Ocular War Injuries of the Iraqi Insurgency, January–September 2004

doi:10.1016/j.ophtha.2005.07.018

Ophthalmology

Volume 113, Issue 1, January 2006, Pages 97-104

https://doi.org/10.1016/j.ophtha.2005.07.018 Get rights and content

Purpose

To document the types and causes of ocular and ocular adnexal injuries treated by United States Army ophthalmologists serving in Iraq during the Iraqi Insurgency.

Design

Prospective hospital-based observational analysis of injuries.

Participants

All coalition troops, enemy prisoners of war, and civilians with severe ocular and ocular adnexal injuries.

Methods

We prospectively examined severe ocular and ocular adnexal injuries that were treated at the 31st Combat Support Hospital during the portion of the Iraqi Insurgency that took place from January 20 through September 12, 2004.

Main Outcome Measures

Incidences and characteristics of ocular and ocular adnexal injuries.

Results

During the time observed, 207 patients suffered severe ocular or ocular adnexal injuries, including 132 open globes. Blast fragmentation from munitions caused 82% of all injuries. The most common single cause of injury was the improvised explosive device (IED), which caused 51% of all injuries. Of 41 eye excisions, 24 were caused by IEDs.

Conclusions

During the portion of the Iraqi Insurgency covered in our report, munitions fragments were the most common cause of ocular and ocular adnexal injuries. The single most common cause of injury was the IED, which produced devastating ocular and ocular adnexal injuries. The authors’ findings indicate that polycarbonate ballistic eyewear could have prevented many, but not all, of the ocular injuries we report.

Section snippets

Materials and Methods

We prospectively examined severe ocular and ocular adnexal injuries treated at the 31st Combat Support Hospital (CSH) during the portion of the Iraqi Insurgency that took place from January 20 through September 12, 2004. This was the time in which the authors served in Iraq. We did not include data from the land invasion of Iraq. The variables studied were type of injury, cause of injury, size of full-thickness globe lacerations, distribution of those injured, and associated ocular and ocular

Results

From January 20 through September 12, 2004, there were 2794 total patients (including medical and psychiatric admissions) and 2077 surgical patients admitted to the 31st CSH. Of these, 207 (10% of all surgical admissions) suffered severe ocular or ocular adnexal injuries. There were 44 bilateral ocular injuries, for a total of 251 severe injuries.

The types of ocular and ocular adnexal injuries are listed in Figure 1. The causes of these injuries are listed in Figure 2. The causes of open-globe

Discussion

In our current study, 82% of all severe ocular and ocular adnexal injuries were caused by blast fragments from munitions, and 80% of eye excisions resulted from some type of fragmentation injury. Although there is a wide range of exact etiologies and methods of analysis, the percentage of ocular wounds caused by fragments has been remarkably consistent in previous conflicts. Table 1 lists a summary of the etiologies of ocular war injuries since World War I,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,

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Ocular biomechanics during improvised explosive device blast: A computational study using eye-specific models
2022, Injury
Eye injuries comprise 10–13% of civilian improvised explosive device (IED) injuries. The bomb blast wave induces a normal and shear forces on the tissues, causing a large acute IOP elevation. This study calculated the biomechanical stresses and strains in the eye due to IED explosion via eye-specific fluid-structure interaction (FSI) models.
Blast occurred at 2, 3, and 4 m from the front and side of the victim and the weights of the IED were 1 and 2 kg. The ground was covered with the deformable soil to mimic the realistic IED explosion condition and reflect the blast wave.
The IOP elevation of ∼6,000–48,000 mmHg was observed in the eyes while the highest IOP was occurred with the IED weight and distance of 2 kg and 2 m (front) and the lowest was occurred with the IED weight and distance of 1 kg and 4 m (side). Our findings suggest the importance of the victim location and orientation concerning the blast wave when it comes to ocular injury assessment. IOP elevation of ∼2900 and ∼2700 mmHg were observed in ∼1.6 ms after the blast for the IEDS weight of 2 kg and a victim distance of 2 m in front and side blasts, respectively, in consistence with the literature. Nonetheless, IOPs were considerably higher after ∼1.6 ms due to the merging of the bomb blast wave and its reflection off the ground.
The stresses and strains were highest for the frontal blast. Both side and frontal blasts caused higher stresses and strains at the rectus muscle insertions where the sclera is thinnest and prone to rupture. Blast angle has no considerable role in the resultant IOP. Front blast with a heavier IED resulted a higher stresses and deformations in the eye connective tissues compared to the side blast.
Ocular biomechanics due to ground blast reinforcement
2021, Computer Methods and Programs in Biomedicine
Bomb blast injuries exerts a shearing force on the air-tissue interfaces, causing devastating ocular injury from the blast wave. Improvised explosive devices (IEDs) are usually placed at different heights from the ground to induce more severe injury through ground blast reinforcement (GBR). However, there is still a lack of knowledge of the role of GBR and IED height from the ground on ocular biomechanics, and how they can affect the intraocular pressure (IOP) in the eye. This study aimed to estimate the IOP due to frontal IED explosion at different heights from the ground using a fluid-structure interaction model with and without GBR effects.
A 2 kg IED was placed within 5 m of the victim at 5 different heights from the ground, including 0, 0.42, 0.85, 1.27, and 1.70 m. Two different blast formulations were used to simulate the IED explosion: (a) spherical airburst, with no amplification of the initial shock wave due to interaction with the ground-surface, and (b) hemispherical surface-burst, where the initial blast wave is immediately reflected and reinforced by the ground (GBR).
Results revealed that the blast wave due to GBR reaches to the skull prior to the IED blast itself. The GBR also reached to the skull ∼ 0.6 ms earlier when the IED was on the ground compared to the height of 1.70 m. The highest and lowest IOPs of ∼ 17,000 and ∼ 15,000 mmHg were observed at the IED heights of 1.70 and 0 m from the ground considering GBR. However, when the role of the GBR is ignored, IOP of ∼ 9,000 mmHg was observed regardless of the IED height from the ground. The deformation in the apex of the cornea was higher when considering the GBR (∼ 0.75 cm) versus no GBR (∼ 0.65 cm). Considering GBR led to higher stresses and strains in the sclera.
When the role of GBR was ignored, the results showed similar patterns and magnitudes of stresses and deformations in the skull and eye regardless of the height of the IED from the ground, which was not the case when GBR was considered. The findings of this study suggest the critical role of GBR in ocular blast simulations.
Ocular trauma in counter insurgency and proxy war environment: Epidemiological study, 1992–2004
2021, Medical Journal Armed Forces India
Citation Excerpt :
They are mainly targeted to harm and disable the enemy, thereby increasing the morbidity rather than mortality. The present study showed that 19% cases were owing to IED blast, whereas it was the cause in 51% of all injuries in Mader et al.4 series and 58.3% in study by Gundogan et al.6 This clearly indicates the weapons of preference by the militant in two regions and during different time period, that is, Kashmir and Iraq, respectively. The cases owing to IED blast increased after year 1998 due to technical skill acquired by militants by then leading to its more and more use to cause large number of casualties as compared with gun battle or grenades.
To analyze the epidemiology of hospitalized ocular injuries occurring in counter insurgency and proxy war environment in a forward area of northern India over a period of 13 years.
Retrospective observational study of medical records was performed of 458 patients with ocular injuries primarily treated at zonal referral hospital of Indian Army between January 1992 and December 2004.
A total of 559 eyes with ocular injuries were studied. The average age of the victims was 30 years. In 77% cases, injuries were sustained by army personnel and remaining by paramilitary forces. Of all cases, 86.5% cases were due to combat-related (militant action), of which 93.9% cases were caused by splinters from munitions. Among the eyes injured due to militant action, 60.36% were open globe injuries, 31.19% were closed globe injuries and 8.45% were isolated adnexal injuries. Among the eyes injured, 76.33% of the eyes with open globe injuries owing to militant action had perforating injuries, whereas in closed globe injuries, 47.74% eyes had corneal foreign body. Among eyes with open globe injuries, Corneo-scleral, scleral and corneal lacerations were seen in 45%, 28% and 27% eyes respectively. 15.75% of eyes with ocular injuries underwent eviscerations.
The study reveals that splinter eye injuries from munitions were the most common cause of ocular morbidity in counter insurgency and proxy war. Implementation of use of protective glasses by the personnel deployed in such hostile environment and strict compliance of preventive measures would be effective in saving eyes and also medical and economic resources.
War-related ocular injuries in Damascus during the Syrian Crisis
2021, Injury
Citation Excerpt :
Among civilians, males are more susceptible to ocular injuries since they tend to leave their homes more than females [25]. Next, the mean age of our sample was 24.9 years, which was consistent with similar studies including that conducted by Özal et al. [6,18–20,26]. Moreover, 36% of our population were minors, which partially explains the high percentage of patients that had intermediate or primary education (51%), were unskilled or unemployed (62%), and were injured at home (37%).
. Ocular injuries constitute a major cause of visual morbidity, and they have a significant socioeconomic impact worldwide. We aimed to document the types and causes of Syrian War related ocular injuries in Damascus, Syria.
. Medical records were retrospectively reviewed to evaluate all patients in Al-Mouwasat University Hospital and Damascus Hospital, whose ocular injuries were caused by war-related activities during the period extending between January of 2016 and December 2017.
. 150 eye injuries in 127 patients were reviewed, in which 46 (31%) were bilateral and 87 (58%) were open globe injuries. The leading cause of the observed ocular injuries was improvised explosive devices (IED) [37 eyes (41%)]. The majority of patients presented with an initial best corrected visual acuity (BCVA) of “light perception” (LP) to “hand movement” (HM) [51 eyes (34%)]. Information on the final BCVA was available for 69 injured eyes only, and it was “no light perception” (NLP) in 20 eyes (29%).
. Explosive weaponry is the main culprit in most war-related ocular injuries in Syria. The high incidence of open globe injuries caused many of the cases to be severe in nature. Education on the precautionary measures that protect the eyes such as the use of combat eye protection during wartimes ought to be enforced, so that future ocular injuries can be prevented.
Ocular injuries incurred by Israeli defense forces during low-intensity conflicts
2021, Injury
To describe ocular injuries sustained by Israeli Defense Forces (IDF) soldiers during low-intensity conflicts from 1998 to 2017, and to evaluate the use of protective eyewear.
Retrospective analysis of data retrieved from two tertiary Israeli medical centers and the military trauma registry. The analysis included all IDF soldiers with ocular injuries who were referred to these centers between 1998 and 2017. Data on injury type, the use of protective eyewear, and interventions were retrieved and analyzed. Additional data regarding the use of protective eyewear and ocular injuries in 108 patients with head and neck injuries in one operation was analyzed.
A total of 126 soldiers, all males, mean age 22 (SD 5.3) years, sustained ocular injuries during low-intensity conflicts and treated at one of the two participating medical centers. Blast was the most common type of injury (n = 70/126, 56%), followed by shrapnel (n = 37/126, 29%) and gunshot wound (n = 12/126, 9%). The Birmingham Eye Trauma Terminology System (BETTS) injury pattern disclosed lamellar laceration (n = 34/126, 27%), intraocular foreign body (n = 27/126, 21%), penetrating (n = 10/126, 8%), and perforating (n = 7/126, 6%) injuries. Average VA improved from 20/140 at presentation to 20/60 after surgical or conservative intervention, the median VA improved from 20/40 to 20/30 (P < 0.001). Forty-nine patients (49/126, 39%) had poor visual outcome. The mean follow-up lasted 22 (SD 31) months. The use of protective eyewear was correlated with better initial VA(20/30 vs 20/217, P = 0.07). Among 108 patients with head and neck injuries, there was a higher rate of ocular injuries in the group of patients who did not use protective eyewear (n = 26/73, 36% vs n = 4/35, 11%, P = 0.016).
Ocular injuries are common occurrences in low-intensity conflicts. The use of protective eyewear significantly reduces these injuries and should be mandatory.
III, prognostic
Finite element modeling of the eyeglass-related traumatic ocular injuries due to high explosive detonation
2020, Engineering Failure Analysis
Traumatic ocular injury due to glass shards is a challenging issue that might occur due to automobile crashes, airbag expansions, military operations, sports, etc. Eyeglass breakage due to a high explosive detonation, shoot a group of randomly sized shards into the eye at a dramatically high speed along with a primary blast wave (PBW) propagation which might invoke extensive scarring and damage to the internal ocular tissues following by permanent visual impairment. Understanding the mechanisms of this injury and its following complications in each component of the eye might not be achievable experimentally unless using numerical simulations, i.e., finite element method (FEM). Although our group performed two separate studies to investigate the ocular injury because of glass shards and high explosive detonation, it would be interesting to understand how the combination of these two together damage the components of the eye. Therefore, this study was aimed to compute the stresses and deformations in the eye components, including the cornea, aqueous body, iris, ciliary body, lens, vitreous body, retina, sclera, optic nerve, orbital muscle, and orbital fat (intraconal and extraconal), attributed to glass shards breaking down because of PBW induced by trinitrotoluene (TNT) explosion. A three-dimensional (3D) FE model of the eye globe was established using CT/MRI data and subjected to glass shards at a high speed resulted from a TNT explosion. The injury to the components of the eye and the skull were calculated right after the blast wave and right after the glass shards reach to the eye/skull to reveal the role of each factor separately. The highest amount of stresses/injuries occurred in the sclera, which might trigger eye globe rupture. These findings may contribute in understanding of the mechanisms of ocular injury aiding in the management of the eyeglass-related traumatic injuries due to explosion, car accident injuries and or combat injuries.

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Manuscript no. 2005-155.

The authors have no financial interest in any product, drug, instrument, or equipment discussed in the article.

The opinions expressed in the article are solely those of the authors and do not represent the views or official policy of the United States Army or the Department of Defense.

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Original ArticleOcular War Injuries of the Iraqi Insurgency, January–September 2004

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Surv Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

J Oral Maxillofac Surg

Ophthalmic injuries in war

Br J Ophthalmol

Etiologie des blessures oculaires par projectiles de guerre

Ann Oculistique

Protection of the eyes from war injuries

Trans Ophthalmol Soc U K

The value of ophthalmic treatment in the field

Br J Ophthalmol

War surgery of the eye in forward areas

Br J Ophthalmol

An analysis and follow-up of 301 cases of battle casualty injury to the eyes

Br J Ophthalmol

Original Article
Ocular War Injuries of the Iraqi Insurgency, January–September 2004