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17

Lessons Learned

Chapter 2

LESSONS LEARNED

FRANCIS G. LA PIANA, MD*; AND THOMAS H. MADER, MD†

INTRODUCTION

EYE CARE IN THE THEATER OF OPERATIONSGeneral PrinciplesSpecific Principles

OPHTHALMIC CARE IN THE PERSIAN GULF WAREquipment and FacilitiesFrequency and Severity of Eye InjuriesMedical EvacuationInsights From the Persian Gulf War

SUMMARY

*Colonel, US Army (Ret); Ophthalmology Residency Program Director, Department of Ophthalmology, The Washington Hospital Center,Washington, DC 20010; and Professor of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda,Maryland 20814-4799; formerly, Consultant in Ophthalmology to The Surgeon General, US Army, and Ophthalmology Residency ProgramDirector, Ophthalmology Service, Walter Reed Army Medical Center, Washington, DC

†Colonel, US Army (Ret); Alaska Native Medical Center, Anchorage, Alaska 99508; formerly, Chief of Ophthalmology, Madigan Army Medi-cal Center, Tacoma, Washington

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Ophthalmic Care of the Combat Casualty

INTRODUCTION

This chapter summarizes some of the lessonslearned from experiences in the Vietnam War (F. G.La P.) and the Persian Gulf War (T. H. M.). Our com-bined expertise in military ophthalmology—boththe treatment of injured soldiers and the workingsof the military medical system—leads us to believethat some of the same difficulties that the US mili-tary medical establishment experienced early in ournation’s history continue to be repeated. Some ofthe hard-won lessons from our own experience andthose from previous wars, which should be remem-bered by current and future generations of militaryophthalmologists, include the following:

• Having experienced ophthalmologists atthe forward echelons will ensure that oursoldiers get the best possible initial and de-finitive care.

• Having a senior ophthalmologist in theatermay ensure that (a) the concerns of all eye-care professionals are heard and (b) train-ing of nonophthalmologists is accom-plished.

• Hands-on inspection of supplies prior todeployment is mandatory to ensure thatmodern and usable equipment is availableto treat the injured soldier.

If we do not learn from our predecessors, we willcontinue to make the same mistakes they did.

Allen Greenwood, MD (1866–1942), a prominentUS ophthalmologist, volunteered his services in theSpanish–American War, volunteered again to servein France during World War I, and became SeniorOphthalmic Consultant for the American Expedi-tionary Forces. At the end of that war, GeneralPershing cited him for exceptionally meritoriousand conspicuous services. Greenwood’s descriptionof hospital conditions in France in 1918 underscoresour first lesson, that experienced ophthalmologistsmust be deployed to forward echelons:

I want to take a minute to draw a word-picture ofan evacuation hospital in time of stress. During theheight of the Argonne offensive I went to the mostforward of the evacuation hospitals, at the tip ofthe forest, which had been opened only two days.It had been raining a week, was still raining whenI arrived, and the roads were a sea of mud. Thehospital was in an old chateau, with tents arrangedaround it, and practically every ambulance wheelwent up to the hub in the mud. The nurses and of-ficers were wearing rubber boots, and those that

were there to help out or to see how things weregoing wore overshoes. I entered the hospital atthree o’clock in the afternoon. Every ward wascrowded. Ambulances were coming at the rate ofone every two or three minutes. The officer whohad charge of the shock ward had four tent wardsfilled with shock cases. Among these were ten orfifteen men whose faces were partly destroyed. Iwish I had the gift of easy speech and the ability todraw word-pictures, so as to draw for you a realpicture of that hospital—the rain coming down intorrents, the sea of mud, the shock ward filled, alittle heater at the foot of each bed, with men look-ing at their last gasp, ambulances coming in everytwo or three minutes, and the drivers exhausted.About thirty miles away we had a special hospitalfor head cases, but it seemed a crime to ask the driv-ers and the patients to go the extra thirty miles toreach this eye hospital. This shows the necessity ofhaving a competent ophthalmic surgeon right at the spotto take care of such cases” [emphasis added].1

What was true and vitally important in WorldWar I remains even more so today, because—giventhe resources—today’s ophthalmic surgeon withsubspecialty expertise can salvage eyes that in pastwars were inevitably lost, and therefore can increasethe number of casualties returned to duty. AsSpalding and Sternberg commented in 1990:

The advent of microsurgery in the 1960’s, leadingto better closure of ocular lacerations, and the de-velopment of vitrectomy techniques in the 1970’s,allowing successful repair of posterior segmentwounds, have resulted in a dramatic improvementin the prognosis for patients with penetrating ocu-lar injuries.2

The objective of this chapter is to specify exactlywhat theater of operations eye care (TOEC) shouldbe and why. Its genesis lies in the preparation ofthe history of Army ophthalmology in the VietnamWar3 and of the history of eye armor development,4

in the review of reports of military ophthalmologistsfollowing World War I, World War II, the Korean War,and the Persian Gulf War, and in discussions withpresent and former military ophthalmologists of theArmy, Navy, and Air Force. A radical revision of eyecare provided at all four echelons within the the-ater of operations (TO) is required if the woundedare to receive optimal care.

The soldier who cannot see, cannot fight. Tinyfragments that produce minor if any disability whenimpacting elsewhere often produce incapacitatingvisual disability and, through sympathetic spasm

19

Lessons Learned

of the orbicularis oculi of the fellow uninjured eye,functional bilateral blindness. The incidence of eyeinjuries has increased from 0.5% in the AmericanCivil War to 9% in the Vietnam War mainly becauseof the increasing use of munitions that producemyriad, small, metallic and nonmetallic fragmentson detonation. Battlefield eye injuries frequentlycoexist with other serious and even life-threaten-ing injuries. Other threats to the eye include bluntforces (eg, tree branches, rifle butts and barrels),blown sand and dirt, flechettes, laser wavelengths,blistering agents, heat, and, in the future, probablymicrowaves and particle beams.

In Vietnam, a soldier struck in the eye in combathad a 50% chance of losing the eye.3 Only 25% ofthe Vietnam eye casualties studied by Tredici5 couldreturn to active duty, while 83% of all survivingwounded could do so.6 Eye injuries are expensivefor society at large as well as for the casualty, inthat these patients will have a permanent disabil-

ity and will need rehabilitation and job training.Polycarbonate eye armor (Ballistic Laser Protec-

tive Spectacles [BLPS] and Special ProtectiveEyewear Cylindrical Surface [SPECS]) has beendeveloped and improved over the last several de-cades. Studies have indicated that 2-mm-thick poly-carbonate will prevent almost all blunt-force inju-ries and 39% of injuries caused by missiles.7 Two ofthe threatening laser wavelengths will be defeatedby a laser-protective attachment, and polycarbon-ate intrinsically provides significant protection fromthe carbon dioxide laser emitted wavelength. Un-fortunately for the soldier’s eye, conventional mu-nitions are being improved, tunable dye lasers arein development, flechettes penetrate 2-mm-thickpolycarbonate, and current eye armor provides nospecific protection against microwaves or particlebeams, so that eye injuries can be expected to oc-cur, to be of great seriousness, and to demand ex-pert and immediate care.

EYE CARE IN THE THEATER OF OPERATIONS

The principles that should govern the provisionof medical care in the TO to the eye-injured and-diseased can be divided into two groups: the gen-eral and the specific. The general principles areexpertise, immediacy, control, assertiveness, com-plexity, cooperation, integration, reassessment, in-novation, and education, and are discussed below.The specific principles apply to the care of the inju-ries and diseases of the anterior and posteriorsegments of the globe, the ocular adnexa, and thebony orbit, and are expressed in the Practice ofTOEC section of this chapter.

General Principles

There is no delayed primary closure in oph-thalmic surgery. The first surgical procedure per-formed on the injured eye and/or its adnexa isalmost always the definitive one, and it must be per-formed as soon after injury as possible. It thereforefollows that we must be prepared to practice suchdefinitive ophthalmic surgery in the TO. To do sorequires the presence of ophthalmologists with sub-specialty expertise in certain hospitals in the TO.Ophthalmology residents and physicians who havereceived on-the-job training (OJT) are never quali-fied to practice independently as ophthalmologistsin the TO. Some argue that eye casualties who re-quire vitrectomy and other sophisticated posteriorsegment surgical procedures can and should receivesuch care after being evacuated from the TO. They

are wrong, because (1) we may not be able to evacu-ate our casualties from a TO soon enough to pro-vide such care at the appropriate time after injurybecause of other nonocular injuries that render thepatient nontransportable, or (2) the means for suchevacuation may not be available. We cannot assumethat we will always have air superiority. There-fore, we must be prepared to practice definitivevitreoretinal surgery in the general hospital (GH)(see the section on Practice of TOEC). Ophthalmolo-gists in the TO hospitals must (1) be supported bynurses and corpsmen specially trained to assist inophthalmic surgery and (2) be provided with nec-essary diagnostic and therapeutic instruments andsupplies.

These principles were first enunciated in 1918 byAmerican ophthalmologists who had served in Eu-rope in World War I and have been reiterated bytheir successors following World War II, the KoreanWar, the Vietnam War, and the Persian Gulf War. Ifwe continue to fail to provide early definitive oph-thalmic surgery for our casualties, as occurred inWorld War II and the Korean, Vietnam, and PersianGulf wars, we will continue to condemn them topreventable blindness.

Expertise

Army ophthalmologists who served in WorldWar I, World War II, the Korean War, the VietnamWar, and the Persian Gulf War agree that the major

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elements in the successful care of the eye injuredare twofold: the expertise of the ophthalmologistproviding such care, and the promptness withwhich it is provided. The US Army ophthalmolo-gist who surveyed the provision of eye care by theBritish and French medical departments in 1917 and1918 called for specially trained ophthalmic sur-geons to serve in forward hospitals.8

As Wood stated in 1921, regarding the need forexpert ophthalmological care near the front:

In the American Expeditionary Forces ophthal-mologists were finally stationed in most of the frontline hospitals (casualty clearing hospitals) so thatevery ocular wound should receive attention at theearliest possible moment, the principle having be-come generally recognized by time of our entry intothe war, that the golden opportunity in the treat-ment of traumatic corneal ulcers, penetrating andother wounds of the eye, as with all generalwounds, lay between the moment of injury withits usual contamination and the time when simplecontamination flamed into active infection. Furtherit has long been an ophthalmic axiom that the ear-lier the removal of intraocular foreign bodies thegreater the chances of ultimate vision, and placingof these skilled men behind the front, backed bybase hospitals and placed as far forward as pos-sible and having radial control through their spe-cialist chiefs, led accordingly to incalculable sav-ing of vision and of life, as well as to the lesseningof the final deformities in thousands of wounds.9

Vail expressed a similar thought in the officialhistory of World War II:

Experience showed that it would have been a wiserpolicy to staff evacuation hospitals with the best oph-thalmic talent available rather than to concentrate itin the communication zone where, when the casu-alty was eventually received, there was not a greatdeal that even the most experienced ophthalmolo-gist could do for him [emphasis added].10

In the early days of World War I, before ophthal-mologists were fully functional in the combat zone,a great wastage of sight resulted from the enucle-ation of every perforated eye by general surgeons.9

And the identical problem occurred at the onset ofWorld War II.11

In the same vein, regarding the experience inWorld War II, Stone stated:

[M]any traumatisms of the eye were unduly com-plicated by failure to treat the conditions properlyat the time of the injury and in the period immedi-ately thereafter.12

And King succinctly commented:

The primary operation upon an eye is usually thedefinitive one and the surgeon seldom has a sec-ond chance. … [T]he complete examination whichis necessary before surgery demands specializedequipment; this equipment and the small delicateinstruments which are required for ocular surgeryare not usually available to the general surgeon.13

To provide our wounded with the quality of careto which they are entitled, it is mandatory that oph-thalmologists who possess subspecialty expertiseprovide such care at 3rd- and 4th-echelon hospitalsin the TO. Ophthalmology has advanced so rapidlysince the 1980s that clearly defined subspecialtieshave emerged, each requiring 1 or more years offellowship training and near-exclusive concentra-tion on them by their practitioners. The results ofsubspecialization have been (1) a dramatic improve-ment in the diagnosis and management of ocularand ocular adnexal injury and disease, and (2) thedisappearance of the general ophthalmic surgeon,for no one can master all types of ophthalmic sur-gery. The ophthalmic subspecialties most neededin the TO are those of the

• anterior segment (cornea/lens),• posterior segment (vitreoretinal), and• ocular adnexa (ocular plastic surgeon).

This matter will be considered in detail in the Prac-tice of TOEC section. We must plan to put our bestophthalmic surgeons (Regular Army and Reserve)who possess subspecialty expertise in the TO andnot keep them, for the most part, within the conti-nental United States (CONUS), as was done duringthe Vietnam War.

Immediacy of Treatment

Any number of people have recognized thatthe sooner combat casualty care is given, the betterthe outcome for the patient, including the Ameri-can College of Surgeons’ Committee on Trauma:

The most significant ingredient necessary for opti-mal care of the trauma patient is commitment, bothpersonal and institutional. For the institution, op-timal care means providing capable personnel whoare immediately available. It also implies usingsophisticated equipment and services that are fre-quently expensive to purchase and maintain. Itmeans there must be a priority of access to sophis-ticated laboratory and radiologic facilities as wellas to the operating suites and intensive care units.14

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Lessons Learned

As with all serious injuries, the outcome follow-ing eye injury is directly related to the rapidity withwhich expert care is provided. Bellamy’s commentsregarding lifesaving surgery in World War II applyto sight-saving surgery, as well:

[E]mphasis … [was] … placed upon providing life-saving surgery far forward on the battlefield. Dur-ing the North African campaign of 1942–1943 it wasrecognized that evacuation of the seriouslywounded to hospitals in the rear without first per-forming needed surgery was associated with anunacceptably high mortality. The problem was suc-cessfully solved by attaching to clearing companiesand evacuation hospitals near the front ad hoc unitsable to provide surgical care for casualties withtrunk and serious extremity wounds.15

This principle of immediacy is most applicablein the management of severe posterior segment(retina, vitreous, choroid, and sclera) injuries, for itis now established that such injuries must be man-aged surgically as soon as possible,16,17 and that thespeedy repair of a retinal detachment decreases theincidence of proliferative vitreoretinopathy—a ma-jor cause of treatment failure. Corpsmen and gen-eral medical officers must be capable of detectingeye and ocular adnexal injuries, making an initialassessment of their significance, rendering appro-priate care, and arranging for evacuation to theophthalmologist (Figures 2-1 and 2-2). Skilled oph-thalmologists must be available at 3rd-and 4th-ech-elon hospitals to provide expert definitive care assoon as possible after injury (Figures 2-3 and 2-4).

Fig. 2-1. Aeromedical evacuation helicopter. Air superi-ority and the ability to evacuate critically injured patientsby air has resulted in faster delivery of definitive repairto our soldiers on the modern battlefield. Photograph:Courtesy of Albert Hornblass, MD, Major, Medical Corps,US Army (Ret), New York, NY.

a

b

Fig. 2-2. (a) After performing the evaluation of airway,breathing, and circulation, the triage officer evaluates allbody systems. (b) Examination of the eye, adnexa, andorbit must be done by the ophthalmologist in an expe-ditious but thorough manner to determine the extent ofocular injuries and establish the priority of surgical re-pair of these injuries. This information is then conveyedback to the triage officer. Reproduced with permissionfrom La Piana FG, Hornblass A. Military ophthalmol-ogy in the Vietnam War. Doc Ophthalmol. 1997;93:39.

Such care may include, in addition to a full oph-thalmic examination, additional diagnostic proce-dures (eg, ultrasonography, computed tomography[CT] scan), surgical repair, and initiation of antibi-otic therapy. The ophthalmic surgeon will fre-quently work as a member of a head and maxillo-facial trauma team and should be as familiar aspossible with the procedures of neurosurgeons andmaxillofacial surgeons (Table 2-1 and Figures 2-5through 2-7). Edwards’s comments, published in1954, are highly relevant:

At the beginning of the [Korean] war, definitivesurgery was done mostly at Tokyo Army Hospitaland some at the hospital ship in Pusan. The timeelapsed between injury and arrival at Tokyo was

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TABLE 2-1

CONCOMITANT INJURIES ASSOCIATEDWITH OCULAR TRAUMA* DURING THEKOREAN WAR

Number and Percentage ofOther Injuries Associated Ocular Injuries

Facial 42 (15%)

Maxillofacial 47 (16%)

Neurosurgical 32 (11%)

Thorax 6 (2%)

Abdomen 3 (1%)

Extremities 48 (17%)

None 59 (21%)

Unknown 49 (17%)

TOTAL 286 (100%)

*Attention is invited particularly to the 32 eye injuries that wereseen in conjunction with neurosurgical injuries and to the 47eye injuries with associated maxillofacial wounds.Reproduced from King, Edwards. Recent Advances in Medicineand Surgery. US Army Medical Service Graduate School, ArmyMedical Center [now Walter Reed Army Medical Center], Wash-ington, DC: 1954: 477–478, 481.

often in excess of 24 hours. We found that the pa-tients operated on by an ophthalmologist aboardthe ship arrived in better condition at Tokyo thanthose who came directly, thus indicating the needfor earlier surgery. For this reason, ophthalmolo-gists were pushed forward into evacuation hospi-tals in Korea. Thereafter, definitive treatment couldbe given in 6 to 8 hours from even the most distantportions of the front line. In the opinion of every-one, the end-results justified this system. Thus, inthe light of the experience in both wars, it is rec-ommended that ophthalmologists be placed as farforward as possible, depending on their availabil-ity, to enable preoperative time lags of less than 12to 18 hours.13

A major objective of TOEC is to maximize thenumber of casualties who can return to duty withinthe theater. Many eye and ocular adnexal injuriesare initially incapacitating but—if managed ex-pertly and promptly by ophthalmologists, with therequisite personnel, support, and equipment—canheal or at least stabilize rapidly enough to permitthe patient’s return to duty. If inappropriately man-aged, however, many will progress to a conditionnecessitating evacuation from the TO and perhapsultimate retirement for medical disability. Corneallacerations, hyphemas, blowout fractures of the or-bit, and major lid and tear-duct lacerations are ex-amples of such injuries.

Fig. 2-3. Eye Clinic, 24th Evacuation Hospital, Long Binh,Vietnam. A complete ophthalmology lane allows for de-finitive evaluation of eye injuries. The complete eye lanemust have at a minimum a slitlamp and an indirect oph-thalmoscope. Reproduced with permission from La PianaFG, Hornblass A. Military ophthalmology in the VietnamWar. Doc Ophthalmol. 1997;93:40.

Fig. 2-4. Third- and 4th-echelon facilities have operatingroom capabilities. Often, the ophthalmologist will haveto manage the patients with multiple injuries in coordi-nation with a neurosurgeon or otolaryngologist. Photo-graph: Courtesy of William Dale Anderson, MD, Major,Medical Corps, US Army (Ret), Colorado Springs, Colo.

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Lessons Learned

Fig. 2-5. During the Vietnam War, this soldier, having suffered severe midface and eye injuries, was seen (a) at thetime of triage and (b) in the operating room.

Fig. 2-6. A gunshot wound to the orbit has caused severedamage to this soldier ’s globe and adnexa during theVietnam War. Ophthalmologists at the 3rd and 4th ech-elons must be prepared to treat patients with severe in-juries of the globe and surrounding structures.

a b

Control of Medical Resources

The need for control of Army Medical Depart-ment (AMEDD) resources by AMEDD personnel isagreed on by all. An extension of this principleto the conduct of ophthalmology in the TO is nec-essary, because only a senior ophthalmologyconsultant possesses the understanding required forthe appropriate allocation and utilization of re-sources. There is ample historical support for thisprinciple. Based on experiences gained in WorldWar I, it was recommended that the chief consult-ant in a specialty should not only supervise treat-ment but also

give wise advice, instruction and actual demonstra-tions as to the best and most efficacious methodsof treatment, in order that the work of his depart-ment may conform to the recognized and accepted stan-dards of the best civil and military practice [emphasisadded].8

This report also commended the Eye Centers of theBritish Expeditionary Forces under the BritishMedical Service for their efficiency, equipment, andorganization, especially the appointment of oneophthalmic surgeon to supervise and coordinate

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Fig. 2-7. Multiple fragmentation wounds (a) before and(b) after preparation for surgical repair. Fragments thatmay barely penetrate the superficial layers of the skin have the potential to cause severe damage to the eye. Photo-graph a: Reproduced with permission from Wong TY, Seet B, Ang CL. Eye injuries in twentieth century warfare: Ahistorical perspective. Surv Ophthalmol. 1997;41:452. Photograph b: Courtesy of William Dale Anderson, MD, Major,Medical Corps, US Army (Ret), Colorado Springs, Colo.

a b

services for the entire force.Based on experience gained in World War II, the

US Army official history recommends that in theevent of the outbreak of future hostilities,

1. [a] Consultant in Ophthalmology should atonce be placed on active duty in the Office ofthe Surgeon General, and

2. [u]pon the activation of each Overseas Theatre,a Consultant in Ophthalmology should at oncebe placed on duty and made responsible forophthalmic programs within the theatre.18

Speaking of the lack of a consultant in ophthal-mology throughout the US military in World WarII, Vail stated:

The chief fault of the past was the delay in settingup the position of chief consultant in ophthalmol-ogy in the office of the Surgeon General of theArmy. The Navy never has such an officer; and theAir Force, even in those days, was a law unto it-self. All of these errors and much of the waste couldhave been prevented by a skilled and experiencedophthalmologist with appropriate rank and author-ity placed in the offices of the Surgeon General ofthe various forces. At the present time there is nosuch officer any place.19

Apparently, however, some improvement was evi-dent during the Korean War:

The advice of Consultants was given great weightin matters of assigning personnel as well as ofmaintaining high caliber of medical care. The sys-tem worked out very well in Korea and should becontinued in the future.13

Fig. 2-8. Doctor ’s quarters at the 24th Evacuation Hospi-tal in the Republic of Vietnam (1968–1969). Photograph:Courtesy of William Dale Anderson, MD, Major, Medi-cal Corps, US Army (Ret), Colorado Springs, Colo.

In Vietnam, the Consultant in Ophthalmology to theMilitary Assistance Command Vietnam (MACV)Surgeon was usually the ophthalmologist of the24th Evacuation Hospital (EH) (Figure 2-8). Thisophthalmologist was, most of the time, a relativelyjunior officer and too busy to function as a true se-nior consultant and to effect necessary changes. Onthe outbreak of hostilities, a senior Army ophthal-mologist should be assigned as the Consultant inOphthalmology on the Theater Army Surgeon’s/Medical Brigade Commander ’s staff. This indi-vidual should directly and personally oversee allaspects of planning for and practice of ophthalmol-ogy within the theater. This individual and the Con-

25

Lessons Learned

sultant in Ophthalmology to The Surgeon Generalmust be experienced in both military medicine andophthalmology, and work closely together.

The senior Army ophthalmology consultantsshould be selected on the basis of their proven abil-ity to perform their jobs (as are chiefs of staff of theArmy and hospital commanders) and not simplyon the basis of seniority. The consultant should

• have operational control of all ophthalmicand optometric resources within the TO;

• be responsible for, and personally supervisethe care of, the eye-injured and diseased—not only by the ophthalmologists and op-tometrists but also by all who render suchcare (other medical corps officers, corps-men, and nurses);

• understand the pertinent aspects of geo-graphic ophthalmology in the theater (en-demic/epidemic diseases);

• interact effectively with his Navy and AirForce counterparts in patient care andevacuation matters;

• see to the proper orientation of new arriv-als to the theater and proper utilization ofOJTs;

• control the distribution and use of K-teams(potentially the ophthalmic equivalent ofthe Auxiliary Surgical Groups of World WarII), if employed15; and

• oversee the operation of a registry of eye dis-eases and injury that should immediately beestablished on formation of the theater force.

The importance of the establishment and mainte-nance of such a registry is evidenced by the greatvalue of data concerning eye injuries and diseasecollected during World War II20 and by the costs ofthe relative failure to acquire such data for eye in-juries in Vietnam.

Assertiveness

AMEDD considers ophthalmology to be a con-stituent of surgery, and this subordination is ex-pressed at all levels. Because many Army sur-geons—like most physicians—know little and careless about the eye and think of ophthalmologists aslittle more than optometrists who perform cataractsurgery, ophthalmology has often not been pro-vided the attention and resources it requires to mosteffectively execute its missions. Therefore, Armyophthalmologists must assertively compete for re-sources, educate their fellow physicians, and planfor the provision of eye care to the war casualty—

who otherwise will continue to be condemned topreventable blindness. Military ophthalmologistsmust make themselves the preventive medicine of-ficers for the eye, working to diminish risks of in-jury by promoting (a) safe practices both on and offduty and (b) the wearing of eye armor during theconduct of all eye-hazardous activities (see Chap-ter 26, The Development of Eye Armor for theAmerican Infantryman). In general, the wearing ofhard and soft contact lenses in the combat zonemust be discouraged, because contact lenses en-hance the likelihood of eye infections.21 Militaryophthalmologists must also be assertive in the pre-vention and management of ocular malingering, asmanifested by gazing at the sun (solar macu-lopathy) or breaking the eyeglasses.

Complexity of Injuries

Eye injuries in a civilian setting in peacetime canprofitably be compared with those produced bywar. Whereas in peacetime, few ocular structuresare injured and few coexisting injuries occur, thepicture is quite different in wartime (Table 2-2),when eye injuries tend to be multiple, averagingabout two per eye. Cohen22 analyzed 281 cases ofsevere globe injury sustained in Vietnam and sub-sequently treated at Fitzsimons Army Medical Cen-ter (FAMC) between 1967 and 1970. He found thatthe 133 eyes (47% of the total) that remained in situon presentation to FAMC had a total of 277 injuries,for an average of 2.1 injuries per eye. Likewise, analy-sis of 57 patients evacuated from Vietnam to WalterReed Army Medical Center Ophthalmology Servicefrom May 1968 to September 1969 showed that thosepatients sustained 100 injuries to the globe and/orocular adnexa, an average of 1.8 injuries per eye.3

TABLE 2-2

OCULAR INJURIES SEEN IN WARTIME VS INA PEACETIME EMERGENCY DEPARTMENT

Injuries Wartime Peacetime

Ocular Structures Several FewInjured

Number of Patients Multiple Usually one

Coexisting Injuries Very often Usually not

Time Available to Limited UnlimitedProvide Care

Stress on the Surgeon Severe Moderate

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Cooperation Among Specialists

Most ophthalmic surgery in peacetime is per-formed without the need for support from othersurgeons. Military ophthalmologists caring for warcasualties, however, must often work intimatelywith other surgeons because of many casualties’multiplicity of injuries. Because of such combinedinjuries, ophthalmologists should be co-locatedwith neurosurgeons and maxillofacial surgeons.The ophthalmologist will work not only withneurosurgeons, otolaryngologists, and plastic sur-geons, but also with orthopedic and general sur-geons. Thus, military ophthalmologists should par-ticipate in courses dealing with the management ofwar casualties (eg, the Combat Casualty Carecourse, which includes both the C-4 course and theAmerican College of Surgeons’ Advanced TraumaLife Support [ATLS] course) and seize every oppor-tunity to participate in the care of patients withmidface trauma.

Reassessing, Updating, and Integrating WithOther Plans

Plans for TOEC must be periodically reassessedbecause (a) weaponry, tactics, and, therefore, threatschange and (b) better means of preventing and car-ing for eye injuries and disease will be developedand need to be integrated into the plan. Break-throughs in both prevention and therapy must beimmediately identified by military ophthalmolo-gists and exploited for the benefit of service per-sonnel.

Planning for TOEC must be fully integrated withgeneral AMEDD planning to ensure that the mis-sion is accomplished while resources are conserved.Military ophthalmologists must participate activelyat all levels in AMEDD planning for TO casualtycare.

Continuing Military Medical Education forOphthalmologists

Education of all those who practice TOEC is acontinuing obligation of the military ophthalmolo-gist. Civilian ophthalmologists must also be keptaware of the plans for TOEC so they can help imple-ment them, if necessary. The Tri-Service OcularTrauma Course currently provides such educationfor active duty military ophthalmologists of theArmy, Navy, and Air Force and could be expandedto include civilian ophthalmologists. All militaryophthalmologists should attend the Tri-Service

Ocular Trauma Course, preferably first in their se-nior year of residency and then at 3-year intervals.Through lectures and practical sessions, this courseattempts to familiarize the student with the reali-ties of practice in a TO and also facilitates exchangeof information and joint planning by representativesof the Army, Navy, and Air Force.

In addition, a 4-hour block of instruction in thedetection, diagnosis, and management of ocular andocular adnexal trauma is given the fourth-yearmedical students at the Uniformed Services Univer-sity of the Health Sciences. This course provides abase of knowledge that medical officers can buildon.

Instruction of all eye-care providers is a majorand continuing responsibility of all military oph-thalmologists and its accomplishment should be adirect responsibility of the theater Army ophthal-mologist. Nonophthalmologists (physicians, phy-sician assistants, and corpsmen) should receive in-struction that is similar to or, if possible, identicalto that presented in the ATLS manual.

Specific Principles

The practice of TOEC, including evacuation ofeye casualties, takes place at each of the four ech-elons of care.

1st and 2nd Echelons: Initial Care of Ocular andOcular Adnexal Injuries

It is mandatory that eye injuries be properlymanaged by those caring for the patient before heor she reaches an ophthalmologist. The “patch andship” policy exacerbates morbidity. Corpsmen, phy-sician assistants, and physicians at all echelons ofcare within the theater must be taught what mustand must not be done for the eye-injured patient atthe site of injury, during evacuation, at the battal-ion aid station, and at hospitals not having an oph-thalmologist assigned. The person providing thecasualty’s initial care must inspect the eyes andadnexal structures for injuries, and detect such in-juries; at least develop a differential diagnosis andmake a diagnosis, if possible; and render appropri-ate management. All of this must be performed insuch a manner that no additional injury is inducedeither by the care provider himself or by those whorender subsequent care (eg, during ground ambu-lance or helicopter evacuation). The relevant in-struction included in the 1988 revision of EmergencyWar Surgery,23 the ATLS Manual24 and the 1991 Com-bat Casualty Guidelines: Operation Desert Storm25 is a

27

Lessons Learned

EXHIBIT 2-1

RECOMMENDATIONS FOR INITIAL CARE OF OCULAR AND ADNEXAL INJURIESAT THE 1ST AND 2ND ECHELONS

1. Do not “patch and ship.” Get visual acuity and history of the injury.2. Inspect eyes and adnexal structures using bent paper clips, if necessary.3. Detect injuries without further injuring the globe. Look for blood in the anterior chamber, lens disloca-

tion, iris disinsertion, blood in the vitreous, retinal detachment, and retained intraocular foreign body(IOFB). A black reflex often indicates the presence of an intraocular hemorrhage. Palpate for disconti-nuity of the orbital rim and detachment of the medial canthal tendon.

4. Remove nonimpaled conjunctival FBs (using irrigation or a wet cotton-tipped applicator stick) andimpaled-lid FBs that can contact the globe.

5. Do not remove impaled conjunctival (intraocular or intraorbital) FBs, but rule out intracranial injuries.6. Irrigate corneal FBs, and wipe them off the cornea with an applicator stick, if necessary. Apply a broad-

spectrum ophthalmic antibiotic ointment and a tight patch.7. Treat corneal abrasions with a broad-spectrum antibiotic ointment and a tight patch if the patient is not

a contact lens wearer. Patients who do wear contact lens have a higher risk of developing a cornealulcer, so their abrasions should be treated with a broad-spectrum ophthalmic antibiotic ointment orsolution and no patching. Do not use corticosteroids.

8. Identify a ruptured, penetrated, or perforated eyeball by edema of the conjunctiva, a shallow or deepanterior chamber, hyphema, decreased ocular motility, decreased visual acuity, or an intraocularhemorrhage (the inside of eye looks black or red). Apply a broad-spectrum ophthalmic antibioticsolution and a Fox or other rigid shield (no patch), and evacuate to a 3rd-echelon ophthalmologist.Apply no pressure to the eye, and ask the patient not to squeeze the lids.

9. Do not apply topical steroids.10. Do not use ointment on an open eye.11. Apply moist dressings on eyelid lacerations and medial canthal angle lacerations.12. Do not attempt enucleation or evisceration (ie, no eye removal) at the 1st or 2nd echelons.13. Use topical anesthesia only for examination purposes. Never give the patient the topical anesthetic for

personal use, as self-medication can lead to a serious keratopathy.14. For chemical burns, provide at least 60 minutes of irrigation and remove any particles from the cornea

and conjunctiva, especially the fornices.15. For white phosphorus burns, identify particles if necessary with 0.5% copper sulfate, and if possible,

remove all particles under water.16. For severe injuries, use tetanus prophylaxis and systemic antibiotics.17. If intraorbital bleeding causes decreased visual acuity, perform a lateral canthotomy and cantholysis.18. Tell patients with orbital fractures to refrain from nose blowing, and teach them how to stop sneezing

by pressing hard just above the upper lip. If the sneeze cannot be stopped, they should not try to holdit in. Begin systemic antibiotics to cover sinus flora (ie, amoxicillin/clavulanate).

19. Consider repairing lacerations of the eyelid that involve the skin and muscle only without fat prolapseor involvement of the lid margin. Close the eyelid laceration with 6-0 silk.

20. Evacuate casualties with deeper lid lacerations and those involving the margin to a 3rd-echelonophthalmologist.

21. Look carefully for lacerations of the canaliculi (tear ducts) and evacuate patients with such lacerationsto a 3rd-echelon ophthalmologist. Apply a wet dressing on the injured area.

22. Keep orbital soft tissues moist in case of traumatic enucleation/partial exenteration and evacuate to a3rd-echelon ophthalmologist.

23. Any further decrease in visual acuity after injury demands immediate evacuation to a 3rd-echelonophthalmologist.

24. Treat laser burns of the cornea with topical ophthalmic antibiotics, patching, and daily examinations.25. Evacuate casualties with laser burns of the retina to a 3rd-echelon ophthalmologist.26. After any injury to the eyelids (eg, avulsion, thermal burns), keep the cornea covered. Any corneal

exposure requires immediate evacuation to a 3rd-echelon ophthalmologist.

28


valuable introduction to and overview of this criti-cally important subject. Some specific recommen-dations are listed in Exhibit 2-1.

The theater Army ophthalmologist should as-sume responsibility for the continuing education ofall eye-care providers in theater. He or she must alsowork closely with those personnel responsible foraeromedical evacuation to assure that eye casual-ties are provided necessary in-flight care.

3rd and 4th Echelons: Evacuation to an Ophthal-mologist

Pressure exerted on an eye that has been pen-etrated can extrude intraocular contents through thewound of entry and thereby convert a repairableinjury to an irreparable one. Similarly, the admin-istration of ointment to such an eye can result inpassage of the ointment into the eye, where it doesgreat damage. Therefore, only solutions of oph-thalmic medications should be applied to an eyethat might be penetrated, and all patients with suchinjuries must be evacuated wearing a Fox (alumi-num) shield or a shield made of some semirigidmaterial (eg, the bottom of a paper cup) over theinjured eye. Severe eye injuries must receive anevacuation priority equal to that granted severeextremity injuries and second only to life-threaten-ing injuries, because sight-saving care must rapidly,as well as expertly, be provided. Obviously, medi-cal regulating officers must know at all times whichhospitals in theater are prepared to provide care foreye casualties.

At 3rd- and 4th-echelon hospitals (Figure 2-9),the ophthalmologist should be a member of a “headand neck team,” composed of a neurosurgeon, oto-laryngologist, plastic surgeon, and oral surgeon, asexperience in the wars of this century has clearlyshown that combat casualty care is thereby opti-mized.

Definitive, expert, early care will be provided atthe 3rd echelon for patients who have sustained aninjury to the eye and/or ocular adnexal structuresto expedite their return to duty or to save the globe.Watertight closure of the penetrated globe will en-able subsequent additional stabilizing surgery to beperformed at the 4th echelon. Lacerations of theeyeball, eyelids, and tear ducts will be closed pri-marily and immediately, utilizing a portable oper-ating microscope. If necessary, the patient will sub-sequently be evacuated to the 4th echelon, wherevitrectomy capability exists. Neurosurgeons andophthalmologists will work together to decompressthe optic nerve as necessary. Various injuries that

may be encountered at the 3rd and 4th echelons(Figures 2-10 through 2-12) and sutures that I rec-ommend for their repair are listed in Exhibit 2-2.

Fig. 2-9. The 3rd Field Hospital in Vietnam. Fourth-ech-elon hospitals are often in fixed facilities and should havefull ophthalmic and head-and-neck capabilities.

Fig. 2-10. A patient with an open globe with prolapse ofuveal tissue needs immediate evacuation to an ophthal-mologist for definitive repair of the corneal, scleral, orcorneoscleral wound. Photograph: Courtesy of the lateRichard M. Leavitt, MD.

29

Lessons Learned

a

b

Fig. 2-11. (a) The marked proptosis of the eye in this in-dividual is due to a retrobulbar hemorrhage. Withoutprompt intervention, vision may be permanently lost. (b)Also of note is the blood in the mouth and the numerousfacial lacerations. Photographs: Courtesy of Blackwell S.Bruner, MD, Potomac, Md.

Fig. 2-12. Numerous metallic fragments are seen to in-volve the cranium and orbit on this lateral skull film (con-ventional radiograph). Fragmentation injuries commonlyinjure more than one organ system. Management of thesecasualties will involve the ophthalmologist for the eyeand orbit, the neurosurgeon for the brain, and the oto-laryngologist for the airway, sinuses, ears, and nose. Re-produced with permission from Wong TY, Seet B, AngCL. Eye injuries in twentieth century warfare: A histori-cal perspective. Surv Ophthalmol. 1997; 41:433–459.

Ultrasonography is required at the 3rd echelonfor the detection and localization of intraocular for-eign bodies (IOFBs) and retinal detachments. Theportable operating microscope increases the speedof surgery by optimizing the view of the operativefield, as well as enabling better surgical results,thereby decreasing ocular morbidity and increas-ing return to duty. The portable operating micro-

scope can also be employed outside the surgicalsuite (eg, in the minor/outpatient surgical facility)for minor repairs and suture removal, and it canalso be used by other surgeons. The suction/cuttershould be available at the 3rd echelon to removevitreous from the anterior chamber. Irrigation andaspiration of a cataractous lens will be performedonly if the lens is ruptured and prolapsed or mixedwith vitreous. Otherwise, patients with traumaticcataracts will be evacuated to the 4th echelon.

Surgical repair of eye and adnexal injuries canbe performed concurrent with repair of other inju-ries. CT is necessary for the localization of intraocu-lar and intraorbital foreign bodies (FBs) and fordefinition of orbital fractures. The CT scanner mustbe able to provide 1.5-mm cuts and coronal and sag-ittal reformats.

An eye clinic set is required wherever an oph-thalmologist is assigned, as the specialized diagnos-tic instruments included therein (eg, slitlamp) aremandatory for the care of patients with eye injuriesand diseases. The eye clinic should be able to per-form minor surgery. Two ophthalmologists (onewith anterior segment subspecialty expertise and

30


EXHIBIT 2-2

RECOMMENDED SUTURES FOR THE REPAIR OF VARIOUS ORBITALAND ADNEXAL INJURIES

1. Close corneal lacerations with a 10-0 monofilament nylon.2. Close scleral lacerations with 8-0 nylon, 8-0 silk, or 5-0 Mersilene, as determined by the size and

location of the injury.3. Repair orbital and adnexal soft-tissue lacerations with 4-0 and 6-0 chromic gut.4. Repair extraocular muscle with 6-0 Vicryl.5. Repair the medial canthal tendon with 4-0 Mersilene.6. Close conjunctival lacerations with 6-0 plain gut.7. Close adnexal skin with 6-0 silk.8. Repair lid margin with 4-0 or 6-0 black silk suture through the tarsal plate (cut long so that it can be

used as a traction suture), and 6-0 black silk suture at the anterior and posterior lid-margin borders.9. Stent lacerated canaliculi and nasolacrimal duct with silicone tubing or a monocanalicular stent, to be

left in place up to 6 months. Close the wound with 6-0 chromic and 6-0 or 8-0 silk sutures.

one with ocular plastic and adnexa subspecialtyexpertise) are required at the 3rd echelon, wherethey will be supported by three corpsmen who aretrained to assist in ophthalmic surgery.

The ophthalmologists at the 4th echelon not onlymust be able to handle all the injuries that are usu-ally seen at the 3rd echelon but also able to provideadditional subspecialty care. More-extensive oph-thalmic surgical procedures to save the globe willbe performed at the 4th echelon, where a microsur-gical augmentation set and an operating microscopewill be located so as to permit vitreoretinal surgery.Required are all diagnostic and therapeutic instru-ments needed to manage definitively all forms ofophthalmic injury, including IOFB, retinal detach-ment, and intraocular hemorrhage (including thatfrom laser injury).

Vitreoretinal surgery will generally be performedbetween 0 and 14 days following an injury; other-wise, fibrous proliferation increases ocular morbid-ity. Patients requiring vitreoretinal surgery includeall those suffering from penetrating eye injuries ofthe ciliary body and the posterior segment of theeyeball (sclera, choroid, retina). These patients fallinto two categories:

1. those without major posterior segment dis-ruption (ie, no major retinal, choroidal, oroptic nerve damage) who, after vitrectomyand intraocular lens implant (if necessary),can return to duty within 30 days; one pos-terior and one anterior chamber–style in-

traocular lens must be available at this ech-elon of care; and

2. those whose posterior segments have beensignificantly disrupted and will requireevacuation to CONUS after vitrectomy.

A patient with an IOFB is not to undergo mag-netic resonance imaging (MRI) until the FB is shownnot to be magnetic (eg, by the magnet-ultrasoundtest).

Intraorbital, but extraocular, FBs will be left inplace unless they are (a)large enough to produce adisturbance of eye or optic nerve function, (b) com-posed of vegetable matter or wood, or (c) infected.Orbital fractures will be repaired if clinically indi-cated; few pure blowout fractures of the orbital floorwill require surgery.

At the 4th echelon, three ophthalmologists arerequired: one with vitreoretinal subspecialty exper-tise, one with anterior segment expertise, and onewith ocular plastic and adnexa subspecialty exper-tise. The ophthalmologists should be supported byfive corpsmen trained to assist in the care of oph-thalmic patients in the clinic and in surgery. Theclinic should be large enough and so equipped thattwo ophthalmologists can work simultaneously.

It must be kept in mind that surgical ophthalmicpatients require evaluation in an outpatient clinic(an “eye lane”) before they are returned to duty, andthat the ophthalmologists in theater will have manyophthalmic patients (eg, those suffering from infec-tions and inflammations) who require medical care.

31

Lessons Learned

One optometrist should be assigned to each 3rd-and 4th-echelon hospital where ophthalmologistsare assigned. The optometrist will perform refrac-tions and supervise the optical shop for the region;he or she should be co-located with the ophthal-mologists to speed patient care and thereby increasereturn-to-duty rates.

The benefit of expertly performed ophthalmicsurgery at the 3rd and 4th echelons can be totallyundone by poor or no care of the eye casualty dur-ing aeromedical evacuation to CONUS. The theaterArmy ophthalmologist must work closely with hisor her Air Force counterpart to ensure adequate in-flight care of the eye casualty.

All utilizable ophthalmologists must be identi-fied with a military occupation specialty (MOS) thatspecifies whether or not the ophthalmologist is asubspecialty expert (eg, 60S9B0, general ophthal-mologist; 60S9B1, anterior segment subspecialist;60S9B2, vitreoretinal expertise). Military ophthal-mologists must be prepared, especially if their hos-

pital provides area support, to treat members ofallied forces and indigenous peoples—the lattergroup necessitating an awareness of relevant geo-graphical ophthalmology (eg, the diagnosis andtreatment of endemic trachoma). Hygiene is of evenmore importance, albeit harder to effect, in the com-bat zone than in the United States. If contact lensesare worn in the combat zone, significant keratop-athy can be expected to occur, possibly leading tothe loss of an eye. In outpatient facilities, epidemickeratoconjunctivitis and gonococcal conjunctivitismay be encountered. In the operating room (OR),the use of prophylactic antibiotics should be care-fully considered.

The vagaries of military medical supply will en-sure that military ophthalmologists will have toimprovise at times. The ophthalmologist may needto quickly learn to lead and administer an eye ser-vice, supervising perhaps an optometrist and sev-eral corpsmen, some of whom will be expected toprovide optician services.

OPHTHALMIC CARE IN THE PERSIAN GULF WAR

The eye care provided by ophthalmologists dur-ing the Persian Gulf War, both its 6-month defen-sive buildup phase, Operation Desert Shield, andthe short (6-wk) offensive phase, Operation DesertStorm, encompassed a broad range of ophthalmicissues and problems in theater, from the combatsupport hospital (CSH) to the GH. In future con-flicts, ophthalmologists will again be charged withthe awesome responsibility of preserving the visionof wounded soldiers and civilians. Unfortunately,there are no all-encompassing answers to many ofthe problems that arose during the Persian Gulf War.Necessity and individual initiative frequentlyprompted the only pragmatic solutions. Specificocular injuries encountered during the Persian GulfWar have been described and analyzed else-where.26,27 For the sake of completeness, I (T. H. M.)will briefly comment on these injuries; however, thethrust of this section will be to describe how thetheater evolved over time, what problems arose,how attempts were made to deal with these issues,and what lessons were learned.

During the Persian Gulf War, it was my privi-lege to serve a dual role as both the Theater Oph-thalmology Consultant and Deputy Commander forClinical Services of the mobile 47th CSH. This com-bination of duties gave me the opportunity to travelto different parts of the theater and interact withmany hospitals, both reserve and active duty. ThePersian Gulf War evolved as a war of movement,

where many medical units (such as my own) movedfrequently to provide medical care to a huge army,which moved in a generally northerly direction. Themedical mission also gradually shifted as the mili-tary strategy changed from the defensive postureof Operation Desert Shield to the offensive one ofOperation Desert Storm. In an attempt to conveythe changing nature of the medical mission, I willoccasionally describe the status of my own unit asthe military situation matured and go beyond thescope of a pure ophthalmic discussion. Ophthalmol-ogy did not exist in a vacuum during the PersianGulf War, and any discussion of ophthalmic caremust, of necessity, encompass nonophthalmic is-sues.

Following the invasion of Kuwait in August 1990,the United States responded with the deploymentof the 82nd Airborne Division, along with otherrelatively small Air Force and Navy units. LocalSaudi Arabian ophthalmologists provided the ini-tial ophthalmic care for these units. Later, duringOctober and November, as corps-sized combat ele-ments were formed, larger hospitals arrived withsurgical subspecialists, including ophthalmologists.The smallest units with ophthalmologists assignedas staff were CSHs. Most of the more than 20 activeduty and reserve ophthalmologists in theaterthroughout operations Desert Shield and DesertStorm were assigned to Army EHs and GHs, as wellas to Navy fleet hospitals and hospital ships. Usu-

32


ally, such hospitals had one ophthalmologist each.There were no Air Force ophthalmologists in the-ater.

I was a staff ophthalmologist at Madigan ArmyMedical Center (MAMC), Fort Lewis, Washington,at the time of the invasion of Kuwait. Not long af-ter the invasion, I joined the 47th CSH stationed atFort Lewis, which had been alerted to go to SaudiArabia. As with nearly all medical units eventuallysent to Saudi Arabia, we were by no means com-pletely ready for deployment. Few, if any, medicalunits had actually inventoried and used their equip-ment in the field for real surgical cases. Fortunately,our unit had several weeks to break down and ex-amine our equipment. This was indeed fortunate,because some equipment was found to be missingor inadequate. Given the lack of state-of-the-artequipment, particularly in surgical subspecialties,many surgeons “borrowed” equipment fromMAMC. This borrowed equipment was to proveinvaluable in the treatment of injured and woundedsoldiers. (The use of borrowed equipment was verycommon in active duty medical units deployed tothe theater.)

Equipment and Facilities

Because I frequently use the term “state-of-the-art field equipment,” it is appropriate to define thisterm with respect to ophthalmology. With a severeocular injury, as is frequently observed in war,prompt definitive surgery is absolutely necessaryto preserve vision. It is generally accepted that acorneal/scleral laceration, for example, must besutured with watertight closure within no morethan 12 hours of injury. Simultaneously, an anteriorvitrectomy and a lensectomy must frequently beperformed. These basic procedures help (a) preventhypotony, bacterial contamination, and massiveinflammation, and (b) preserve the anatomical in-tegrity of the eye, which will improve the successof later ocular surgery, if it is indicated. Any well-trained ophthalmologist can perform these proce-dures quickly in any field OR with the aid of an ORmicroscope and a battery-operated vitrectomy unit.Since the mid 1980s, portable OR microscopes (suit-case-sized) and battery-powered vitrectomy units(briefcase-sized) have been available. They arelargely designed for ocular surgery in the ThirdWorld and have been used under conditions farmore crude than those experienced by most mili-tary surgeons in a war zone. Thus, for purposes ofthis discussion, state-of-the-art ophthalmic equip-ment is defined as

• a portable operating microscope,• a battery-powered vitrectomy unit,• appropriate microsurgical instruments,• appropriate sutures, and• ophthalmic medications.

Our unit personnel arrived by commercial air inDhahran, Saudi Arabia, on 11 October 1990. Ourhospital equipment, and that of nearly all hospitalsof mobile army surgical hospital- (MASH-) size orlarger, was transported by ship. We were quicklytaken by bus to “Cement City,” a heavily guarded,barbed wire–enclosed camp erected within the con-fines of an old cement factory. It was composed ofrow after row of large Arab tents. During this time,nearly all incoming units, medical and otherwise,were temporarily billeted in this facility. Early inthe deployment, because of the rapid rate of unitarrival, this encampment was overwhelmed withsoldiers, the numbers of whom far exceeded thisarea’s capacity for support. The poor sanitary con-ditions coupled with extreme heat resulted in manydiarrhea and heat casualties; numerous soldierswere hospitalized, including some from our unit.

Many hospitals had similar experiences using theCement City staging area before they moved westinto various desert locations. After leaving CementCity, most MASHs and CSHs were establishedroughly along a north/south line about 100 mileswest of Dhahran. This configuration was necessaryto support combat divisions, which were spread outin this general area. The larger EH and fleet hospi-tals were initially constructed near the coast, withthree EHs located around Dhahran and a GH and aNavy fleet hospital located in Bahrain. Later, fourEHs were located at King Khaleid Medical Center,and several more were located along an east/westline, roughly along Tapline Road from Rafha to nearthe Persian Gulf coast. There were 21 EHs in the-ater, and a GH was located in Riyadh. Also, theNavy hospital ships Mercy and Comfort were presentin the Persian Gulf before, during, and after thePersian Gulf War.

Some of the first hospitals constructed in SaudiArabia, including my own, used Vietnam-era inflat-able MUST (medical unit, self-contained, transport-able) equipment (ie, the inflatable subsections werelatched together to form hospital wards). If leftalone, the inflatable sections would leak air, simi-lar to a leaking car tire; to remain functional,the MUST hospitals needed constant reinfla-tion. The first ophthalmic emergency surgical casesperformed during Operation Desert Shield weredone uneventfully in MUST OR boxes, which are

33

Lessons Learned

about one-third the size of a standard DEPMEDS(deployable medical system) OR.

Numerous problems became apparent during thehospital-construction phase, and these were toplague medical units for months. Proper suppliesand equipment, ophthalmic and otherwise, werealmost universally lacking in theater when we ar-rived. Although many ophthalmologists blamed“the Army,” the reasons for this oversight werefourfold:

1. Many ophthalmologists simply never tookthe initiative to examine their equipmentprior to deployment. Thus, even thoughsome PROFIS (professional filler system)ophthalmologists had been assigned totheir hospitals for years, very few had everperformed a hands-on inventory of theirequipment.

2. Some ophthalmologists were assigned tounits far from their home stations, and forthem, equipment inspection was logisti-cally difficult.

3. Some hospital administrators were reluc-tant to break down equipment for exami-nation by physicians. Many felt that re-viewing the equipment list should beenough. However, the equipment list wasfrequently difficult to interpret and did notnecessarily reflect what was actuallypresent.

4. The Table of Organization and Equipment(TO&E) was outdated, and modern equip-ment and supplies were never part of theplan. This equipment problem was com-pounded by the fact that many units wereundergoing a transition from MUST toDEPMEDS equipment at about the time ofthe deployment.

For many reasons, therefore, units found themselveswithout proper equipment. In fact, of more than 20ophthalmologists in theater, only 1 or 2 at most hadoperating microscopes on arrival in Saudi Arabia.No vitrectomy units were ever delivered, and verylimited supplies of viscoelastics and even basic mi-crosurgery instruments existed in theater.

Thus, the theater MEDSOM (medical supply, op-tical and maintenance), which was originallylocated in Dhahran, was put in the unenviable po-sition of trying to provide medical supplies, oph-thalmic and otherwise, to many medical units ar-riving in theater. Although these dedicated supplypersonnel did a remarkable job overall, they were

never able to supply all medical units with all oph-thalmic needs. I might add that the equipmentshortfalls were not limited to ophthalmology. Forexample, some EHs arrived in theater without func-tioning anesthesia machines, ventilators, propersutures, and other basic equipment and supplies.

Lack of equipment proved to be an almost insur-mountable problem. In late October and early No-vember 1990, it was becoming obvious (for the rea-sons mentioned above) that surgical units werearriving without even basic ophthalmic equipment.With this in mind, I contacted the OphthalmologyConsultant to the Surgeon General, Colonel KenyonKramer, at Walter Reed Army Medical Center,Washington, DC, and we formulated a plan to pur-chase and ship operating microscopes, slitlamps,and other equipment to Saudi Arabia. Although thisequipment acquisition was well coordinated atWalter Reed and the Dhahran MEDSOM, we hadno control of the circumstances between these twopoints, and our plans met with limited success. Forexample, of the 12 or so operating microscopes pur-chased and shipped to Saudi Arabia during Opera-tion Desert Shield, I am aware of only 2, includingthe 1 that I received, that actually arrived at theproper receiving units. Very few of the operatingmicroscopes were ever found—even after the warended—although numerous attempts were made totrack this equipment. Basically, we found that try-ing to fill such critical gaps in specialty equipmentafter arriving in theater was hopeless. The resultwas that ocular casualties were, in general, poorlytreated by many hospitals, particularly those near-est where the casualties were generated.

Fortunately, the personnel of one GH and sev-eral EHs were actually moved directly into well-equipped, preexisting Saudi Arabian medical cen-ters. Thus, ophthalmologists and other surgicalsubspecialists from these units inherited relativelyhigh-quality equipment and a modern hospital set-ting. This arrangement enabled the evacuation sys-tem to have several high-quality eye centers inSaudi Arabia, where some severe ocular casualtiescould be diverted.

At other hospitals, unfortunately, because pa-tients had coexisting wounds that left them unstablefor evacuation, ophthalmologists were frequentlyforced to treat severe ocular injuries with substan-dard equipment or risk complications as a result ofnot closing the wounds. For example, suturing cor-neal lacerations with loupes, inappropriate sutures,and without viscoelastics was commonplace. Thisresulted in the need for many patients to beresutured on transfer to a hospital with appropri-

34


ate microsurgical equipment and supplies. There isno question that this lack of proper equipment ledto increased ocular morbidity in wounded soldiers.Thus, fewer than a half dozen well-equipped ophthal-mologists in Saudi Arabia provided most of the de-finitive ophthalmic care, which led to some ophthal-mologists being overwhelmed with surgical cases.

In addition to equipment needs, ophthalmologysupplies such as viscoelastics, silicone tubing, andsome antibiotics were difficult to obtain through theoverwhelmed medical supply system. Many oph-thalmologists found the US mail, coupled with over-seas telephone service, to be a viable resupply al-ternative.

To improve troop morale, the military quicklyestablished civilian-operated satellite telephonebanks in Saudi Arabia. These were initially creatednear the coasts, but by December 1990, divisions inmore remote areas also had telephones. This high-priority communication system was of far higherquality than the poor systems used by medicalunits. In fact, it was easier to contact anyplace inthe United States from these telephone banks inSaudi Arabia than to use the military telephones tocall an EH that was only 100 miles away. The mailsystem from the United States was also dependableand well cared for, and it was a major moralebooster. Thus, the fastest and most dependable re-supply system for small medical items was to call afriend at your parent hospital in the United Statesand ask him or her to obtain supplies and send themto you via the US mail. This method used two, high-priority, dependable, established systems, and itproved beneficial to physicians and patients; usingit and individual initiative could somewhat enhancethe supply system.

Frequency and Severity of Eye Injuries

Fortunately, few serious ocular injuries occurredduring Operation Desert Shield. Several corneal/scleral lacerations, hyphemas, lid lacerations, andfacial fractures were treated, but considering thatover half a million troops were present in theater,the number of serious injuries was surprisingly low.I suspect that the no-alcohol policy helped to de-crease the incidence of serious accidents, and thiswas reflected in the low number of ocular injuries.However, corneal abrasions and FBs were extremelycommon. Several severe sandstorms occurred be-fore Operation Desert Storm, and they producedinnumerable soldiers with embedded sand cornealFBs. These injuries were usually painful and inca-

pacitating. Fortunately, several CSHs in the Corpsarea had slitlamps that were used effectively toremove corneal FBs. This local ability to remove cor-neal FBs greatly decreased the need for time-con-suming medical evacuation to larger hospitals. Fre-quently, periocular fractures, lid and canalicularlacerations, and corneal/scleral lacerations werealso successfully repaired and followed up at CSHs,which greatly lessened the strain on the evacuationsystem. Finally, contact lens problems related todust and sand were extremely common early in thedeployment, because many soldiers arrived in the-ater without backup eyeglasses. This situationlargely resolved after facilities for making prescrip-tion eyeglasses became available in theater.

By the start of the air war in mid January 1991,more than 20 ophthalmologists were in theater.Most were in stationary Army EHs and Navy fleethospitals, and few had access to state-of-the-artbasic ophthalmic field equipment. By variousmeans, however, ophthalmologists were slowly ac-cumulating equipment and supplies that wouldenable them to provide some form of care towounded soldiers. Most had acquired slitlamps.The 6 weeks of air war gave ophthalmologists an-other reprieve in which they cross-leveled equip-ment and supplies to the best advantage. Althoughtheater ophthalmologists made a concerted effortto share supplies and equipment, the extremelypoor theater communication system between hos-pitals made this difficult.

Simultaneously with the air war, mobile hospi-tals slowly moved closer to the Iraqi border, roughlyin the same area with the divisions they would latersupport during the ground invasion. For example,by the start of the air war, my unit had moved 150miles further north and was located about 20 milessouth of King Khaleid Medical Center, which wasless than 100 miles south of the Iraqi border. Dur-ing the entire air war, our mobile hospital, as wellas most others, was nonfunctional, because all theequipment was packed on trucks in preparation forthe invasion of Iraq. Therefore, any serious injury,ocular or otherwise, that occurred during this timewas sent directly to the closest EH, bypassing themobile hospitals. About 3 weeks before the inva-sion, most mobile hospitals, including my own,moved further north to within about a dozen milesof the Iraqi border. By the time of the invasion, ourCSH had been downsized for increased mobility.We went from a 200-bed, partially mobile hospitalto a 24- to 30-bed, fully mobile hospital (Figure 2-13). (NOTE: construction of a 200-bed CSH required

35

Lessons Learned

Fig. 2-13. Aerial view of the 47th Combat Support Hos-pital at Division Support Area 3 in Iraq (24th InfantryDivision). Such downsized hospitals were used duringthe Persian Gulf War to increase mobility.

several days, whereas the small, fully mobile ver-sion could be functional in < 6 h.) This change wasnecessary to keep up with divisions that would soonbe advancing fast, deep into Iraq. On the day of theinvasion, my unit was incorporated into a huge con-voy that entered Iraq in support of the 24th Infan-try Division.

During the air war, which began 15 January 1991,ocular casualties continued to be light, for the mostpart. Most ocular injuries were of the variety thatwe would expect to see with a large number ofyoung troops, and were related to accidents or ath-letic injuries. There were two exceptions:

1. Not long into the air war, the Iraqis beganto launch SCUD missiles into Saudi Arabia.They were poorly aimed and frequently hitby our Patriot missiles, but the SCUDs oc-casionally landed in or around the troopsor other populated areas and caused nu-merous injuries, ocular and otherwise.SCUD missile alerts were also a disruptivenuisance to all because they forced soldiersto don their cumbersome chemical protec-tive clothing.

2. The second exception was the Iraqi attackinto Kafji, Kuwait, just north of the SaudiArabian border. This led to an Allied re-sponse, largely Marine, which resulted ina small number of serious ocular injuries.Thus, the air war provided a few Alliedocular casualties but nothing that stressedthe system.

Medical Evacuation

With the onset of Operation Desert Storm, themedical situation changed drastically and exposedthe strengths and weaknesses of the medical caresystem. All hospitals, from forward surgical teamsto GHs, had known for weeks of the plan and tim-ing for the invasion of Iraq and Kuwait. The care-fully planned medical evacuation system, heavilydependent on helicopter assets, was well under-stood by all units (Figure 2-14). The basic medicalevacuation plan was (1) to provide lifesaving medi-cal and surgical care to wounded patients at mo-bile hospitals in Iraq and Kuwait, and then (2) totransport the injured quickly by air to larger, bet-ter-equipped hospitals in northern Saudi Arabia formore-definitive care. Because of the long distancestraveled into Iraq by Allied forces, however, par-ticularly in the western desert, the evacuation chainwas longer and considerably more complex in theIraqi theater, compared with the less-extendedevacuation lines of the Kuwaiti theater.

The chief strength of the plan was the evacua-tion system itself. The air ambulance assets, largelyUH-1 and UH-60 aircraft, were dependable andnumerous enough to provide excellent and timelypatient transport. For ophthalmologists, the chiefweakness of the medical system, as previously dis-cussed, was the lack of appropriate equipment toadequately treat serious ocular injuries, largely atthe EH level. Thus, although the movement of pa-tients was well planned and supported, the oph-

Fig. 2-14. Map showing hospital positions in Iraq andnorthern Saudi Arabia at the time of the ceasefire in thePersian Gulf War.

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thalmic treatment rendered was, in general, sub-standard.

Insights From the Persian Gulf War

Although detailed descriptions of ocular andocular adnexal injuries treated during the PersianGulf War have previously been published,26,27 fourfindings should be emphasized:

• Fragmentation injuries from various muni-tions accounted for 78% of ocular injuriesin Operation Desert Storm (Figure 2-15).This approximate percentage has been re-markably consistent in every major warsince World War I. Thus, not surprisingly,corneal/scleral lacerations, IOFBs, retinalinjury, and traumatic cataract accounted fortwo thirds of ocular injuries described dur-ing Desert Storm. These data suggest thatocular surgeons must have the surgical skilland equipment to treat such injuries—sothey can salvage injured eyes.

• Of the nearly 200 serious ocular injuriesreported during Operation Desert Storm,32% occurred in Iraqi troops. The Iraqimedical evacuation and treatment systemswere greatly disrupted during the air warbefore the ground invasion. Thus, many Ira-qis who were wounded in the ground warreceived little or no care before they were

Fig. 2-15. Fragmentation wounds in a young soldier. Notethat some degree of protection was offered at the time ofinjury by the patient’s flak vest. This is in contrast to theneck and face areas, which received numerous fragmen-tation wounds.

treated by advancing Allied medical per-sonnel. In the mobile hospitals in Iraq andKuwait, where many Iraqis first receivedcare, it was common to see gangrenous,debris-laden, nearly amputated limbs,which had never received even basic firstaid. Although no statistics are available, thisdelay in treatment of injured Iraqi person-nel undoubtedly increased ocular morbid-ity. The most common injury by far in Iraqisoldiers occurred as a result of blast frag-mentation from exploding ordnance of an“unknown” variety. Most Iraqis literallyhad no idea what hit them.

• Among the battle wounded of any nation-ality during Operation Desert Storm, iso-lated ocular injuries were rare. Becausemost ocular injuries resulted from blastfragmentation, the typical wounded soldierhad numerous additional nonocular frag-mentation wounds. Patients were rarelyanesthetized solely to treat an eye wound.Typically, a patient was delivered by heli-copter, quickly evaluated in the emergencyroom by various surgeons, and then, if nec-essary, taken to the OR. Once anesthesiawas achieved, several surgeons would op-erate simultaneously on the patient toquickly and efficiently treat all the injuries.During mass casualties, OR time was veryvaluable; the goal was to treat the patientand rapidly turn the room around for thenext casualty. Only rarely was time allot-ted for extensive, time-consuming surgeryof any kind. The main ophthalmic goal ina mass casualty situation was to obtainwatertight ocular closure. If time was avail-able during the initial surgical procedure,more-complex surgery such as extensivevitrectomy and lensectomy was accom-plished. Frequently, such time-consumingprocedures were postponed until appropri-ate operating time was available.

• The Persian Gulf War also demonstrated theoccurrence of ocular injuries caused byplastic landmines (Figure 2-16) as well aslasers. Although their mechanisms of injurydiffer markedly, plastic landmines and la-sers have some elements in common: bothare relatively inexpensive to produce andeasy to use, and their damage potential andlethality will increase with advances intechnology. Although the numbers of theseinjuries were comparatively small during

37

Lessons Learned

Fig. 2-16. Landmines used by Iraqi forces during the Per-sian Gulf War. Those on the left and right were made inItaly, and the landmine in the center was manufacturedin Russia; all are composed largely of plastic. Reproducedwith permission from Mader TH, Aragones JV, ChandlerAC, et al. Ocular and ocular adnexal injuries treated byUnited States military ophthalmologists during Opera-tions Desert Shield and Desert Storm. Ophthalmology.1993;100:1465.

the Persian Gulf War, the potential is hugethat such injuries will occur in future con-flicts. Unfortunately for the casualties, the

localization of plastic FBs and the propercare of laser injuries has been and contin-ues to be problematical.

SUMMARY

Few would contest the proposition that thosewho stand in the day of battle for us all deserve thebest medical care possible. It should, therefore, bethe objective of the military ophthalmologist tomake the gap between the practice of ophthalmol-ogy in the TO and the highest standards in CONUSas small as possible. This is accomplished by

• keeping in mind the principles that under-lie such practice in the TO;

• incorporating advances made in civilianophthalmology into military ophthalmol-ogy as soon as possible;

• fighting for the resources required to pro-vide such care;

• educating all who deal with eye-injuredcasualties;

• putting the best military ophthalmologistsin the TO so that they can provide immedi-ate, expert, definitive care to casualties witheye injuries and diseases;

• urging the wearing of eye armor during theconduct of all eye-hazardous activities;

• having a senior ophthalmologist serve asthe TO ophthalmology consultant; and

• learning to work with neurosurgeons andhead-and-neck surgeons.

The injuries that cannot be prevented should receivethe very best care our country is capable of provid-ing, and that care must be provided within the TO.Deferring expert eye care until after the casualty isevacuated from the theater will produce prevent-able blindness. Denying appropriate eye care to thenontransportable casualty in the TO will do thesame.

The Persian Gulf War demonstrated how quicklyocular injuries can be generated in a modern battle-field. The war also exposed the fact that the overallophthalmic surgical capabilities in theater weresuboptimal. It clearly showed the absolute neces-sity of providing appropriate equipment and train-ing to surgical units during peacetime so that theycan be properly prepared for wartime deployment.This conflict may also have given us a preview ofnew types of ocular injuries to be seen in futurewars. Therefore, the Persian Gulf War confirmed thelessons of the past and was perhaps an ominousintroduction to the ophthalmic injuries of the fu-ture.

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Lessons Learned

25. Zajtchuk R, Bellamy RF, Jenkins DP, eds. Combat Casualty Care Guidelines: Operation Desert Storm. Washington,DC: Department of the Army, Office of The Surgeon General, and Borden Institute; 1991.

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