resources and specialist staffing. This is where the first ophthalmologist appears and provides first repair. However, the ophthalmic team does not always include retina or oculoplastic specialists, and supplies are often limited, Ruban said.

“At fourth echelon level, we provide highly specialized care, but delays and disruption of evacuation lines as well as the presence of life-threatening conditions in many of our soldiers cause delays of several days or even weeks, affecting the results of our surgery in specialized centers,” he said.

Neither side in this war has air superiority, and transportation and evacuation are therefore exclusively by ground.

“It might be by train, car or truck or in the back of a pickup. It might even be horse and buggy or cart, across roads that have been bombed out, where bridges have been blown up. Water isn’t running, and the onset of infection is very common during that transport time. The clock works against us,” Mazzoli said.

Eye injuries should be addressed within 8 to 12 hours, and currently, Ukrainians are facing 3-day evacuation times, challenging the system of medical care, he said.

In addition, the indiscriminate bombing of civilian areas and the attacks on medical infrastructures stress the system even more, with a high number of wounded civilians that need to be transported a long way to the nearest functioning hospital.

Teamwork needed

“Our clinic belongs to the highest level of medical care. As a rule, we receive patients after first aid and primary surgery and provide highly specialized reconstructive surgery. However, in case of very high tension in the frontline, we switch to providing primary surgery and first aid,” Ulianova said.

Since February 2022, more than 800 operations have been performed in her department, most for blast injuries with delayed presentation due to other life-threatening injuries that needed more urgent care.

“Often we work as a multidisciplinary team in complex cases where the person is simultaneously operated on by ophthalmologists, neurosurgeons and general surgeons,” Ulianova said.

She has also repeatedly traveled to other clinics for complex operations.

“There is no place in war medicine for individual projects — it’s only teamwork. There are nine departments in our eye institute, and in case of military trauma, several specialists are involved to improve the reconstructive surgery, specialists in retina, corneal transplantation and oculoplasty,” she said.

Blast never forgets

Blast injuries present unique management challenges, and functional results are often poor.

“Sometimes we see characteristics of closed eyeball trauma, with no anatomical damage in the anterior segment, but the presence of chorioretinitis sclopetaria heavily impacts on the end functional results. In eyes with opaque corneas, vitrectomy can only be performed by using a temporary keratoprosthesis and eventually implanting a full-thickness corneal graft. But only 30% of these eyes maintain a transparent corneal graft after this early surgery due to severe inflammation and active vascularization in the anterior segment,” Ulianova said.

For their entire life, blast injury patients are at a high risk for other ophthalmic problems, Ruban said.

“Glaucoma, retinal detachment, optic neuropathy. Now we understand that we have a huge problem, not only today in the OR, but tomorrow and after tomorrow and beyond,” he said.

Ocular injuries associated with explosive blasts need to be addressed in a different way from any other injury that may appear similar, such as a car wreck injury. The energy involved is different and causes fundamental derangements of physiology that interfere with wound healing and evolution.

“Blast never forgets,” Mazzoli said. “And if you address the blast injury the way you address a car wreck injury, the injury repair will fail and will fail early.”

His recommendation is to restrain from doing too much too soon because a blast injury evolves over time, and intervening too definitively too early, before it has fully evolved, almost invariably leads to failure. Even reoperations, if undertaken too soon, will reignite all the blast derangement.

“Temper your enthusiasm and save your silver bullet operation for later. Do some smaller intervention that will buy you time. Don’t burn your bridges,” he said.

Take care of the essentials

One example of burning bridges is the attempt to treat eyelid lacerations with the large flaps and grafts that are used for eyelid reconstruction following a car wreck or a firework explosion.

“In the OR, it looks great, but 6 weeks or 6 months later, those flaps and grafts are going to pull apart. They are going to die, to slough, to scar, and you are back to where you used to be,” Mazzoli said. “Do something else to cover the eyeball and postpone the fancy flaps and grafts to a later stage.”

He also warned against wasting time and energy on details, such as applying small astigmatically neutral sutures in eyes with large corneal lacerations.

“That’s a great kind of approach if the mechanism of injury was flying glass from a shattered window, and the energy involved was relatively low. But with an eyeball that has been exploded, you have to worry about closing the eye and making it watertight,” he said. “When the best vision is going to be light perception, how much difference is astigmatically neutral sutures going to make?”

The normal tendency when closing facial and ocular lacerations is to close them tight from the bottom upward in multiple layers. This is to be avoided, Mazzoli said, because combat wounds are always highly contaminated, and microbes would thrive in a closed watertight space.

“You want to put drains in the deep spaces and leave the wounds closed but not closed tightly the way you would in a planned surgery where you are in control of everything,” he said.

For the same reason, porous implants should never be used in case of enucleation.

“Use a solid implant like acrylic, silicone rubber or a dermis-fat graft, something that is not going to sequester an infection in an area where there may be an open roof and the orbit communicating with the brain. You don’t need an infection going into the brain,” Mazzoli said.

Enucleation should be avoided whenever possible, and reconstructive surgery should be performed instead, Kuhn said. The risk for sympathetic ophthalmia is rare and should never be used as an excuse to remove the eyeball.

“Try to reconstruct it, even if the eye has no light perception. You don’t really increase the risk of this inflammatory process much, but you will prevent the patient from undergoing an additional mental trauma,” he said.

He also recommended that surgeons use full-thickness corneal sutures to close corneal wounds.

“It is not what the literature advises, but I do my sutures 100% deep. The edema rapidly disappears, and I am able to do the posterior segment work when it’s ideal and not when it’s possible because of the visibility issue in the cornea,” he said.

A temporary keratoprosthesis should be used otherwise “because the cornea can wait; the retina and the ciliary body cannot,” he said.

Prophylactic chorioretinectomy is highly recommended to prevent post-traumatic proliferative vitreoretinopathy, and the ciliary body should be cleaned to prevent it from being involved in the scarring process.

“Once that happens, the eye’s gone, even if you have a functional retina,” Kuhn said.

The human tragedy of war

Explosive weapons in and near towns and cities are causing severe eye injuries in civilians as well. These cases more often involve trauma with intraocular foreign bodies such as glass, wall fragments and other objects as compared with the blast injuries seen in combatants.

“We have seen a lot of penetrating wounds. When an explosion occurs, people instinctively run toward the windows to see what happens, and we have seen a lot of glass foreign bodies that are difficult to diagnose, treat and remove,” Ulianova said.

Explosions may occur in crowded civilian environments. Ruban shared the story of a young woman named Natalia who was driving to work when a cruise missile landed in the center of Kyiv during peak hours. Many were killed. Natalia survived but was severely wounded in her body and face, with perforating injuries in both eyes.

“Over 3 months, she has undergone nine eye surgeries. She has spent 16 hours in our operating room and still needs anterior segment reconstruction, but she is optimistic, and she is not blind,” Ruban said.

He operated on innumerable soldiers, young men the age of his son, about 20 years old. Many of them quickly return to the frontline after surgery, and there is no opportunity for proper follow-up.

“It’s not clinical cases. It’s tragedy. And the biggest problem will be when the war is over, with psychological rehabilitation and getting them back in civilian life,” Ruban said.

Ulianova showed the photo of a soldier with a myriad of small foreign bodies encrusted in his face, anophthalmos on the right side, multiple foreign bodies and total corneal opacity in the left eye.

“He lost his right eye on the frontline. The doctor there was unable to save it,” Ulianova said.

Using a temporary keratoprosthesis, she was able to remove the foreign bodies from the vitreous and from the surface of the retina. He had no retinal detachment and an intact macular structure. IOL implantation was performed, followed by iridoplasty and penetrating keratoplasty.

“We saw this patient 1 month ago. The cornea was not perfectly transparent, but he had 20/63 vision,” Ulianova said. “Preserving this level of visual acuity is still a gift for this patient, also emotionally. He can see his wife and his daughter, a small pretty princess, 5 years old.”

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• For more information:
• Ferenc Kuhn, MD, PhD, chairman of the International Society of Ocular Trauma, director of research at Helen Keller Foundation and visiting professor at the department of ophthalmology at the University of Pécs, can be reached at fkuhn@mindspring.com.
• Robert A. Mazzoli, MD, professor of surgery (ophthalmology) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, can be reached at robert.mazzoli@comcast.net.
• Andrii Ruban, MD, PhD, president of the Ukrainian Vitreoretinal Society and retina consultant at the Center of Clinical Ophthalmology in Kyiv, Ukraine, can be reached at ruban33@gmail.com.
• Nadiia Ulianova, MD, PhD, head of the department of post-traumatic eye pathology at the Filatov Institute of Eye Diseases and Tissue Therapy in Odesa, Ukraine, can be reached at ulyanova@ukr.net.

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