Trauma of War Laid Bare in Ukraine Focus Session

Ukrainian ophthalmologists face a daunting array of challenges—medical, organisational, and logistical—trying to provide sight-saving care for its military and civilian population on the front line of its ongoing war with Russia.

The extent of these challenges, and the horrific toll on the Ukrainian people in devastating eye injuries incurred during the conflict, were described in graphic detail in a special session on ocular trauma at the 40th Congress of the ESCRS in Milan.

Andrii Ruban MD, PhD discussed the challenges of treating patients in a war zone, with specialised ophthalmic equipment often destroyed or damaged and a shortage of trained medical and support personnel, making it extremely difficult for clinics to function properly. He noted the medical challenges are primarily associated with the severity of operating on combat-related eye injuries.

“We encounter a high level of complex ocular polytrauma and a high level of association of ocular injuries with other head, neck, face, or systemic injuries,” he said. “There are delays in being able to treat patients due to the conditions of war and difficulties with evacuation. And the patients often have other life-threatening injuries that need to be treated first.”

The advanced fragmentation weapons used in modern conflicts result in a high rate of ocular trauma, Dr Ruban noted.

“Blast injuries are the most horrific thing I have ever encountered,” he said. “One in every three patients is blind in one eye, and one in every ten is blind in both eyes. The surgery is very challenging and requires knowledge of the anterior and posterior segments and oculoplasty skills as well.”

All of these factors, he added, can take a mental toll on the treating surgeon.

“The challenges for the ophthalmic surgeon are also psychological; there is a lot of stress, overload from working around the clock in difficult conditions, and dealing with the absence of family and friends while facing traumatic situations every day.”

The nature of the ocular injuries facing surgeons in Ukraine was described in detail by Ihor Novytskyy MD, who reported on 48 eyes of 42 patients treated at Lviv Military Hospital. The injuries included, among others, corneal trauma, iris damage, traumatic cataract, vitreous haemorrhage, intraocular foreign bodies, and retinal detachments.

“The majority of the eyes had combined damage of the different structures of the eye,” he explained. “Eleven patients had blunt trauma injuries, and 31 patients had penetrating eye injuries. Many of these patients will need to be reoperated in the future.”

Focusing on reconstructive surgery for combat eye injuries, Natalia Grubnyk MD pointed out that although February 2022 is considered the official start of the war with Russia, the conflict actually started with the annexation of Crimea by Russian forces in 2014. She expressed gratitude for ESCRS support, adding that supplies of ophthalmic equipment—including an endoscope to the hospital where she works in Odesa—have proven very helpful in treating eye injuries. She noted reconstructive vitreoretinal surgery timing remains a major problem due to difficulties evacuating and transporting patients, as well as the need for polytrauma treatment in other hospitals.

Discussing cases of traumatic cataract in the Ukrainian military, Volodymyr Melnyk MD, PhD noted obtaining the best results in cataract surgery usually involves a combination of criteria difficult to obtain in a conflict scenario: a minimal corneal incision between 2.0 to 2.5 mm, undamaged capsular bag and ciliary band, and no penetration of vitreous into the anterior chamber, followed by IOL implantation corresponding to the patient’s needs at the greatest extent possible.

“Obviously it is not the same for all cases of traumatic cataract, but we still try to do our best for our patients to ensure they obtain the best outcome possible under difficult circumstances,” he said.

Traps to avoid

Ferenc Kuhn MD, PhD also underlined this point, discussing common traps to avoid when dealing with traumatic cataract. The initial traps are essentially diagnostic, he said.

“We have to be sure this is really a cataract and not perform cataract surgery unless the diagnosis is absolutely certain,” he stressed. “A second, more complicated diagnostic dilemma entails knowing whether the posterior capsule is intact or not, which goes unrecognised intraoperatively in about half of all operated eyes.”

Another key difference is traumatic cataract patients are invariably younger than standard cataract cases, which means a strong adherence between the posterior capsule and the anterior hyaloid, as well as between the anterior hyaloid and the peripheral retina.

“The risk, if phacoemulsification is employed, is that you may aspirate vitreous and put traction on the peripheral retina,” Dr Kuhn said. “The only way to really know if the vitreous has prolapsed is to use triamcinolone, which is not typically what cataract surgeons do.”

Andrii Ruban MD, PhD President of the Ukrainian Vitreoretinal Society.

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

Volodymyr Melnyk MD, PhD The Head of the Society of Ukrainian Ophthalmic Surgeons. suo.org.ua@gmail.com

Natalia Grubnyk MD

Ferenc Kuhn MD, PhD is a noted authority on ocular trauma with teaching positions in the United States, Poland, and Serbia. fkuhn@mindspring.com