Ocular War Injuries of the Iraqi Insurgency,
January–September 2004
Thomas H. Mader, MD, COL (R),1 Robert D. Carroll, MD, LTC,2 Clifton S. Slade, MD, LTC,3
Roger K. George, MD, LTC,4 J. Phillip Ritchey, MD, LTC (R),5 S. Page Neville, CRNA, LTC6
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. Ophthalmology 2006;
113:97–104 © 2006 by the American Academy of Ophthalmology.
After the end of the ground offensive against Iraq in 2003,
the United States and its coalition allies have fought a
difficult campaign against well-armed insurgents. This conflict has produced a large number of casualties among U.S.
military personnel, coalition forces, enemy combatants, and
Iraqi civilians. During the first 8 months of 2004, the period
our report covers, American forces suffered over 4000
wounded and 500 soldiers killed in Iraq. In April 2004
alone, over 1200 Americans were wounded. During this
same 8-month time frame, 207 patients with severe ocular
and ocular adnexal injuries, from multiple nationalities,
were treated by American military ophthalmologists in Iraq.
The purpose of this article is to present and discuss these
injuries.
Throughout the duration of the insurgency, the enemy
has effectively used conventional weapons such as mortars,
rockets, sniper rifles, and automatic weapons. However, our
data suggest that improvised explosive devices (IEDs)
caused devastating ocular and ocular adnexal injuries and
have become a major source of ocular morbidity in this
costly conflict. Also, gunshot wounds produced a relatively
high number of ocular injuries relative to recent conflicts.
More consistent use of ballistic protective lenses would
have prevented some but not all of the injuries we report.
Originally received: February 14, 2005.
Accepted: July 25, 2005.
Manuscript no. 2005-155.
1
Alaska Native Medical Center, Anchorage, Alaska.
2
General Leonard Wood Army Hospital, Fort Leonard Wood, Missouri.
3
Evans Army Community Hospital, Fort Carson, Colorado.
4
Madigan Army Medical Center, Tacoma, Washington.
5
New Horizons Surgical Eye Center, Fayetteville, North Carolina.
6
Conway Medical Center, Conway, South Carolina.
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.
Reprint requests to Thomas H. Mader, MD, Department of Ophthalmology, Alaska Native Medical Center, 4315 Diplomacy Drive, Anchorage,
AK 99508.
Materials and Methods
© 2006 by the American Academy of Ophthalmology
Published by Elsevier Inc.
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 adnexal injuries.
All patients were examined and treated by the 1967th Surgical Eye
Team, 31st CSH, in Baghdad, Iraq. The U.S. Army eye surgeons
comprising this team were the only military ophthalmologists in
Iraq during the time of our study. Our CSH was located in a
preexisting hospital building known to the Iraqis as the Ibn Sina
Hospital, located within the Green Zone of Baghdad. This location
was the major U.S. military trauma hospital for central Iraq and the
ISSN 0161-6420/06/$–see front matter
doi:10.1016/j.ophtha.2005.07.018
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Ophthalmology Volume 113, Number 1, January 2006
referral center for all serious ocular, maxillofacial, and intracranial
injuries that occurred in the Iraq theater. Usually, those wounded
were transported by helicopter or ground ambulance to our hospital from a battalion aid station or directly from the geographic
location where the injury occurred. The mission of our eye team
was to provide emergency surgical treatment to patients with acute
ocular injuries. This usually involved globe-salvaging surgical
repair within a few hours of the injury. It should be noted that
many of these ocular injuries occurred during periods of heavy
casualties, which greatly limited operating room time and hospital
bed space. As soon as patients were medically stable after surgery
at our hospital, they were flown to Landstuhl Army Medical Center
in Germany for further care and to free our bed space for more
wounded. Therefore, most of the wounded were inpatients in our
hospital for ⬍24 hours after their injury; rarely were they inpatients in our CSH for ⬎72 hours. Because of the brief nature of
patient visits, information on endophthalmitis, retinal detachments,
follow-up surgeries, and documentation of final visual outcome
were not available to us.
We included all patients with severe ocular and/or ocular
adnexal injuries, including those with concurrent systemic injuries.
Thus, many of our patients had multiple and severe systemic
wounds in addition to their ocular injuries. Any ocular or ocular
adnexal injury we report was serious enough to have required
surgical admission based on the severity of this injury alone,
regardless of concurrent injuries. These injuries included open
globes, destroyed globes, intraocular foreign bodies, globe perforations, and massive orbital trauma. We used globe drawings and
photographs to document the location of full-thickness corneal/
scleral lacerations. An open-globe injury was defined as a fullthickness wound of the cornea, sclera, or both. We did not include
patients with relatively minor corneal foreign bodies removed at
the slit lamp, small hyphemas, or adnexal lacerations sutured in the
emergency room. However, these injuries were common, war
related, and sometimes incapacitating. Intraocular and ocular adnexal foreign bodies we report were confirmed by direct visualization or computed axial tomography. We counted only one injury
per ocular structure. Thus, if one patient had multiple corneal
lacerations, we counted only the largest laceration as one corneal
laceration. With respect to the cause of injury, we listed only those
causes that were documented positively by the patient or a reliable
witness. We included several patients with severe ocular and
ocular adnexal injuries who expired in our hospital before surgical
treatment as a result of concomitant injuries. We are aware that our
results are not totally inclusive. Other ocular injuries that occurred
during this period were treated at civilian institutions in Iraq and
are not included in this report. For the purposes of this report,
Figure 1. Types of ocular and adnexal injuries (eyes). Some eyes may have
had more than one type of injury.
98
Figure 2. Causes of all severe ocular and ocular adnexal injuries.
under the heading eye excisions we included eviscerations, enucleations, explosive globe ruptures, and contaminated orbits with
largely destroyed globes. Such grossly contaminated orbits, which
contained only globe remnants, were extensively debrided but not
closed.
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 injuries are listed in Figure 3. One hundred
sixteen patients suffered open-globe injuries. Of these open-globe
injuries, 16 were bilateral, for a total of 132 open globes. A total
of 35 eyes with open globes had intraocular foreign bodies, and 3
of these were enucleated. The age range for all those wounded was
4 to 53 years (mean, 26). Four were under the age of 18. One
hundred ninety-nine (95%) of the patients were male. One hundred
seventy patients (82%) were injured as a result of fragments from
munitions.
Figure 4 represents the relative percentages of those injured.
The causes of eye excisions are listed in Figure 5. The age of those
whose eyes were excised ranged from 4 to 53 years of age. Of 41
total eyes excised, 40 (98%) had corneal/scleral lacerations in
excess of 10 mm that extended past the insertion of the rectus
muscles. Seventeen of the excised eyes were completely disrupted,
with areas of the cornea or sclera avulsed as well as portions or all
of the lens, uvea, retina, and vitreous absent. Twelve of the excised
Figure 3. Causes of open globes.
Mader et al 䡠 Iraqi Insurgency—Ocular War Injuries
Figure 4. Distribution of the injured patients. ING/Pol ⫽ Iraqi national
guard/police.
eyes, in 10 patients, had burst violently after the impact of highvelocity projectiles, leaving only shreds of scleral tissue. Of these
10 patients with burst globes, 6 were injured by IEDs, 3 by
gunshots, and 1 by a rocket-propelled grenade (RPG). Two IED
patients suffered bilateral burst globes. The size of corneal/scleral
lacerations versus our repair success is presented in Figure 6. In
addition to the 41 eyes surgically excised, 5 eyes of 5 patients were
missing altogether after severe orbital trauma from large highvelocity fragments. Three of these 5 injuries were caused by IEDs
and 2 by RPGs. Twenty-one patients suffered severe ocular or
ocular adnexal injuries from gunshot wounds (23 eyes). American
soldiers alone accounted for 11 ocular gunshot injuries (46%).
Of 136 eyes (107 patients) injured by IEDs, 24 (18 %) were
excised primarily or had no light perception (NLP) vision. We
performed 2 bilateral primary eye excisions on 2 IED patients. Of
the 107 patients with ocular injuries from IEDs, 17 (16%) had
concomitant cerebral injuries requiring craniotomy, and all had
accompanying facial fractures, lacerations, or serious orthopedic
injuries. Eleven suffered serious burns of the ocular adnexa caused
by IEDs.
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,1–14
taken from the review by Wong et al.15 Additionally, analysis of over 5000 eye injuries during the Iran–Iraq War
documented over 4000 eyes severely injured from shrapnel,
blunt, or indirect trauma.16 During the Persian Gulf War, the
most recent Middle East conflict, 78% of the 198 serious
ocular and ocular adnexal injuries reported were caused by
fragments from munitions.14 In this 1991 conflict, the specific etiology of munitions injuries was known in only 37%
of those injured. By contrast, in our current study of the
Iraqi Insurgency we accurately identified the specific cause
of injury in 91% of all injuries from munitions. During the
allied advance in the Persian Gulf War, the open terrain of
Kuwait and southern Iraq led to easy target identification,
even from distant locations. Therefore, artillery, rockets,
bombs, and other long-range ordnance commonly were
used. In this setting, the victim was rarely able to detect the
explosive device until it impacted nearby. This scenario
completely differed during the Iraqi Insurgency, in which
there were no front lines and most attacks took place at
relatively close range, frequently in an urban setting and
usually in the presence of witnesses. This was particularly
true in ambushes, RPG attacks, mortar attacks, and IED
incidents.
Improvised explosive devices, which have been used effectively by the enemy during this conflict, caused devastating
ocular and ocular adnexal damage. The term improvised
explosive device covers a wide spectrum of remotely controlled explosive devices that were used as antipersonnel
weapons. These explosive devices commonly included
scavenged high-explosive artillery rounds, mortar rounds,
and plastic explosives. Such devices were placed in cars,
buildings, trees, and under overpasses, or simply buried
beside the road. In April 2004 alone, as many as 1000
homemade bomb attacks were attempted in Iraq. These
devices caused disastrous injuries, as evidenced by the fact
that 6 of the 107 IED patients with eye injuries we report
died of their injuries in the hospital before they could even
be brought to the operating room for surgical intervention.
Seventeen had intracranial injuries requiring craniotomy, 24
IED-injured eyes required primary excision, and 3 additional eyes were completely blown away, leaving no ocular
remnants whatsoever. The ocular injuries created by IEDs
commonly had avulsed portions of sclera or cornea, and the
wound edges were extremely ragged and difficult to repair.
Because these explosive devices were frequently buried
beside the road, secondary projectiles such as rocks and dirt
commonly complicated their surgical management. Thus,
the wounds created by IEDs were hideous and nearly always grossly contaminated by large amounts of mudlike
debris as well as stones, glass, wood, metal, plastic, or
fiberglass (Fig 7). The presence of multiple foreign bodies
necessitated meticulous particle removal and extensive surgical debridement. The mudlike substance, presumably a
mixture of dirt and body fluids, was tightly packed and
difficult to remove. Frequently, it continued to ooze from
the wounds days later, even after repeated washings. Later
Figure 5. Causes of injuries resulting in loss of the eye.
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Ophthalmology Volume 113, Number 1, January 2006
Figure 6. Surgical outcome of open globes based on laceration size.
in the conflict, insurgents effectively used IEDs composed
of jellied gasoline, which caused extensive burns, often
involving the face and ocular adnexal areas.
Most of those injured by IEDs were drivers or passengers
in vehicles that were usually parts of convoys. The military
reacted to this IED threat with several countermeasures that
met with only marginal success. Although ballistic protective eyewear was strongly recommended for use by all
soldiers and, especially, those in convoys, only 28 (26%) of
the 107 IED patients we report were using protective lenses
at the time they were injured. Unfortunately, due to the
extremely destructive nature of the IEDs, many soldiers
Table 1. Eye Injuries in Twentieth Century Warfare: Etiology of Eye Injuries (%)
War
World War I*
World War II
Korean
Arab–Israeli
Yom Kippur
Vietnam
Lebanon
Desert Storm
Current study
Artillery and
Tank Shell
Fragments
Grenades
39.3
51.8
70.6
36.8
46.7
31.3
16.3
57.9
56.8
49.0
62.3
85.9
61.9
65.5
56.8
9.0
—
11.7
—
11.5
11.1
25.0
63.5
5.0
7.1
11.0
3.3
4.2
4.3
3.2
2.5
2.0
Bullets
Mines and
Booby
Traps
Aerial
Bombs
Noncombat
Others
Sample
Size
Reference
60.0
27.4
16.9
6.8
4.7
11.3
12.1
11.3
7.7
4.5
8.9
4.2
5.5
9.7
0.0
10.0
—
—
0
32.1
24.4
12.3
6.8
8
12.7
12
13.1
4.2
16
6.5
13.1
51.0†††
—
9.0
12.5
7.0
2.0
5.3
0.0
—
—
—
4.8
—
3.7
—
1.8
9.0
—
—
—
2.6
—
—
—
6.7
—
—
7.3
—
8.3
—
22.5
11.0
—
0.1
—
3.2
10.6
12.8
1.2
11.0
15.6
23.5
—
1.4
0.3
15.1
3.3
11.0
165
698
—
585
440
301
382
300
—
—
140
—
163
—
160
207
Shimkin (1940)†
Morax and Moreau (1916)‡
Parsons (1941)§
Dansey-Browning (1944)储
Zorab (1945)¶
Scott and Michaelson (1946)#
Sommerville-Large (1946)**
Bellows (1947)††
Lada and Reister (1975)‡‡
Treister (1969)§§
Treister (1969)§§
Belkin (1983)储储
Hornblass (1981)¶¶
Belkin et al (1984)##
Mader et al (1993)***
Mader et al (2005)
Parts of this table were reprinted from: Wong TY, Seet MG, Ang CL. Eye injuries in twentieth century warfare: a historical perspective. Surv Ophthalmol
1997;41:433–59. Permission pending.
*Excludes injuries from chemical weapons.
†
Shimkin NI. Ophthalmic injuries in war. Br J Ophthalmol 1940;24:265– 85.
‡
Morax V, Moreau F. Etiologie des blessures oculaires par projectiles de guerre. Ann Oculistique 1916;153:321–32.
§
Parsons J. Protection of the eyes from war injuries. Trans Ophthalmol Soc U K 1941;61:157–78.
储
Dansey-Browning GC. The value of ophthalmic treatment in the field. Br J Ophthalmol 1944;28:87–97.
¶
Zorab EC. War surgery of the eye in forward areas. Br J Ophthalmol 1945;29:579 –93.
#
Scott GI, Michaelson IC. An analysis and follow-up of 301 cases of battle casualty injury to the eyes. Br J Ophthalmol 1946;30:42–55.
**Sommerville-Large LB. Ocular casualties in the Burma campaign. Trans Ophthalmol Soc U K 1946;66:647– 60.
††
Bellows JG. Observations on 300 consecutive cases of ocular war injuries. Am J Ophthalmol 1947;30:309 –23.
‡‡
Lada J, Reister FA, eds. Medical Statistics in World War II. Washington: Office of the Surgeon General, Department of the Army; 1975:330 –1, 387–9.
§§
Treister G. Ocular casualties in the Six-Day War. Am J Ophthalmol 1969;68:669 –75.
储储
Belkin M. Ocular injuries in the Yom Kippur War. J Ocul Therap Surg 1983;2:40 –9.
¶¶
Hornblass A. Eye injuries in the military. Int Ophthalmol Clin 1981;21(4):121–38.
##
Belkin M, Treister G, Dotan S. Eye injuries and ocular protection in the Lebanon War, 1982. Isr J Med Sci 1984;20:333– 8.
***Mader TH, Aragones JV, Chandler AC, et al. Ocular and ocular adnexal injuries treated by United States military ophthalmologists during operations
Desert Shield and Desert Storm. Ophthalmology 1993;100:1462–7.
†††
Includes injuries from improvised explosive devices.
100
Mader et al 䡠 Iraqi Insurgency—Ocular War Injuries
suffered serious ocular and even fatal injuries while using
ballistic protective eyewear, ceramic body armor, and Kevlar (DuPont, Wilmington, DE) helmets. As the insurrection
progressed and the dangers from IEDs became apparent,
some vehicles were fitted with factory-made ballistic protective panels and glass for protection. However, despite a
major effort by the U.S. military, only a minority of military
vehicles in the Iraq theater actually were equipped with such
protective devices. For example, of approximately 15 000
high-mobility multipurpose wheeled vehicles in Iraq in
early May 2004, only 2750 (18%) had factory-made armor.17 Few, if any, transport vehicles were equipped with
factory-made armor. Therefore, many soldiers were forced
to use individual initiative to construct their own protective
bolt-on hardware from scrap metal, flak vests, sandbags held
in place with plywood sheets, or other protective material. This
jury-rigged construction activity created a unique fleet of
Mad Max-style mobiles that were unsightly by military
standards but at least offered some protection against the
fragments produced by IEDs (Fig 8).
Gunshot wounds accounted for 11% of the total injuries
we report, which contrasts with previous conflicts. The
reported incidence of ocular bullet injuries, as documented
in previous wars, is summarized in Table 1. Gunshot
wounds during the Iraqi Insurgency often were suffered
during assaults, ambushes, and sniper attacks. We hypothesize that the relatively high number of ocular gunshot
wounds we report may be explained by one or more of 3
mechanisms:
1. Because every American soldier was required to
wear a Kevlar helmet as well as body armor, the
face, neck, and eyes were relatively vulnerable to
Figure 7. Multiple orbital foreign bodies from an improvised explosive
device.
enemy riflemen and undoubtedly sought out as targets. Of the 21 gunshot wounds we report, 13 were
associated with neck, face, or intracranial injury.
2. In Coalition troops, the protection offered by the
ceramic protective vests and Kevlar helmets may
have prevented concomitant head and chest wounds
that might have been lethal in previous conflicts.
3. Both the close proximity and the high quality of the
medical evacuation and treatment system were
conducive to the successful resuscitation of badly
wounded patients of any nationality. Definitive
emergent medical and surgical care in the form of a
forward surgical team or, more commonly, a CSH
was frequently available within just a few minutes’
travel time by helicopter or ground ambulance from
the place of injury. This led to a scenario where
patients with severe facial and other injuries lived to
obtain surgical care by an ophthalmologist.
Although insurgents possessed a variety of indirect fire
weapons, 60- and 82-mm mortars were probably the most
commonly used. The 60-mm mortar has a range of about
1500 m and can be assembled and carried by one person.
The 82-mm mortar has a range of approximately 3000 m
and requires a crew of 3 to 5 personnel for efficient assembly, transport, and firing. Both mortars fire high-explosive
rounds that explode on impact. Because of the high angle of
fire, mortars are effective weapons against targets on narrow
streets or alleys as well as troops in the open. To avoid
counterbattery fire by coalition troops, insurgents were
forced to drop the rounds in rapid succession and then
quickly disassemble and move the components. The enemy
sometimes purposely located their firing positions near inhabited areas to discourage counterfire. Although mortars
can be precisely aimed, many insurgent rounds were fired at
random into areas thought to contain troops or supplies.
Even heavily guarded areas such as the Green Zone were
regularly targeted. Thus, many of those wounded by mortars
were in relatively secure areas at the time of injury. Mortar
explosions invariably caused multifragment wounds. The
degree of penetration of the explosive fragments was related
largely to the distance from the blast. Although the zone of
maximum lethality is in the 5- to 12-m range, the unprotected eye can be penetrated easily by mortar fragments
ⱖ30 m from the point of round impact. As with IEDs,
secondary projectiles created by the explosion complicated
the surgical management of these patients.
The Soviet-designed RPG-7 was also a weapon commonly used by insurgents during the period covered by our
report. This hand-carried, muzzle-loaded, shoulder-fired
weapon is easy to use, lightweight (7 kg), rugged, and
readily hidden. It can fire a variety of antitank and antipersonnel grenades. It has an effective range of ⬎300 m against
moving targets and 500 m against stationary targets. Its
2.25-kg grenade explodes on impact and can be designed to
penetrate 12 inches of tank armor. During the insurgency, it
has been used effectively against buildings, high-mobility
multipurpose wheeled vehicles, transport trucks, and armored vehicles. The RPG is also capable of shooting down
helicopters. It does create a dangerous backblast, which
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Ophthalmology Volume 113, Number 1, January 2006
Figure 8. Examples of jury-rigged construction to protect vehicles (hillbilly armor).
Figure 9. Bilateral explosive globe ruptures from an improvised explosive
device. Photograph taken after bulb syringe irrigation and tagging of
conjunctival remnants.
limits its use in closed spaces. As with mortars, the RPG
causes multifragment wounds, and the spectrum of tissue
damage largely depends on the distance from the explosion
and the direction of the projectile on impact.
Sixteen percent of the total injuries we report necessitated primary eye excision. This eye excision rate contrasts
with the approximately 35% to 40% reported during WWII,8,18
25% during the Korean War,19 10% during the 1967 Arab–
Israeli War,10 20% during the Vietnam conflict,12,20 14%
during the Lebanon war of 1982,21 18% during the Persian
Gulf War,14 and 13% during the war in Croatia, Bosnia, and
Herzegovina.22 The outcome for those eyes with perforating
injuries was more ominous. In our report, 31% of perforated
globes had to be excised, as compared with 50% for World
War II,8 39% and 70% for Vietnam,12,20 29% for the 1967
Arab–Israeli War,10 and 36% for the Persian Gulf War.14
We attempted to repair every seeing eye even if it seemed to
have minimal visual potential. Thus the prognosis, even in
many surgically repaired eyes, was quite poor. We removed
only eyes that were functionally destroyed, with no possibility of visual or cosmetic salvage, so our removal rate
Figure 10. Multiple minute foreign bodies from an improvised explosive device.
102
Mader et al 䡠 Iraqi Insurgency—Ocular War Injuries
attests to the severity of the ocular wounds encountered.
Specifically, of the 41 eyes we removed, 40 (98%) had
lacerations ⬎10 mm in length that extended past the insertions of the extraocular muscles, and many had multiple
large lacerations. Seventeen of the 41 eyes were totally
disrupted, and 12 had burst on impact from high-velocity
projectiles. Freitag et al’s study of enucleated eyes from
traumatically ruptured globes documented that ⬎70% had
globe lacerations longer than 10 mm.23 Our findings were
also consistent with those of Gilbert et al, who observed that
90% of eyes with wounds extending past the rectus muscles
required enucleation.24 In our study, all globe lacerations
⬎15 mm in length resulted in NLP vision. During the
Persian Gulf War, of 35 eyes enucleated 31 had corneal/
scleral lacerations of ⬎15 mm.14 As demonstrated in Figure
6, the larger corneal/scleral lacerations were more difficult
to repair and more likely to cause NLP vision and require
removal. Several studies have documented that increasing
length and the more posterior location of full-thickness
lacerations correlated with a poorer visual prognosis.24 –29
An additional 5 eyes, not included in those surgically excised, were blown away completely, such that no ocular
tissue remained in what was left of the orbit.
We documented 12 eyes with explosive globe ruptures, 8
of which were caused by IEDs. The mechanism of such
injuries was well described by Lister in 1918 to explain
severe ocular trauma suffered by World War I combatants.30 This unique form of injury has a different mechanism, clinical appearance, prognosis, and management than
other types of open-globe injuries. An explosive rupture
differs completely from a rupture produced by relatively
slow blunt trauma, such as a fist, which tends to cause a
single arcuate rupture at the limbus or under the extraocular
muscle insertions, leaving the globe largely intact. In contrast, explosive ocular ruptures occur when fragment or
bullet projectiles strike the eye from any direction at high
speed. The explosive pressure produced splits the sclera to
pieces, leaving only shredded remnants of ocular tissue that
can be difficult to identify. We found that such trauma
produced completely destroyed eyes, with no visual potential, and management always consisted of primary excision.
Tissue identification and salvage were made even more
difficult when the projectile had first ripped through parts of
the face or brain, thus prolapsing nonocular tissue into the
orbit before destroying the globe. Figure 9 demonstrates the
severity of one such bilateral IED injury, which largely
involved only the globes. In this case, each eye was split
into a petal-like configuration, as originally described by
Lister.30 This 27-year-old sergeant was wearing a Kevlar
helmet and Wiley X polycarbonate lenses (Protective Optics, Inc., Livermore, CA) while riding in an armored personnel carrier. He was sitting in a top hatch with his upper
body exposed above the armor plate. He ducked his head to
avoid an RPG and quickly sat upright. At that instant, an
IED composed of a mortar round placed at eye level in a
tree was exploded by remote control 2 to 3 m from his face.
Several large fragments from the blast struck and ruptured
both eyes in such an explosive fashion that his intraocular
contents were expulsed onto his face and clothing. He had
numerous other bodily injuries. His example serves to illus-
trate the unique nature of this severe form of ocular war
injury and the difficulty of effective ocular protection when
soldiers are in such close proximity to the explosive device.
Small flying fragments, which might be stopped or impeded by a helmet or a flak vest, may penetrate the eye even
from great distances.8,10,19,31–33 Numerous reports of ocular
trauma have hypothesized that ballistic protective lenses
could have prevented many ocular injuries.10,12–14,33–36 Our
examination of the size of corneal and scleral wounds
during the Iraqi Insurgency seems to support this notion.
The size range of these lacerations was from 1 to 40 mm.
However, 56 eyes (42%) suffered lacerations that were ⱕ10
mm in length, which suggests that many of the small fragments responsible for these injuries would likely have been
stopped had ballistic protective eyewear been used (Fig 10).
Also, dozens of patients not included in our report and not
using ocular protection had minute superficial corneal foreign bodies removed at the slit lamp. This concept is further
supported by the fact that, of 116 patients with open-globe
injuries in our report, only 18 (14%) were wearing protective lenses at the time of injury. We witnessed a great
number of cases in which glasses were clearly shown to
protect eyes from the impact of particulate matter after
explosions. This information suggests that the U.S. military
should be much more aggressive in fielding mandatory eye
protection for all troops in this combat zone. Perhaps this
should include some form of polycarbonate face shield,
when practical, for those at very high risk. This is not to say
that currently available ballistic protective eyewear would
have prevented all of the ocular injuries we report. Such
eyewear could not have prevented ocular trauma resulting
from direct hits from high-velocity bullets, large munitions
fragments, or projectiles that may have entered the eye after
having first passed through other parts of the face. Also, the
close proximity to the full concussive force of any large
blast would likely negate the protection offered by standard
ballistic protective eyewear.
We found that a close working relationship between
maxillofacial surgery, neurosurgery, and ophthalmic surgery provided an effective environment for surgical management of head and neck injuries. The importance of this
concept is underscored by the fact that, of the 207 patients
with severe ocular and ocular adnexal injuries, 128 were
associated with coexisting face, intracranial, or neck injuries. Once a wounded patient was stable for transport, all
patients in Iraq with serious eye, head, or neck injuries were
transported by helicopter to the 31st CSH. Because many
patients were wounded in and around Baghdad, sometimes
very near the location of our hospital, we were in an ideal
geographic location to provide timely care for the wounded.
At this location, a head and neck surgical team composed of
neurosurgeons, maxillofacial surgeons, ophthalmic surgeons, and intrinsic anesthesia personnel was available. As
demonstrated in previous conflicts,12,19,37 this surgical team
concept, with routine access to computed axial tomography,
proved to enhance greatly the surgical capabilities of the
CSH.
In summary, we have reported all serious ocular and
ocular adnexal injuries that occurred during the Iraqi Insurgency from January 20 through September 12, 2004. The
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Ophthalmology Volume 113, Number 1, January 2006
more consistent use of ballistic protective eyewear would
have prevented some, but not all, of the injuries reported.
Improvised explosive devices were by far the leading cause
of severe ocular and ocular adnexal injuries, and we frequently found these extremely difficult to repair. We feel
that the head and neck team concept, as practiced during this
war, greatly enhanced our ability to provide timely highquality surgical care to severely wounded patients.
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