Terror-Related Ocular Trauma in Patients Presenting to a Tertiary Eye Center in the Middle East.

PURPOSE: Injuries caused by explosive materials are associated with severe ocular morbidity and visual impairment. This study aims to document the ophthalmic morbidity of terrorist-related severe injuries at a tertiary eye care center in the Middle East and report specific injury patterns.
METHODS: In a noncomparative, interventional, retrospective case series, the visual outcomes were evaluated of 36 patients treated at a tertiary eye center in the Middle East for terrorist-related injuries from January 2003 to December 2019. Data were collected on age, gender, involved eye, initial examination of ocular injuries, associated systemic injuries, presenting visual acuity, anterior and posterior segment examinations, and the type of injury (open vs. closed globe).
RESULTS: Among the 36 patients (32 males; average age, 28.1 years), 28 (77.8%) sustained trauma to one eye and 8 (22.2%) to both eyes. Despite multiple surgical procedures (average 3.1 surgeries), all patients suffered a severe visual loss. Final visual acuity of no light perception was recorded in 28 (77.8%) eyes and both eyes of 5 patients (13.9%).
CONCLUSION: Ophthalmic morbidity from terrorist-related injuries may be devastating, and the vast majority of patients experience a permanent loss of vision. Copyright:

Introduction

Terrorist-related injuries have been reported to be more severe than nonterror-related injuries.[1] Patients who have experience terror attacks have an increased need for acute care to achieve the best accessible prognosis.[1] The incidence of severely injured eyes in the battleground increased due to the development of weapons with higher explosive and fragmentation power.[2] Terror-related ocular injuries mainly cause open globe injury a significant source of visual impairment.[3]

Among the organs in the body, the globe is very susceptible to injury caused by small fragments from explosives leading to devastating visual outcomes.[3]

Terror-related injuries have become a threat for everyone in the civilized world. These injuries tend to carry a poor prognosis and may be disabling to the community. Saudi Arabia has suffered from several terrorist-related attacks since 1995, resulting in many casualties and injuries including ocular trauma. Many of these patients have been referred to our center for initial or subsequent management. This report aims to review our experience dealing with cases of terror-related ocular trauma at a tertiary eye care center in Saudi Arabia.

Methods

A retrospective review was performed of all terrorism-related ocular injuries in patients presenting to or referred to the Ophthalmic Emergency Department at the King Khaled Eye Specialist Hospital (KKESH) from January 2003 to December 2019. Medical records were reviewed for patient demographics, the extent of ocular or periocular trauma, diagnostic examinations, surgical intervention(s), and final outcome. Medical and surgical interventions, including primary repair and repeat surgeries, were evaluated for impact on the final outcome. The impact of the injuries was evaluated on the individual and their families, especially if they were of working age group.

Data were collected on the following clinical variables: patient age, gender, eye involved, cause of injury, diagnosis, visual acuity at presentation, and the duration of follow-up. The best-corrected visual acuity (BCVA) at the last follow-up (final visit) was compared between open and closed eye injury groups. The type of ocular injury was classified according to the Birmingham Eye Trauma Terminology system. At presentation and all follow-up visits, a comprehensive ophthalmic examination was performed on all patients. BCVA was measured with a Snellen chart at 6 m distance. Data were collected using an Excel spreadsheet (Microsoft Office 2010; Redmond, WA, USA). Univariate analysis was performed using Statistical Package for Social Sciences (SPSS 25; IBM Corp., Armonk, NY, USA). The mean and standard deviation (SD) was reported for normally distributed quantitative variables. Qualitative variables were presented as frequencies and percentage proportions. For subgroup analysis validation of continuous variables, the Student's t-test was performed, and a two-sided P < 0.05 was considered statistically significant.

Results

The study sample comprised 36 patients who were the victims of terrorist-related ocular injuries [Table l]. There were 32 (88.9%) males and 4 (11.1%) females with an average age of 28.1 years (range, 9–57 years). Twenty-eight (77.8%) victims had sustained trauma to one of their eyes [Figures 1-3], while 8 (22.2%) patients sustained bilateral ocular trauma [Figure 4]. All patients had open-globe injuries. Eyelid and/orbital injuries were present in 33 (91.7%). All patients required primary repair of their ocular injuries, and 26 (72.2%) required multiple procedures (average 3.1 surgeries) [Figure 1]. The final visual acuity of No light perception was recorded in 28 (77.8%) eyes and both eyes of five patients (13.9%). Twenty-four (66.7%) patients required evisceration, enucleation, or conjunctival flap for a blind painful eye or cosmetic rehabilitation. The usual indication for early enucleation/evisceration is to prevent sympathetic ophthalmia in nonsalvageable eyes.

Table 1

Demographic features of the study group

Characteristic	n (%)
Age (years)	28.1
Gender
Male	32 (88.9)
Female	4 (11.1)
Laterality
Unilateral	28 (77.8)
Bilateral	8 (22.2)
Type of ocular injury
Open globe	36 (100)
Eyelid/orbital injuries	33 (91.7)
Ocular procedure
Primary repair	36 (100)
Multiple procedures	26 (72.2)

Figure 1

This 36-year-old security guard sustained severe trauma to the left side. Ocular, periocular, and facial injuries along with orbital fractures were documented. The patient required primary evisceration and an orbital implant along with layered closure of his eyelid and facial injuries. Because of the significant enophthalmia on the left side, he required orbital floor augmentation with Medpore implant resulting In adequate volume and improved cosmesis

Figure 3

This 51-year-old physician who was the victim of a suicide bomb attack was referred 3 weeks after sustaining ocular, periocular, and other bodily injuries. The patient required initial repair of his ocular injuries followed by removal of embedded foreign bodies, evisceration, and placement of an orbital implant to achieve acceptable cosmesis

Figure 4

This 28-year-old General Practitioner was referred to our center 3-week after sustaining severe ocular and bodily injuries during a suicide attack. The patient experienced a complete loss of vision in his left eye and was found to have an intraocular foreign body in the right eye. After stabilization of his bodily wounds, the patient required removal of foreign body from his right eye and evisceration along with placement of an orbital implant in his left orbit

This 25-year-old male security guard was a victim of a suicide car blast in which he suffered severe ocular, periocular, and head injuries resulting in loss of vision. The patient required initial repair followed by enucleation and an orbital implant, a cosmetic prosthesis, and repair of his bony orbital fractures

Discussion

Injuries caused by explosive materials are strongly associated with severe ocular morbidity and visual impairment.[4] Terror-related injuries have become an undeniable threat for populations all over the world. Experience has shown that terror-related eye injuries are more severe than nonterror-related ones.[1] Due to ideological differences, bombing in terrorist attacks has increased globally; hence, acute care and strategies to treat the resulting injuries may be necessary to attain the best outcomes.[5] Since 1983, terrorist attacks against civilian and military targets have occurred worldwide including the Middle East, the United States and Europe and most of the developing and developed nations.[16] Although not fatal, ocular trauma generally is a significant problem since the eye provides the most vital function for survival, and ocular injury can be very disabling.[67] The incidence of terror-related eye injuries differs according to the sample size and mechanism of action. For example, in the Oklahoma City bombing, approximately 8% of victims had an ocular injury.[8] On the other hand, in the World Trade Center attack on September 2001, more than 26% of the survivors had ocular injuries.[9]

Our experience dealing with terror-related ocular injuries at KKESH indicated that more than one surgery might be required to achieve functional and cosmetically acceptable results after the initial repair of the ocular and periocular damage. Some additional surgeries include cataract extraction with or without intraocular lens implantation, vitreoretinal surgeries to treat endophthalmitis, removal of retained intraocular foreign bodies, and retinal detachment repair. Some cosmetic surgeries include scar revision, correction of ptosis, and repair of orbital fractures. To the best of our knowledge, no previous study has looked into the patient demographics, the extent of their ocular and periocular injuries, surgical intervention, and treatment outcome in patients with terror-related ocular trauma presenting to a tertiary eye care center such as KKESH. Terror-related injuries are similar to warfare-related eye injuries. For example, during the Korean Conflicts war (1950–1953), the incidence of ocular injuries was between 5% and 7%,[10] and in the desert storm war (1990–1991), the incidence was over 13%.[7] The mechanism of injuries may be either missile fragments due to gunshot wounds and/or falling building debris such as stone and pieces of glass windows.[8] Building occupants and front-line security may encounter both mechanisms of ocular injuries. Similar to previous studies, our results show that males are more likely to be the victims of terror-related ocular injuries.[1] Improvised explosive devices which can be detonated remotely have been used. These weapons are used as anti-personal weapons and can be placed in cars, buildings, or buried along the roadside.[1112]

Kalayci et al.[4] describe the types and severity of ocular injuries experienced by survivors of a bomb-laden blast on December 28, 2019, in Mogadishu, Somalia. Ocular injuries were found in 28 of the 114 individuals. Sixteen open-globe injuries were laceration type, and ten were rupture type. They conclude that the employment of vehicle-borne improvised explosives in terrorist-related incidents is increasing the prevalence of blast-related eye injuries. Our results suggest that despite major advances in ophthalmic surgical techniques and various medical treatments, the prognosis of ocular injuries due to terrorist attacks remains poor.[6] Nevertheless, some victims can still achieve favorable functional vision through early and careful intervention.[1] The outcomes of the current study indicate that it may not be possible to address any preventive and safety measures that could be implemented in the future to reduce the extent of these injuries. However, one may need to be aware of the poor outcomes and potential complications after primary repair of such devastating injuries and the possibility of further surgeries for both functional and cosmetic ocular rehabilitation.

Statement of ethics

The study protocol was approved by the institutional review board of the KKESH, and it adhered to the tenets of the Declaration of Helsinki. The nature of the study and its possible consequences were explained to study participants. All participants have given their written informed consent to participate in this study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.