Where should surgical management of military ocular trauma occur?
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Eye injuries require highest level of care
According to NATO standards, combat casualties should be managed through a system of echelons of care in which the most critically injured patients receive the most urgent care at the earliest time possible.
Generally speaking, medical support and assets that are within 1 km of the front are going to be limited to basic medical necessities that a general physician would be capable of performing. This level does not normally include surgical capabilities because it is not feasible to bring and keep at a forward base the equipment that is needed for ocular microsurgery, such as operating microscopes and viscoelastics that require refrigeration.
Eye injuries are extremely complex and need delicate, specific procedures. It would be difficult to have the logistical support and personnel available to perform those procedures at far-forward echelons of care, whereas if you can centrally control and support treatment of these injuries at a larger center, you will eliminate all the logistical coordination issues that make it a challenge to do far-forward ophthalmic care. This is on condition that you have the capacity to evacuate patients within a reasonable time — I would define reasonable as a time span within 7 to 10 days.
There may be an exception with some forms of oculoplastic or eyelid surgery because, generally speaking, those surgical procedures do not require surgical microscopes and can be handled with surgical loupes and other relatively simple instruments. However, surgical interventions at that level would only make sense if the procedure were likely to return the soldier back to the front sooner. To be realistic, we should consider that in most cases eye injuries are going to prevent the person from returning to the fight for a fairly long period of time, which may be weeks or months. This limits the utility of trying to perform the procedure close to the point of injury.
Marcus H. Colyer, MD, is with Uniformed Services University of the Health Sciences in Bethesda, Maryland, and Madigan Army Medical Center in Washington.
Ophthalmologists needed close to frontlines
In Iraq and Afghanistan, we relied heavily on military helicopters for casualty evacuations.
We had air superiority, and air transportation allowed us to bring injured soldiers back to the U.S., or at least Germany, within 24 to 72 hours. This is not the case in the Ukraine-Russia war, where neither has air superiority and the evacuation of patients to larger combat hospitals is significantly limited. Under these circumstances, decentralized care plays a crucial role and can dramatically change the visual prognosis of many patients.
There is a model currently in the U.S. Army for general surgeons and orthopedic surgeons to push forward from combat support hospitals to help manage injuries nearer to the battlefields. In the future, we should aim at having comprehensive ophthalmologists closer to the frontlines and subspecialists at combat support hospitals. Comprehensive ophthalmologists can practice damage control ophthalmology by managing open globe injuries and stabilizing the eye. It is standard of care to close an open globe within 24 hours to decrease the risk for endophthalmitis and other complications, and if this is not possible due to lack of air superiority, then ophthalmologists need to move closer to the patients.
As ophthalmologists, we do a lot of mission trips and humanitarian work. In view of those missions, we teach residents how to operate outside of their comfort zone, in an austere and decentralized environment with basic instrumentation. We have learned that we can close an open globe without an operating microscope, using a flashlight, loupes and sutures.
Retrobulbar hemorrhage, chemical injuries, hyphema, open globe injuries, severe injuries that require enucleation — most of those can be taken care of by a comprehensive ophthalmologist, at least initially, and then be further managed by oculoplastic and cornea specialists at a later stage. Retina is the most critical issue. Studies have shown that early repair of traumatic retinal detachments results in better outcomes, and this would be an argument for pushing retina specialists closer to the front. However, vitreoretinal surgery requires a certain level of equipment, and no company is currently producing a small, compact vitrectomy platform. It is a major issue, both from a military and a humanitarian perspective, which limits our ability to decentralize the management of retinal injuries.
Grant A. Justin, MD, is with Uniformed Services University of the Health Sciences in Bethesda, Maryland, and Walter Reed National Military Medical Center in Bethesda, Maryland.
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