Saving Sight on the Frontlines

Ukrainian ophthalmologists continue to push their medical and surgical skills to the limit in dealing with the devastating impact of eye injuries incurred among both the civilian population and military personnel in the ongoing war with Russia.

The horrific extent of those injuries—and the various strategies employed by Ukrainian ophthalmologists to deal with them—were brought forcibly home to delegates during a special session on ocular trauma at the 2023 ESCRS Congress in Vienna.

Eye trauma is estimated to account for up to 13% of all injuries in modern warfare, and the war in Ukraine is no exception, said Dr Valerii Serdiuk, who recounted his experience of combat surgery over the past nine years.

“Evolution in warfare tactics means that anti-personnel mines and various explosive devices—both improvised and produced by industry—have become the main causes of eye combat trauma in all military conflicts,” he said. “Other causes include wounds from firearms and accidents.”

Thousands of military and civilian patients have been treated by the eye specialists at Dnipropetrovsk Hospital since the outbreak of conflict, said Dr Serdiuk, adding his teams typically encounter a high level of complex ocular polytrauma, often in association with other head, neck, face, or systemic injuries.

The advanced fragmentation weapons used in modern conflicts result in a high rate of ocular trauma, with binocular injuries in 34% and penetrating injuries in 42% of cases.

“The high percentage of eye injuries in the first months of the war was related to the shortage of protective eyewear and a lack of awareness on the part of military personnel about the threat to their visual health,” he said.

In this regard, he noted eight eviscerations/enucleations were performed from 2014 to 2021, but seven of those were carried out before September 2014, when protective eyewear use became widespread.

Dealing with ocular polytrauma requires a clear strategy on the part of the surgeon, Dr Serdiuk said. In penetrating and blunt eye injuries, there is usually combined damage to the anterior and posterior segments, including the cornea, iris, and retina, causing significant and diverse clinical and functional disorders in the injured eye.

Rapid intervention is also important to improve the prospects of saving sight in patients with severe ocular polytrauma, Dr Serdiuk added.

The complex nature of the ocular injuries facing surgeons in Ukraine was also described in detail by Professor Nadiia Ulianova, who reported on her experience treating combat victims at the Filatov Institute of Eye Diseases and Tissue Therapy in Odesa.

“Modern combat trauma is particularly severe and requires complex reconstructive treatment,” she said. “The optimal timing for pars plana vitrectomy (PPV) for open globe injury varies from one to four weeks from the moment of injury, and eight weeks postinjury for keratoplasty.”

Prof Ulianova outlined the challenges of performing vitrectomy in traumatic injury cases.

“The most common indications for vitrectomy in cases of ocular trauma are vitreal haemorrhage, retinal detachment, intraocular foreign bodies, and macular holes,” she said. “All these indications are usually present in severe combat injuries.”

Although vitrectomy in trauma cases should ideally be performed as soon as possible, the reality is logistical difficulties in displacing wounded individuals from the frontlines and ensuring treatment of other life-threatening injuries often affect the timing of ocular surgery, she added.

Prof Ulianova listed some specific features of eye trauma due to modern combat, including extensive open globe injuries and multiple foreign bodies in the cornea. She highlighted strategies to deal with some of these scenarios, including using keratoprostheses, amniotic membrane, and soft contact lenses—either individually or in combination with PPV to try to rehabilitate the ocular structures and save vision.

Removing intraocular foreign bodies (IOFB) is common in combat-induced ocular trauma, requiring surgeons to call upon a wide range of techniques to achieve a successful outcome, noted Professor Ihor Novytskyy.

He recounted his experience at Lviv Military Hospital operating on 81 patients, 45 of whom had IOFBs.

“We encounter several problems in removing large IOFB,” he explained. “The bigger the size of the object, the bigger the tips of the forceps we must use. We must be careful to avoid retinal damage when manipulating the IOFB and trying to remove it safely and effectively from the eye without incurring further damage to the ocular structures.”

Small metallic IOFBs can be removed using intraocular magnets, but those larger than 3 mm and non-metallic fragments require specialised grasping forceps for removal, he said. To minimise retinal damage during grasping and lifting, perfluorocarbon fluids or viscoelastic in the vitreous cavity use is recommended.

Prof Novytskyy added IOFBs can be displaced from the vitreous cavity through a posterior capsulorhexis into the anterior chamber, followed by removal through a corneal incision.

“This technique usually works quite well, but the problem to be aware of is the possibility of the object retreating into the vitreous cavity,” he concluded.

Valerii Serdiuk MD, PhD, Professor of the Department of Ophthalmology and Neurology of the Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine. ophthalmologygroup.ukraine@gmail.com

Nadiia Ulianova MD, PhD, Head of the Department of Post-traumatic Eye Pathology, Filatov Institute of Eye Diseases and Tissue Therapy, Odesa, Ukraine.

Ihor Novytskyy MD, PhD, Professor of Ophthalmology, Lviv National Medical University, Ukraine. inovytskyy@gmail.com