Terror-Related Open-globe Injuries: A 10-year Review

doi:10.1016/j.ajo.2004.11.009

American Journal of Ophthalmology

Volume 139, Issue 5, May 2005, Pages 937-939

This study was partly presented at 7th Congress of Balkan Military Medical Committee, October 6–10, 2002, Athens, Greece.

https://doi.org/10.1016/j.ajo.2004.11.009 Get rights and content

Purpose

To describe mechanisms and injury characteristics influencing visual outcomes in eyes with open-globe injuries sustained in terrorist acts.

Design

Retrospective, interventional case series.

Methods

The charts of 260 consecutive patients (285 eyes) who had open-globe injury caused by terrorist attack and admitted to the tertiary referral center for military in Turkey between March 1991 and April 2001 were reviewed, and 50 patients (56 eyes) with complete data were evaluated for predicting visual outcome according to the Ocular Trauma Classification System (OTCS).

Results

The mean age of patients was 22.6 years, and the mean follow-up was 5.8 months. Seventeen patients (6.54%) had traumatic amputation in the extremities. Forty-eight eyes (16.84%) were enucleated. Type A, grade V, zone III, and RAPD-positive injuries were associated with unfavorable visual outcome. Land mine and hand grenade injuries had the worst outcome.

Conclusions

In terror-related open-globe injuries, unusual presentations and devastating visual results are common, and OTCS seems to predict visual outcomes.

References (5)

K. Peleg et al.
Patterns of injury in hospitalized terrorist victims
Am J Emerg Med
(2003)
G. Sobacı et al.
Deadly weapon-related open-globe injuriesOutcome assessment by the Ocular Trauma Classification System
Am J Ophthalmol
(2000)

There are more references available in the full text version of this article.

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Hence CT scan becomes radiological investigation of choice in ocular trauma especially in open globe injury.12 In terrorist attack in Turkey between March 1991 and April 2001, forty-eight eyes (16.84%) with open globe injury were enucleated.13 Thach et al. study found that in Iraq war, 14.5% eyes were removed of which 6 patients required bilateral enucleation.7
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.
Closed-globe injuries of the ocular surface associated with combat blast exposure
2014, Ophthalmology
To describe closed-globe conjunctival and corneal injuries and endothelial cell abnormalities associated with blast exposure and their relationships to other closed-globe injuries and blast-event characteristics.
Observational cross-sectional study.
Veterans with a history of blast-related traumatic brain injury (TBI).
History and ocular examination, including slit-lamp biomicroscopy, gonioscopy, specular microscopy.
Type and location of blast injuries to the conjunctiva and cornea.
Ocular surface injuries were present in 25% (16 of 65) of blast-exposed veterans with TBI. Injuries included partial-thickness anterior stromal corneal scars (15 eyes), Descemet membrane ruptures (6 eyes), and conjunctival or corneal foreign bodies (7 eyes). Based on normative information from an age-matched comparison group, endothelial cell abnormalities were identified in 37% of participants. Eyes with ocular surface injury were more likely to have lower endothelial cell density, higher coefficient of variation of cell area, and lower percentage of hexagonal cells compared with eyes without injury. Presence of ocular surface injury or endothelial cell abnormalities was associated with elevated rates of other anterior and posterior segment injuries, as well as impairment of visual acuity. We found no relationship between ballistic eyewear use or severity level of TBI and presence of ocular surface injuries from blast.
Independent of TBI severity or use of protective eyewear, ocular surface injuries and endothelial cell abnormalities were found in significant numbers of veterans with blast-related brain injury. Descemet membrane ruptures from blast exposure were described. Ocular surface trauma was associated with other ocular injuries throughout the globe. Potential mechanisms for the types and locations of ocular injuries seen were discussed. Any corneal or conjunctival injury in a blast survivor should prompt a thorough ocular trauma examination, including gonioscopy and specular microscopy, with appropriate follow-up for associated injuries. Longitudinal studies are required to determine long-term visual outcomes after blast exposure.
Anti-EMP2 diabody blocks epithelial membrane protein 2 (EMP2) and FAK mediated collagen gel contraction in ARPE-19 cells
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A review of veterans who had suffered ocular trauma with intraocular foreign bodies in Iraq during the years 2003–2005 revealed PVR as the cause for poor vision in 21% of the patients (Colyer et al., 2007). Other studies have reported PVR as the cause for up to 38% of severe vision loss associated with combat or trauma (Bonnet and Fleury, 1991; Sobaci et al., 2005, 2000). Surgical therapy for PVR is not always successful.
Epithelial membrane protein 2 (EMP2) regulates collagen gel contraction by the retinal pigment epithelium cell line ARPE-19 by modulating FAK activation. Collagen gel contraction is one in vitro model for an aberrant wound healing response, proliferative vitreoretinopathy (PVR), which occurs as a complication of severe ocular trauma. The purpose of this study is to investigate whether EMP2 specific recombinant diabody decreases activation of FAK and collagen gel contraction in ARPE-19. Anti-EMP2 diabody was recombinantly constructed from a human phage library-derived clone selected for reactivity against an extracellular domain of human EMP2. ARPE-19 cells were exposed to an anti-EMP2 or control diabody, and toxicity, adhesion, and migration were assessed respectively through toluidine blue exclusion, binding to collagen type 1, and a migration assay. Collagen gel contraction was assessed using an in vitro assay. FAK activation was evaluated using Western blot. Exposure to anti-EMP2 diabody, resulted in a 75% reduction in EMP2 protein levels at 4 h. No significant toxicity was observed with anti-EMP2 diabody at levels that maximally reduced EMP2. Anti-EMP2 diabody, but not control diabody, significantly reduced collagen gel contraction (p < 0.001), without changes in adhesion or migration. Concordantly, anti-EMP2 diabody as compared to a control diabody reduced collagen stimulated FAK activation (p = 0.01). Anti-EMP2 diabody decreases EMP2 protein levels, FAK activation, and collagen gel contraction by ARPE-19 cells without an adverse effect on cell survival. Modulation of EMP2 using anti-EMP2 diabody could be a new approach for targeting EMP2 and pathologic consequences associated with EMP2.
Gun-related eye injuries: A primer
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Culture-proven endophthalmitis occurs in 8.5% to 11.9% of deadly weapon-related globe ruptures.68,76 Associations with the development of endophthalmitis include disruption of the crystalline lens and higher grades of injury according to the Ocular Trauma Classification Group system.76 Sympathetic ophthalmia is another frequently discussed phenomenon in the setting of open globe injury, although the condition itself is thought to develop in less than one percent of cases.
Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.
Risk factors for globe removal after open-globe injury in agricultural regions
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Brief reportTerror-Related Open-globe Injuries: A 10-year Review

Purpose

Design

Methods

Results

Conclusions

Am J Emerg Med

Am J Ophthalmol

Brief report
Terror-Related Open-globe Injuries: A 10-year Review