Risk Factors for Failure of Final Anatomic Surgical Reattachment in Retinal Detachments From Combat Ocular Trauma.

BACKGROUND AND OBJECTIVE: The goal of this study was to determine the anatomic outcome of traumatic retinal detachment (RD) from combat ocular trauma. MATERIALS AND METHODS: Retrospective study of patients sustaining a traumatic RD in Operation Iraqi Freedom and Operation Enduring Freedom who were evacuated to Walter Reed Army Medical Center from 2001 to 2011. The Fisher exact test, Wilcoxon rank sum test, and Agresti and Coull methods were used for analyses. RESULTS: There were 143 eyes of 134 patients in which a traumatic RD developed, of a total of 890 eyes of 652 patients in the Walter Reed Ocular Trauma Database. Based on our results, predictors for failure to reattach the retina include maculaoff status (P = .0002), open-globe injury (P = .03), proliferative vitreoretinopathy postoperatively (P = .002), and presence of hyphema (P = .02). Intraocular foreign body and time to initial retinal surgery did not increase risk for failure. Thirty-four percent (34%) of eyes failed to be reattached. CONCLUSIONS: Traumatic RD due to injury sustained in a combat zone resulted in poor prognosis, with 82.09% of eyes with RD having a best-corrected visual acuity worse than 20/200. The anatomic success of RD repair was shown to be 65.71%, likely owing to the severity of the injuries, concomitant systemic injuries, and delayed surgical intervention. [Ophthalmic Surg Lasers Imaging Retina 2022;53:493-501.].

Globe and Adnexal Trauma Terminology Survey.

Importance: Ocular trauma terminology should be periodically updated to enable comprehensive capturing and monitoring of ocular trauma in clinical and research settings. Objective: To update terminology for globe and adnexal trauma. Design, Setting, and Participants: A 2-round modified Delphi survey was conducted from January 1 to July 31, 2021, using an expert panel, including 69 ophthalmologists identified through their membership in ophthalmology (globe and adnexal trauma) societies. Consensus was defined as at least 67% expert agreement. A steering committee developed questions after identifying gaps in the current terminology via a targeted literature review. Round 1 sought consensus on existing and newly proposed terminology, and round 2 focused on unresolved questions from round 1. Experts included ophthalmologists who had managed, on average, 52 globe or adnexal trauma cases throughout their careers and/or published a total of 5 or more globe or adnexal trauma-related peer-reviewed articles. Main Outcomes and Measures: Expert consensus on ocular and adnexal terms. Results: A total of 69 experts participated in and completed round 1 of the survey. All 69 participants who completed round 1 were asked to complete round 2, and 58 responses were received. Consensus was reached for 18 of 25 questions (72%) in round 1 and 4 of 7 questions (57%) in round 2. Existing Birmingham Eye Trauma Terminology system terminology achieved consensus of 84% (58 of 69 experts) in round 1 and 97% (56 of 58 experts) in round 2. Experts agreed on the need for further refinement of the definition of zones of injury (55 of 69 [80%]), as the zone affected can have a substantial effect on visual and functional outcomes. There was consensus that the mechanism of injury (52 of 69 [75%]) and status of the lacrimal canaliculi (54 of 69 [78%]), nasolacrimal ducts (48 of 69 [69%]), lens (46 of 58 [80%]), retina (42 of 58 [73%]), and central and paracentral cornea (47 of 58 [81%]) be included in the revised terminology. Conclusions and Relevance: There was consensus (defined as at least 67% expert agreement) on continued use of the existing Birmingham Eye Trauma Terminology system definitions and that additional terms are required to update the current ocular trauma terminology.

Correlative Factors for Traumatic Brain Injury in Combat Ocular Trauma.

INTRODUCTION: Traumatic brain injury (TBI) remains a significant source of disability for active duty service members in both deployed and training settings as well as those who have left active service. Service members with ocular trauma are at risk for a TBI and should be screened appropriately. Early detection results in treatment to minimize long-term sequelae which can often be debilitating. This study is the first to evaluate different combat-related ocular injuries and their associations with TBI. MATERIALS AND METHODS: A secondary analysis of existing data was conducted from a prospective study of patients who sustained combat ocular trauma (COT) during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) between 2006 and 2020. Clinical data of a total of 88 participants were gathered and each case reviewed, including patient demographics, injury-related factors, history of TBI, and treatments rendered. All cases were then categorized to compare COT (n = 13) versus COT-T (Combat Ocular Trauma associated with TBI; n = 75). The Fisher's exact test was completed for each category to assess for predictive factors of TBI within the ophthalmic trauma cohort. Odds ratios were calculated with their 95% CI. RESULTS: When compared to COT, COT-T was significantly associated with closed globe injuries (56%; OR 4.24, 95% CI 1.08-16.67), blast injuries (89.3%; OR 3.72, 95% CI 0.93-14.9), multiple surgeries (89%; OR 2.51, 95% CI 0.57-11.08), anterior segment injuries (69.3%; OR 1.41, 95% CI 0.42-4.79), optic nerve injuries (24%; OR 1.05, 95% CI 0.26-4.25), orbital fractures (48%; OR 2.08, 95% CI 0.59-7.34), enucleation (17.3%; OR 2.52, 95% CI 0.300-21.08), the use of eye protection (68.6%; OR 2.18, 95% CI 0.57-8.32), and the need to undergo plastic surgery (78.7%; OR 2.30, 95% CI 0.66-8.02). Significant factors associated with COT included penetrating injury (30.8%; OR 0.027, 95% CI 0.07-1.08), posterior segment injuries (92%; OR 0.264, 95% CI 0.032-2.17), bilateral injuries (76.9%; OR 0.678, 95% CI 0.17-2.69), and bilateral blindness (7.7%; OR 0.857, 95% CI 0.092-7.99). CONCLUSIONS: Patients who have sustained combat-related ocular injuries, specifically blast injury, anterior segment injury, or an orbital fracture, were noted to be more likely to have also sustained a TBI. However, of the evaluated variables in predicting the co-occurrence of TBI, only closed globe injury was identified as statistically significant. Service members with injuries requiring multiple surgical procedures, reconstructive plastic surgery, or enucleation of an eye were also more likely to be diagnosed with a TBI, but these variables were not found to be predictive of TBI among ocular trauma patients. The presence of eye protection was not protective against TBI. Further studies are needed to find significant predictors of TBI in combat ocular trauma patients to assist in the early and accurate detection of TBI.

Ophthalmic trauma: the top 100 cited articles in Ophthalmology journals.

OBJECTIVES: To analyze the top 100 cited papers on ophthalmic trauma. METHODS: A literature search of Ophthalmology journals within the ISI Web of Science database for the most cited papers related to ophthalmic trauma. RESULTS: The most cited articles were published between 1943 and 2013, the greatest number being published in 2000. Ophthalmology (45), Archives of Ophthalmology (17), and the American Journal of Ophthalmology (15) published most of the articles. The institutions with the highest number of publications were Wilmer Eye Institute (10) and Massachusetts Eye and Ear Infirmary (7). Sixty-seven percent of the articles originated from the USA. The most common type of trauma studied was non-open-globe injuries and the most frequent topic studied were pathological conditions secondary to trauma (34), particularly endophthalmitis (8), and optic neuropathy (6). Articles presenting a standardized classification system for eye injury received the highest average of citations per publication. Types of research most frequently cited were observational clinical studies (62) and epidemiological studies (30); the least frequent were clinical trials (2). CONCLUSION: This bibliographic study provides a historical perspective of the literature and identifies trends within the most highly influential papers on ophthalmic trauma. Many of these articles emerged within the past three decades and came from Ophthalmology journals that remain high impact to this day. Clinical trials have been difficult to conduct and are lacking, reflecting a critical need in ophthalmic trauma research, as most of our understanding of ophthalmic trauma comes from observational and epidemiological studies.

Endophthalmitis: a bibliographic review.

PURPOSE: To analyze the 100 most cited articles pertaining to endophthalmitis using bibliometric analysis. METHODS: An all-time Web of Science literature search and refined to peer-reviewed articles in the field of ophthalmology with the keyword "endophthalmitis" was completed. Total citation count of articles published pertaining to endophthalmitis, topic, incidence rate, publishing journals, year published, language, country of origin, number of authors, names of the first and last authors, study type, and number of patients/eyes studied. RESULTS: The top 100 most cited articles pertaining to endophthalmitis had a mean citation count of 362.92, with a range of 175 to 3583. They were published in 20 peer-reviewed journals, with Ophthalmology publishing the most (n = 42). Thirteen different countries were represented, with the majority (n = 77) originating from the USA. The most common study type was clinical experiences (n = 52), though eight of the top ten were clinical trials. The number of patients varied widely, represented by a mean of 9680, but with a median of only 229. The majority (n = 67) examined the incidence of endophthalmitis which included 24 articles after anti-vascular endothelial growth factor injections, 18 after ocular surgeries/procedures, 15 after intraocular steroid injections, eight after chemotoxic drug use, and three after ocular injuries. CONCLUSION: This bibliographic study serves as a unique historical analysis of the top 100 cited scholarly articles pertaining to endophthalmitis with many of the articles related to post-procedural endophthalmitis.

Open-globe wounds in operation Iraqi Freedom and Operation Enduring Freedom: risk factors for poor visual outcomes and enucleation.

PURPOSE: To determine the rates and types of open-globe wounds in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries. METHODS: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were patients who suffered open-globe injuries. Open-globe injuries were classified by type of wound: corneal, corneo-scleral or scleral, or type of open-globe injury: perforating, rupture, penetrating or intraocular foreign body. The primary analysis assessed the effect on final visual acuity (VA) and the risk of enucleation. RESULTS: In this study, 285 (32.02%) open-globe injuries were recorded in 890 eyes in the data set. Corneal wounds were noted in 127 (44.56%) eyes, corneo-scleral wounds in 78 (27.37%) and scleral wounds in 129 (45.26%) eyes. The involvement of both the corneal and sclera was associated with poorer visual outcome (BCVA < 20/200) compared to injuries with an injury confined to either the cornea or scleral alone (p = 0.038). At a wound length of greater than approximately 14 mm, patients had 75% chance of having a poor final VA. Enucleation was performed in 64 (22.46%) eyes of patients with wounds. The type of wound was not found to be predictive of enucleation in multivariate analysis, but rather the type of open-globe injury was predictive. Perforating (OR: 1.58, 95% CI: 1.43-1.72) and globe rupture injuries (OR: 1.49, 95% CI: 1.33-1.66) were more likely to undergo enucleation. CONCLUSIONS: Open-globe injuries occur frequently in combat ocular trauma. Poor final VA was noted most with corneo-scleral wounds with approximately 50% of patients having a final VA less than 20/200.

A History of Anti-VEGF Inhibitors in the Ophthalmic Literature: A Bibliographic Review.

Purpose: This work aimed to analyze the 100 most-cited articles on antivascular endothelial growth factor (anti-VEGF) inhibitors. Methods: A literature search for anti-VEGF inhibitors using the Web of Science was completed using the bibliographic databases for peer-reviewed literature published in Ophthalmology, the New England Journal of Medicine, Journal of the American Medical Association, and Lancet. Primary outcomes were the most frequently cited articles and journals with the most citations as well as the specific drug and disease process studied. Results: There were 42 696 cumulative citations among the top 100 articles. The articles were published between 2004 to 2016, with most articles published in 2006. Ophthalmology published the greatest number of articles among the top 100 at 48, whereas the New England Journal of Medicine has the most citations per publication at 1714. Ranibizumab was the medication researched in most articles at 56, followed by bevacizumab at 48, aflibercept at 10, and pegaptanib at 9. Forty-two articles investigated treatment of age-related macular degeneration, followed by 24 investigating diabetic macular edema, 10 for retinal vein occlusion, 8 for proliferative diabetic retinopathy, 2 for retinopathy of prematurity and polypoidal choroidal vasculopathy, and 1 for corneal neovascularization. Conclusions: As evidenced by the considerable number of citations accumulated over the past 20 years, anti-VEGF inhibitors have led to significant research in ophthalmology.

Proliferative Vitreoretinopathy After Combat Ocular Trauma in Operation Iraqi Freedom and Operation Enduring Freedom: 2001-2011.

BACKGROUND AND OBJECTIVE: To determine the risk factors associated with developing proliferative vitreoretinopathy (PVR) from combat ocular injuries in U.S. service members. PATIENTS AND METHODS: Retrospective review of associated risk factors and outcomes of PVR within the Walter Reed Ocular Trauma Database. Ocular injuries in U.S. service members wounded during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2011 were assessed, and of these all cases of PVR were studied. Principal outcome measures were the risk factors associated with PVR development and rate of final visual acuity (VA) less than 20/200. RESULTS: Eight hundred ninety eyes of 651 U.S. service members were evaluated. A total of 76 eyes (8.5%) of 66 patients developed PVR. Five patients had bilateral PVR. Nineteen patients had bilateral eye injuries. Sixty-one eyes (80.2%) had a final VA less than 20/200. PVR was found to be a significant risk factor for a poor final VA (P < .001). Retinal detachment (RD) was found in 52 eyes (68.4%) of patients. In patients with a RD, intraocular foreign bodies (IOFBs) (P < .001), unsuccessful repair (P = .002), and macular hemorrhage (P = .04) were significant risk factors for the development of PVR. Time to initial retina surgery was not found to be a risk factor for PVR development (P = .5). Time to initial retina surgery was available in 41 patients and the time to surgery on average was 22.56 days (range: 3 to 87 days). CONCLUSIONS: PVR occurs frequently in combat trauma and is a significant cause of poor final VA. In patients with PVR and RD, injuries caused by an IOFB, macular hemorrhage, or unsuccessful repair were significant risk factors for the development of PVR. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:556-563.].

Assessment of Corneal Haze After PRK and the Effect of Sutureless Amniotic Membrane Graft by Corneal Densitometry.

PURPOSE: To assess whether densitometry analysis appropriately monitors the development of haze in myopic patients after photorefractive keratectomy (PRK) when compared to subjective slit-lamp haze grade examinations, and whether sutureless cryo-preserved amniotic membrane reduced postoperative haze development when compared to the standard bandage contact lens. METHODS: In this retrospective cohort at the Center for Refractive Surgery, Walter Reed National Military Medical Center, a secondary analysis of prospectively collected data was performed. In the prospective study, participants underwent PRK for myopia. Postoperatively, a standard bandage contact lens was applied to the dominant eye and a sutureless cryo-preserved amniotic membrane graft to the nondominant eye. Participants were evaluated at 1, 3, and 6 months postoperatively for haze formation and corneal densitometry using slit-lamp biomicroscopy and Scheimpflug imaging, respectively. RESULTS: Densitometry measurements at 6 months postoperatively were positively and significantly associated with the presence or absence of haze as assessed by slit-lamp examination in 39 patients (78 eyes; age range: 21 to 44 years). Eyes with increased densitometry measurements had 2.3 to 3.4 times the odds (P ⩽ .014) of having clinical haze on slit-lamp examination. Eyes with the amniotic membrane graft showed a positive correlation with increased corneal densitometry throughout most layers of the cornea. CONCLUSIONS: Densitometry analysis appears to be a useful tool to supplement slit-lamp examination in monitoring haze development after PRK. The amniotic membrane failed to show a reduction in corneal densitometry in myopic eyes after PRK. [J Refract Surg. 2020;36(5):293-299.].

Orbital Fractures and Associated Ocular Injuries in Operation Iraqi Freedom and Operation Enduring Freedom Referred to a Tertiary Care Military Hospital and the Effect on Final Visual Acuity.

PURPOSE: To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. METHODS: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity. RESULTS: Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%). CONCLUSIONS: Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

Global Health Outreach by United States Ophthalmology Residency Programs: Understanding of Host Country Systems-Based Practice.

INTRODUCTION: For medical residents, global health outreach is the first experience of learning how to develop partnerships with foreign medical systems. The overall objective of this project was to develop an overview of global health programs in U.S. ophthalmology residencies. The investigation focused on characterizing the goals and services offered, the didactics taught to residents, and the program director's understanding of systems-based practice gained in the host country. MATERIALS AND METHODS: An online survey was sent to all U.S. ophthalmology residency program directors. The two outcome measures of the study were characterization of global health outreach and didactics completed by U.S. ophthalmology residency programs and review of program director understanding of host country systems of care. RESULTS: Twelve program directors of 117 (10.26%) answered the survey. 100% of programs from the Department of Defense responded. Countries served included Ecuador, Panama, Honduras, Dominican Republic, India, Tanzania, Nepal, Bhutan, Guatemala, Micronesia, Haiti, Mongolia, Bolivia. Sixty five percent worked at a free-standing public hospital. Many programs offered resident participation with only 41.87% giving residents ACGME credit. Most programs (91.67%) offered fewer than 5 hours of global health didactics. When program directors were asked about their knowledge of host country systems of care, most noted understanding of the hospital functions like the referral system, transitions of care, hospital funding, and medical supply chain, but not of the perception of patients with chronic or congenital ophthalmic diseases, host country general or ophthalmic medical education, patient research safeguards and host country malpractice system. CONCLUSION: From the small sample of program directors, Ophthalmology residency program global health outreach varies in faculty and resident participation, and in goals and services offered. In addition, there was a wide variation in ophthalmology program director understanding of host country systems of care.

Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011.

PURPOSE: To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. METHODS: The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. RESULTS: One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). CONCLUSION: Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001-2011.

PURPOSE: To describe outcomes and associated ocular injuries of lateral canthotomy and cantholysis (LCC) as performed in combat ocular trauma. METHODS: Data from the Walter Reed Ocular Trauma Database of patients requiring LCC during Operations Iraqi Freedom and Enduring Freedom was reviewed as a retrospective cohort. Primary outcome measures included final visual acuity (VA) and Ocular Trauma Score. Secondary outcome measures were associated injuries and timing of surgery. RESULTS: Thirty-six LCCs were recorded on a total of 890 eyes (4.04 %) in the Walter Reed Ocular Trauma Database. Eighteen out of 36 eyes (50.00%) had a final VA of the affected eye of 20/200 or worse vision. From the initial available VA measured either at the time of injury or at Walter Reed Army Medical Center, 13 eyes (40.63%) had no change in VA, 15 eyes (46.88%) had improvement, and 4 (12.5%) had a decrease in VA (n = 32, data unavailable for 4 eyes). Ocular Trauma score 0-65 was noted in 14 (38.9%) and 66-100 (61.1%). Retinal detachment (6, 16.67%), optic nerve injuries (7, 19.44%), orbital fractures (20, 55.56%), and retrobulbar hematoma (25, 69.44%) were commonly associated injuries. Of the 36 LCC, 18 (50.00%) were performed as the first surgery performed at the combat support hospital, 13 (36.11%) as the second, 4 (11.11%) as the third, and 1 (2.78%) as the fourth. CONCLUSIONS: The largest subgroup of patients had an improvement in VA associated with performance of LCC; however, half of patients remained with a final VA of equal to or worse than 20/200 due to severe ocular trauma.

Traumatic cataracts secondary to combat ocular trauma.

PURPOSE: To describe the characteristics, visual outcomes, and predictive value of the Ocular Trauma Score (OTS) in eyes with traumatic cataract from combat ocular trauma. SETTING: Walter Reed Army Medical Center, Washington, DC, USA. DESIGN: Retrospective case series. METHODS: Records of service members with traumatic cataract from combat ocular trauma over a 7-year period were reviewed. Visual acuity at initial presentation and visual acuity at the final follow-up were compared in addition to outcomes in closed versus open globes, by final lens status, and in eyes receiving primary versus secondary intraocular lenses (IOLs). Visual outcomes were predicted using the OTS and compared to the achieved corrected distance visual acuity (CDVA). RESULTS: A total of 181 eyes of 167 patients were included in the final analysis. Twenty-six percent of all eye injuries sustained traumatic cataract. The mean final visual outcome was 0.86 logMAR ± 1.01 (SD) with 44 no light perception (NLP) eyes and 26 light perception (LP) eyes compared with an initial visual acuity of 2.41 ± 0.88 logMAR with 27 no NLP eyes and 64 LP eyes (P ≤ .001, 2-tailed Student t test). Final CDVAs in eyes receiving primary IOLs were 0.72 ± 0.84 logMAR with 1 NLP and 1 LP eye versus 0.51 ± 0.78 logMAR with 2 LP eyes in eyes receiving a secondary IOL (P = .37, Student t test). CONCLUSION: Traumatic cataracts are frequently associated with ocular trauma. The OTS is a reliable means of predicting visual outcome. There was no difference in eyes receiving primary IOLs versus secondary IOLs. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Causes of combat ocular trauma-related blindness from Operation Iraqi Freedom and Enduring Freedom.

BACKGROUND: The incidence of eye injuries in military service members is high in the combat setting. This is the first study that identifies the primary reason for poor visual acuity (worse than 20/200). METHODS: This is a retrospective, noncomparative, interventional case series analyzing US Operation Iraqi and Enduring Freedom members who were evacuated from the theater of operations to Walter Reed Army Medical Center from 2001 through 2011. Primary outcome measures were the length of follow-up, globe survival, and anatomic causes of blindness. Secondary outcome measures included surgical procedures performed, use of eye protection, nonocular injuries, incidence of traumatic brain injury, source of injury, visual outcomes, and predictability of Ocular Trauma Score (OTS) on visual outcome. Univariate analysis was performed using χ and Fisher's exact test. A p < 0.01 was considered significant because of the multiple hypotheses tested. RESULTS: There were 265 eyes of 239 patients who had final best-corrected visual acuity of worse than 20/200. The average age was 27.4 years (range, 19-53 years). Of the patients, 97.5% were male, and 28.9% had documented use of eye protection. The average follow-up was 350.19 days (range, 3-2,421 days). There were 128 right-eye and 133 left-eye injuries, with a total of 26 bilateral injuries. There were 206 open-globe and 56 closed-globe injuries, which were further subdivided into zones. Open-globe Zone III injuries (81.6%) were the number one cause of blindness, and most injuries were caused by improvised explosive devices (64.2%). Enucleation was the most common surgery performed (40.6%) and therefore the leading cause of blindness, followed by a multifactorial cause and direct traumatic optic neuropathy. CONCLUSION: Ocular trauma is common among combat injuries. Close to a third of service members that experience an ocular trauma become legally blind. Further research is needed to focus on strategies to prevent injury and improve visual outcomes. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V.

Visual and anatomic outcomes of vitrectomy with temporary keratoprosthesis or endoscopy in ocular trauma with opaque cornea.

BACKGROUND AND OBJECTIVE: To examine the outcomes of vitrectomy in ocular trauma with opaque cornea. PATIENTS AND METHODS: This retrospective study included 17 eyes of 16 patients who underwent vitrectomy with temporary keratoprosthesis or endoscopy at Walter Reed Army Medical Center, Washington, DC, from March 2003 to October 2010. RESULTS: A temporary keratoprosthesis was used in 8 eyes (47%) and endoscopy in 9 eyes (53%). Overall, the number of eyes with visual acuity of 20/200 or better improved from 0 at baseline to 5 (29%) at 6 months. The number of eyes with retinal detachment also improved from 10 (59%) at baseline to 3 (18%) at 6 months. CONCLUSION: Vitrectomy may be safely performed in ocular trauma with opaque cornea using a temporary keratoprosthesis or endoscopy with comparable outcomes. Endoscopy allows earlier diagnosis and treatment of occult pathology and requires less time and fewer procedures to implement than the temporary keratoprosthesis.

Same-day versus delayed vitrectomy with lensectomy for the management of retained lens fragments.

PURPOSE: To evaluate whether performing same-day pars plana vitrectomy versus delayed pars plana vitrectomy affects visual outcomes and ocular morbidity of patients with retained lens fragments after a complicated cataract surgery. METHODS: Retrospective, comparative case series of 172 eyes of 171 patients with retained lens fragments undergoing 3-port pars plana vitrectomy using 20-, 23-, or 25-gauge instrumentation between 2005 and 2008. Outcome measures included best-corrected visual acuity at 6 months, final best-corrected visual acuity, and postoperative complications such as cystoid macular edema, intraocular pressure elevation, retinal detachment, vitreous hemorrhage, choroidal hemorrhage, and endophthalmitis. RESULTS: The median age was 75 ± 0.8 years. The mean time to vitrectomy for the delayed group was 15 ± 2 days. The preoperative logarithm of the minimum angle of resolution best-corrected visual acuity for immediate vitrectomy was 0.73 ± 0.09 versus 0.72 ± 0.06 for delayed vitrectomy. Six-month logarithm of the minimum angle of resolution acuity was 0.44 ± 0.09 for same-day vitrectomy compared with 0.44 ± 0.05 for delayed vitrectomy (P = 0.97, 2-tailed t-test). Of 59 eyes undergoing immediate vitrectomy, 17 (29%) experienced postoperative complications, while 38 of 113 eyes (34%), experienced complications if undergoing delayed vitrectomy (Fisher exact test, P = 0.61). Overall, the most common complication was cystoid macular edema occurring in 25 of 172 eyes (15%). CONCLUSION: The outcomes of same-day pars plana vitrectomy appear to be similar to non-same-day pars plana vitrectomy. The risks and benefits related to the timing of vitrectomy after a complicated cataract surgery should be carefully discussed with each patient. Further investigation is warranted to establish an optimal time for surgical planning.

Retrospective comparison of 25-gauge transconjunctival sutureless vitrectomy to 20-gauge vitrectomy for the repair of pseudophakic primary inferior rhegmatogenous retinal detachment.

PURPOSE: To compare anatomical and functional outcomes of 25-gauge transconjunctival sutureless pars plana vitrectomy (PPV) to standard 20-gauge 3-port PPV for the treatment of pseudophakic rhegmatogenous retinal detachments with inferior breaks. METHODS: Retrospective review of 78 consecutive eyes from 78 patients undergoing primary vitrectomy with a minimum of 3-month follow-up. Thirty patients underwent 25-gauge PPV and 48 patients underwent 20-gauge PPV from May 1993 to July 2008. Variables and outcome measures included patient demographics, retinal reattachment, best-corrected visual acuity, macular status, postoperative intraocular pressures, and surgical complications. RESULTS: Preoperative characteristics were similar in both groups. Single operation success rate was 25/30 (83.3%) for 25-gauge cases and 43/48 (89.6%) for 20-gauge cases (P = 0.50). Transient hypotony occurred in 6/30 25-gauge eyes and 1/48 20-gauge eyes (P = 0.01), whereas hypertension occurred in 10/30 25-gauge cases and 15/48 20-gauge cases. All but 2 eyes were attached at final follow-up (97%). At final follow-up, mean best-corrected visual acuity was 0.28 and 0.32 for the 25-gauge and 20-gauge groups (P = 0.74). CONCLUSION: Outcomes of 20-gauge versus 25-gauge PPV for the management of pseudophakic inferior rhegmatogenous retinal detachments were not significantly different, with hypotony being the most significant postoperative complication in the 25-gauge group as compared with the 20-gauge group.

Traumatic macular holes secondary to combat ocular trauma.

PURPOSE: This study reports on the visual impact of combat related traumatic macular hole formation at a single tertiary referral center. METHODS: Retrospective, noncomparative, interventional consecutive case series. RESULTS: Seventeen of 432 consecutive traumatic macular holes occurred in 387 United States soldiers during Operations Iraqi and Enduring Freedom between March 2003 and October 2006. The median age was 28 +/- 9 years (range, 19-49 years) and the median follow-up was 292 +/- 453 days (range, 59-1640 days). Closed-globe macular holes equaled 11 of 234 cases (5%), and open-globe macular holes were 6 of 198 (3%). Traumatic macular hole was associated with a retinal detachment in 8 of 17 cases (47%). The overall documented macular hole closure rate was 9 of 15 cases (60%). There was no statistical difference in hole closure rates between surgery and observation (P = 0.34). Severe nonocular injuries occurred in 12 of 17 (71%), with the median time to macular hole surgical repair of 18 +/- 37 days (range, 7-132). There was a significant positive association between the Ocular Trauma Score equal to or greater than 80 and a best-corrected visual acuity of 20/200 or greater (r = 0.87, n = 15; P < 0.005). CONCLUSION: Traumatic macular hole occurs in both open and closed globe combat trauma with high rates of nonocular injuries. Visual outcome is highly variable despite macular hole closure in a majority of patients due to concomitant globe injuries. The Ocular Trauma Score is useful in predicting final visual acuity and traumatic macular hole closure.

Combat ocular trauma and systemic injury.

PURPOSE OF REVIEW: To review the recent literature regarding combat ocular trauma during hostilities in Operations Iraqi Freedom and Enduring Freedom, describe the classification of combat ocular trauma, and offer strategies that may assist in the management of eye injuries. RECENT FINDINGS: Several recent publications have highlighted features of combat ocular trauma from Operation Iraqi Freedom. The most common cause of today's combat ocular injuries is unconventional fragmentary munitions causing significant blast injuries. These explosive munitions cause high rates of concomitant nonocular injuries such as traumatic brain injury, amputation, and other organ injuries. The most frequent ocular injuries include open-globe and adnexal lacerations. The extreme severity of combat-related open-globe injuries leads to high rates of primary enucleation and retained intraocular foreign bodies. Visual outcomes of intraocular foreign body injuries are similar to other series despite delayed removal, and no cases of endophthalmitis have occurred. Despite these advances, however, significant vision loss persists in cases of perforating globe injuries as well as open and closed-globe trauma involving the posterior segment. SUMMARY: This review summarizes the recent literature describing ocular and systemic injuries sustained during Operations Iraqi and Enduring Freedom. An emphasis on classification of ocular injuries as well as a discussion of main outcome measures and complications is discussed.