- Email: [email protected]
Eye injury in the Israeli Defense Force: “An ounce of prevention is worth a pound of cure”
G Model
JINJ-6069; No. of Pages 4 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’ Sami Gendler a,b,*, Roy Nadler a,b, Tomer Erlich a,b, Ofir Fogel b, Guy Shushan c, Elon Glassberg a,b a b c
Surgeon General’s HQ, Israel Defense Force, Ramat Gan, Israel Department of Military Medicine, Hebrew University, Jerusalem, Israel Technology and Logistics Branch, Personal Protection Equipment Section, Israel Defense Force, Ramat Gan, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 22 January 2015
Background: The eye occupies 0.1% of the total body surface yet it accounts for 8–13% of battle injuries in modern warfare worldwide. Protective eyewear can prevent over 90% of these eye injuries in both military and civilian settings. This study presents an analysis of a military casualty database and describes the proportion and distribution of eye injuries among Israel Defense Force (IDF) Soldiers. Methods: All trauma patients recorded in the IDF Trauma Registry (ITR) in whom ocular injury related to combat or to training was documented were reviewed. Results: There were 129 patients with documented eye injury sustained during combat or training between 1997 and 2013: 75% of injuries were related to combat and the remainder occurred during training. Penetrating fragmental injuries accounted for 74% of combat related injuries and 28% of training related injuries. Sixty-six percent (66%) of these casualties were subsequently re-classified as no longer fit for combat duties. Combat related injuries resulted in a higher incidence of severe injuries compared to training related injuries (P < 0.05). Conclusions: Despite optimal medical care, the majority of soldiers who sustain eye injuries during military service suffer from substantial disability and most are no longer fit for combat service. A majority are discharged from military service. Protective eyewear could potentially prevent penetrating fragmental wounds which are the most common cause of injury. Further research on optimal orbital protection is critical for both the military and the civilian sectors. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Ocular injury Protective eyewear Military
Background The eye represents 0.1% of the total body surface yet it accounts for 8–13% of battle injuries in modern warfare worldwide [1,2]. Compromise of eyesight can have serious adverse effects on quality of life in both the military and the civilian setting but there are additional implications for soldiers. In the military setting, eye injuries may require the redirection of limited available resources for evacuation of the casualty thus endangering his fellow combatants and jeopardizing the success of the mission.
* Corresponding author at: The Trauma and Combat Medicine Branch, Medical Corps, Surgeon General’s Headquarters, Military POB 02149, Israel Defense Force, 02149, Israel. Tel.: +972 54 5454021; fax: +972 3 7373917. E-mail address: [email protected] (S. Gendler).
It may also render the soldier unfit for further service in a combat unit. The proportion of ocular injuries has increased in military conflicts from 2% in the First and Second World Wars and 2.8% during the Korean war, rising to 9% in the Vietnam war and 13% in Operation Iraqi Freedom and Operation Enduring Freedom [1,3]. During the period of this study, 1997–2013, The Israeli Defense Force (IDF) was constantly engaged in routine security missions and, at times, in high intensity conflicts (the 2nd Lebanon war in 2006 and operation ‘‘Cast Lead’’ in the Gaza strip in 2009). Eye injuries come at high cost to society [4,5] and can be reduced by the use of protective gear [6,7]. The purpose of this study was to analyze a military casualty database and to describe the proportion and distribution of eye injuries among soldiers and to evaluate whether these injuries could have been prevented or mitigated with the use of eye protection.
http://dx.doi.org/10.1016/j.injury.2015.01.035 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Gendler S, et al. Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.01.035
G Model
JINJ-6069; No. of Pages 4 S. Gendler et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
Methods The IDF Trauma Registry (ITR) The Israel Defense Force Trauma Registry (ITR) is a pre-hospital registry active since 1997 under the Trauma and Combat Medicine Branch (TCMB), Surgeon General’s Headquarters. Data are collected in the form of casualty cards that include demographics, information concerning mechanism and anatomic distribution of injury and point of injury vital signs, and interventions including procedures, use of medications and administration of fluids. These cards allow for documentation of the injury scenario including tactical responses. The casualty card is attached to the patient, allowing for data collection along different echelons. Upon arrival at the hospital, the card is scanned and later conveyed to the TCMB. Data are then recorded and registered at the ITR. For the purpose of this study, a search was done through the registry for patients suffering ocular injuries between 1997 and 2013. The IDF medical profiling system The IDF medical profiling system is a set of numbers assigned to various medical conditions. The medical profile (MP) reflects the recruit’s current health status and is used by the Personnel Directorate to assign a military position that is consistent with that health status. Similar to coding systems such as the International Classification of Diseases (ICD), medical functional classification codes describe disorders, and their severity, and thus determine the profile [8]. The MP ranges from 21 (not fit for military service) to 97 (subject is fit for all assignments): an MP of 64 or lower precludes service in combat positions. Each diagnosis is assigned a range of MP’s, depending on the severity (e.g. minor fractures are assigned a MP of 82, severe fractures can result in a MP of 21). Statistical analysis Continuous data are presented as means and standard deviations, categorical data are presented as numbers and percentile where appropriate. This report was conducted under the approval of the IDF MC as a process review and improvement project.
Results From September 1997 to April 2013 a total of 7476 casualties were recorded in the ITR. 237 suffered from eye injury, of which 108 eye injuries were occupational or recreational. 129 occurred during combat or training and were included in the study. Table 1 Casualty demographics and characteristics.
N Male/female Age Urgency Urgent Non urgent Dead Unknown Mechanism Blunt Penetrating Unknown
Mean age was 22.7 (5.0) years, 127 (98%) were male. The mechanism was penetrating in 93 (72%) casualties of which 81 (63%) were due to fragments; 3 injuries were the result of a GSW to the eye. In 6 additional patients the reported mechanism of injury was listed as blast injury but the significant component of the injury was probably the fragments propelled by the blast (secondary blast injury). Blunt injury accounted for 22 (17%) casualties. In 5 patients the eye was injured by thorns or branches. In 6 casualties the mechanism of injury was not recorded. The IDF medical corps CPGs instructs triage of trauma casualties into three categories. Those sustaining injuries resulting in risk to life, limb or function (including eyes) are defined as ‘‘urgent’’ while casualties suffering less severe injuries are defined as ‘‘nonurgent’’. A third category, ‘‘expectant’’, is used mostly in multiple casualty events: it refers to casualties who are deemed non salvageable. In this series of patients suffering ocular injuries, 68 casualties were triaged as ‘‘non-urgent’’ whereas 48 casualties were triaged as ‘‘urgent’’. Three casualties classified as ‘‘expectant’’ died. The cause of death for all three casualties was severe penetrating head injury. One casualty was determined dead before reaching a Medical Treatment Facility (MTF), while the remaining two casualties died after reaching a MTF. Ninety-seven (75%) of the injuries were combat related and the remainder (25%) injuries occurred during training. Demographic data and injury characteristics according to injury setting are presented in Table 1. Distribution of Concomitant injuries is presented in Table 2. Facial injuries were the most common (61.2%), followed by injuries to the extremities (19.4%). Apart from concomitant injury to the face, injuries to extremities were most associated with eye injury. Data relating the specific ocular injury and the resultant medical profile were available for 65 (50%) patients. Of these 65 casualties, 43 (66%) were assigned a MP of 64 or lower precluding further combat duties; 26 (40%) soldiers received a MP of 21 and were discharged from military service. Table 3 lists the diagnosis and appropriate medical profile in the study group. Discussion The incidence of combat eye injury has risen progressively since 1967. During the six-day war in 1967 the ocular injury rate was 5.6% [9]. In Yom Kippur war, 1973, ocular injuries were recorded in 6.7% of all casualties [10] and the same rate 6.8% was noted [11] in the first Lebanon war. In the second Lebanon war in 2006, Israel’s last major high intensity conflict, ocular injury rate was 8% [2]. The ocular injury rate peaked at 11% during Operation ‘‘Cast Lead’’ in 2008 (unpublished data). The higher incidence of ocular injury during the latter two conflicts is probably reflective of the improvement in truncal protective armour as well as in vehicle armour which led to a relative increase in the proportion of ocular injury [11]. Table 2 Distribution of concomitant injuries.a
Combat related
Training
P
97 96/1 22.4 (3.0)
32 31/1 23.61 (6.1)
0.44 0.47
39 49 3 6
9 21 0 2
0.2
17 78 2
13 15 4
0.05
Face Upper extremity Lower extremity Head Chest Burn Abdomen and pelvic Neck Spine a
Count
Column Total N %
79 14 11 9 8 6 4 3 1
61.2% 10.9% 8.5% 7.0% 6.2% 4.7% 3.1% 2.3% .8%
Some casualties had more than one injury.
Please cite this article in press as: Gendler S, et al. Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.01.035
G Model
JINJ-6069; No. of Pages 4 S. Gendler et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx Table 3 Assigned medical profiles and diagnosis. Diagnosis
MP range
N
Retinal injury Corneal erosions CNS injury Facial fractures Visual acuity Lens injury Pupil injury Cranial nerve damage Conjunctivitis
21–82 82 21–24 45–97 21–82 21–82 64 21 64
18 17 10 10 10 9 3 2 2
The scope of this report is unique as it characterizes military related ocular injuries sustained during combat or training over a period of 15 years during which the IDF engaged in both high intensity conflicts and ongoing security missions. Interim periods are characterized by a relatively stable overall incidence of ocular injury (under 5%) interrupted by transient increases in ocular injury incidence during high intensity conflicts. Sixty-six percent (66%) of the patients suffering ocular injuries had their medical profile lowered to a level not suitable for combat duties: 60% of these casualties were discharged from the military service because of the severity of their ocular damage. Although ocular injuries are not considered life threatening, these data emphasize the substantial burden caused by these injuries. Since providing proper assessment of severity of eye injuries and definitive treatment are almost impossible in the pre-hospital settings, the mainstay of first responder eye injury care is shielding, pain control and urgent transport to an appropriate centre for immediate ophthalmologic evaluation and consultation [12]. For Injuries during training, urgent evacuation to a medical facility involves few considerations other than the combatant’s well-being but urgent evacuation during combat entails risks to both the injured soldier and his fellow combatants. According to the IDF-MC all eye injuries should have been classified as urgent. In our series less than 50% of casualties were appropriately triaged as urgent while most were wrongly triaged as non-urgent resulting in an under estimation of the tactical burden that these injuries entail. Considering the economic burden (cost of surgery, compensation claims, disability pensions) and the personal non-economic burdens (aesthetic, quality of life), it is clearly cost-benefit effective to use eye protective gear [13]. Evidence regarding the contribution of protective eyewear (PE) is highly consistent. In the civilian setting, in the U.S., more than 2.5 million eye injuries occur each year resulting in more than 50,000 patients suffering complete or partial loss of vision [14]. In
Fig. 1. Standard IDF CGS.
3
such settings it is estimated that more than 90% of all eye injuries can be prevented with the use of protective eyewear [15,16]. It is also well established that PE significantly reduces both the incidence and the severity of combat related eye injuries. A study on 408 British combatants participating in the war of Iraq and Afghanistan showed that using PE reduced the risk of sustain eye injury by 90% [17]. Among IDF’s casualties of the first Lebanon war, there were no ocular injuries in soldiers who had ballistic protective goggles properly placed over the eyes at the time of injury [18]. In the current series penetrating fragmental wounds accounted for 65% of the injuries. Fragmental penetrating injury is the leading cause of all eye injuries and the second leading cause in training related events. These data are similar to those reported by Ari et al., in an analysis of 207 casualties sustaining eye injury in Iraq in 2004, 82% of the ocular injuries were caused by fragmentary munitions [13]. Given that published data support the beneficial effects of PE on fragment related ocular injuries and since these injuries constitute the most frequent mechanism of eye damage in the IDF, it is clear that special emphasis should be placed on improving ocular protection. In the IDF, prior to 2012, Combat Googles System (CGS Fig. 1 were the eye protection glasses most often used). Adherence to use was inadequate. The reasons soldiers gave for not using PE were: limited field of view, tendency to fog up, easily scratched lenses and especially the shape and style of the frame [19]. In the first year of Operation Iraqi Freedom (OIF) 85% of soldiers sustaining combat related eye injuries were not using PE [20]. Due to the increase in eye injury incidence and combatant’s low compliance in using the standard PE, new alternatives were sought. The Authorized Protective Eye Wear (APEL) is the US army approved list for Ballistic Protective eyewear of qualified products that was assembled to encourage soldiers to use PE [21]. The approved commercial eyewear provides ballistic fragmentation as well as ultraviolet protection, and is available with both clear and grey lenses. The IDF adopted APEL’s PE standard. Accordingly in November 2012 the IDF purchased the Smith Optics Aegis (Smith Optics Inc., Idaho, Fig. 2) and since then it issued this eyewear to all combatants upon their recruitment. The IDF’s new protective spectacle consists of a plastic frame with interchangeable polycarbonate lenses. The frame and lens assembly weighs 43 g (3 times lighter than the CGS). The highimpact system exceeds U.S. military ballistic impact requirements for spectacles [22]. Tactical commanders are required to encourage and enforce the use (both in combat and in training) of this protective eyewear. The
Fig. 2. Smith Optic Aegis.
Please cite this article in press as: Gendler S, et al. Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.01.035
G Model
JINJ-6069; No. of Pages 4 S. Gendler et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
4
combatants’ compliance is essential for the prevention and mitigation of ocular injuries. Until 2013, it was not obligatory to record the casualty’s use of protective eyewear in the ITR. For that reason, although we can assume that the majority of casualties sustaining injury from fragments munitions were not wearing PE, it cannot be determined with certainty. In order to assess the effectiveness of the currently used PE, it is obligatory to record the use of PE in the latest version of the ITR. PE use in the IDF, in training as well as in combat is stressed through all echelons of command and as part of the IDF comprehensive approach towards improving casualty care. Considering that 108 soldiers suffered eye injuries in non-military (occupational or recreational) activities, the use of protective eye wear should be encouraged in these ‘‘civilian’’ situations as well. Finally, since data collection ended shortly after the introduction of the new IDF protective spectacles, further studies will be needed in order to describe the severity and incidence of eye injury in the IDF following the implementation of the new eye protective gear. Conclusion Despite optimal medical care, military eye injuries are a significant cause of substantial disability as the majority of these injuries result in incompatibility with combat duties in previously healthy soldiers. Penetrating fragmental wounds are the most prevalent cause of combat related eye injuries. They are potentially preventable by appropriate protective eyewear. Lessons learned from the data presented led the IDF to modifications in doctrine, procurement and training. Ongoing data acquisition and analysis serves as the basis for improvement in combat casualty care as well as injury prevention. Financial support None. Conflict of interest None.
References [1] Weichel ED, Coyler MH, Ludlow SE, Bower KS, Eiseman AS. Combat ocular trauma visual outcomes during operations Iraqi and enduring freedom. Ophthalmology 2008;115(12):2235–45. [2] Barak A, Elhalel A, Pikkel J, Krauss E, Miller B. Incidence and severity of ocular and adnexal injuries during the Second Lebanon War among Israeli soldiers and civilians. Graefes Arch Clin Exp Ophthalmol 2011;249(12):1771–4. [3] Scott R. The injured eye. Philos Trans R Soc Lond B Biol Sci 2011;366(1562): 251–60. [4] Buckingham RS, Whitwell KJ, Lee RB. Cost analysis of military eye injuries in fiscal years 1988–1998. Mil Med 2005;170(3):196–200. [5] Negrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5(3):143–69. [6] Thomas R, McManus JG, Johnson A, Mayer P, Wade C, Holocomb JB, et al. Ocular injury reduction from ocular protection use in current combat operations. J Trauma 2009;66(4 Suppl.):S99–103. [7] Cotter F, La Piana FG. Eye casualty reduction by eye armor. Mil Med 1991;156(3):126–8. [8] Chaiter Y, Palma E, Machluf Y, Yona A, Cohen A, Pirogovsky A, et al. Quality control and quality assurance of medical committee performance in the Israel defense forces. Int J Health Care Qual Assur 2010;23(5):507–15. [9] Treister G. Ocular casualties in the six-day war. Am J Ophthalmol 1969;68(4): 669–75. [10] Belkin M. Ocular war injuries in the Yom Kippur war. J Ocul Ther Surg 1983; 2:40–9. [11] Schwartz D, Glassberg E, Nadler R, Hirschhorn G, Marom OC, AharonsonDaniel L, et al. Injury patterns of soldiers in the second Lebanon war. J Trauma Acute Care Surg 2014;76(1):160–6. [12] American College of Surgeons. Pre hospital life support. Military 7th ed. 2011. [13] Ari AB. Eye injuries on the battlefields of Iraq and Afghanistan: public health implications. Optometry 2006;77(7):329–39. [14] Owens PL, Mutter R. Emergency Department visits related to eye injuries, 2008: statistical brief #112. In: Healthcare Cost and Utilization Project (HCUP) statistical briefs; 2006. Rockville, MD. [15] American Academy of Ophthalmology and American Society of Ocular Trauma. United States Eye Injury Registry summary report, 1998–2002. [16] National Institute for Occupational Safety and Health (NIOSH). Healthy people 2010.Vision. Fact sheet: Eye safety at work is everyone’s business 2014. www. cdc.gov/Features/dsworkPlaceEye/ [last accessed February 2014].. [17] Blanch RJ, Scott RA. Military ocular injury: presentation, assessment and management. J R Army Med Corps 2009;155(4):279–84. [18] Belkin M, Treister G, Dotan S. Eye injuries and ocular protection in the Lebanon War, 1982. Isr J Med Sci 1984;20(4):333–8. [19] Weichel ED, Colyer MH. Combat ocular trauma and systemic injury. Curr Opin Ophthalmol 2008;19(6):519–25. [20] Thach AB, Ward TP, Dick 2nd JS, Bauman WC, Madigan Jr WP, Goff MJ, et al. Intraocular foreign body injuries during Operation Iraqi Freedom. Ophthalmology 2005;112(10):1829–33. [21] Soldier PEO. Authorized protective eyewear list; 2010, Available from: https:// peosoldier.army.mil/equipment/eyewear/. [22] Soldier PEO. Authorized spectacles: Smith Optics Aegis; 2014, Available from: http://www.peosoldier.army.mil/equipment/eyewear/smithopticsaegis.asp.
Please cite this article in press as: Gendler S, et al. Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.01.035
JINJ-6069; No. of Pages 4 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’ Sami Gendler a,b,*, Roy Nadler a,b, Tomer Erlich a,b, Ofir Fogel b, Guy Shushan c, Elon Glassberg a,b a b c
Surgeon General’s HQ, Israel Defense Force, Ramat Gan, Israel Department of Military Medicine, Hebrew University, Jerusalem, Israel Technology and Logistics Branch, Personal Protection Equipment Section, Israel Defense Force, Ramat Gan, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 22 January 2015
Background: The eye occupies 0.1% of the total body surface yet it accounts for 8–13% of battle injuries in modern warfare worldwide. Protective eyewear can prevent over 90% of these eye injuries in both military and civilian settings. This study presents an analysis of a military casualty database and describes the proportion and distribution of eye injuries among Israel Defense Force (IDF) Soldiers. Methods: All trauma patients recorded in the IDF Trauma Registry (ITR) in whom ocular injury related to combat or to training was documented were reviewed. Results: There were 129 patients with documented eye injury sustained during combat or training between 1997 and 2013: 75% of injuries were related to combat and the remainder occurred during training. Penetrating fragmental injuries accounted for 74% of combat related injuries and 28% of training related injuries. Sixty-six percent (66%) of these casualties were subsequently re-classified as no longer fit for combat duties. Combat related injuries resulted in a higher incidence of severe injuries compared to training related injuries (P < 0.05). Conclusions: Despite optimal medical care, the majority of soldiers who sustain eye injuries during military service suffer from substantial disability and most are no longer fit for combat service. A majority are discharged from military service. Protective eyewear could potentially prevent penetrating fragmental wounds which are the most common cause of injury. Further research on optimal orbital protection is critical for both the military and the civilian sectors. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Ocular injury Protective eyewear Military
Background The eye represents 0.1% of the total body surface yet it accounts for 8–13% of battle injuries in modern warfare worldwide [1,2]. Compromise of eyesight can have serious adverse effects on quality of life in both the military and the civilian setting but there are additional implications for soldiers. In the military setting, eye injuries may require the redirection of limited available resources for evacuation of the casualty thus endangering his fellow combatants and jeopardizing the success of the mission.
* Corresponding author at: The Trauma and Combat Medicine Branch, Medical Corps, Surgeon General’s Headquarters, Military POB 02149, Israel Defense Force, 02149, Israel. Tel.: +972 54 5454021; fax: +972 3 7373917. E-mail address: [email protected] (S. Gendler).
It may also render the soldier unfit for further service in a combat unit. The proportion of ocular injuries has increased in military conflicts from 2% in the First and Second World Wars and 2.8% during the Korean war, rising to 9% in the Vietnam war and 13% in Operation Iraqi Freedom and Operation Enduring Freedom [1,3]. During the period of this study, 1997–2013, The Israeli Defense Force (IDF) was constantly engaged in routine security missions and, at times, in high intensity conflicts (the 2nd Lebanon war in 2006 and operation ‘‘Cast Lead’’ in the Gaza strip in 2009). Eye injuries come at high cost to society [4,5] and can be reduced by the use of protective gear [6,7]. The purpose of this study was to analyze a military casualty database and to describe the proportion and distribution of eye injuries among soldiers and to evaluate whether these injuries could have been prevented or mitigated with the use of eye protection.
http://dx.doi.org/10.1016/j.injury.2015.01.035 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Gendler S, et al. Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.01.035
G Model
JINJ-6069; No. of Pages 4 S. Gendler et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
Methods The IDF Trauma Registry (ITR) The Israel Defense Force Trauma Registry (ITR) is a pre-hospital registry active since 1997 under the Trauma and Combat Medicine Branch (TCMB), Surgeon General’s Headquarters. Data are collected in the form of casualty cards that include demographics, information concerning mechanism and anatomic distribution of injury and point of injury vital signs, and interventions including procedures, use of medications and administration of fluids. These cards allow for documentation of the injury scenario including tactical responses. The casualty card is attached to the patient, allowing for data collection along different echelons. Upon arrival at the hospital, the card is scanned and later conveyed to the TCMB. Data are then recorded and registered at the ITR. For the purpose of this study, a search was done through the registry for patients suffering ocular injuries between 1997 and 2013. The IDF medical profiling system The IDF medical profiling system is a set of numbers assigned to various medical conditions. The medical profile (MP) reflects the recruit’s current health status and is used by the Personnel Directorate to assign a military position that is consistent with that health status. Similar to coding systems such as the International Classification of Diseases (ICD), medical functional classification codes describe disorders, and their severity, and thus determine the profile [8]. The MP ranges from 21 (not fit for military service) to 97 (subject is fit for all assignments): an MP of 64 or lower precludes service in combat positions. Each diagnosis is assigned a range of MP’s, depending on the severity (e.g. minor fractures are assigned a MP of 82, severe fractures can result in a MP of 21). Statistical analysis Continuous data are presented as means and standard deviations, categorical data are presented as numbers and percentile where appropriate. This report was conducted under the approval of the IDF MC as a process review and improvement project.
Results From September 1997 to April 2013 a total of 7476 casualties were recorded in the ITR. 237 suffered from eye injury, of which 108 eye injuries were occupational or recreational. 129 occurred during combat or training and were included in the study. Table 1 Casualty demographics and characteristics.
N Male/female Age Urgency Urgent Non urgent Dead Unknown Mechanism Blunt Penetrating Unknown
Mean age was 22.7 (5.0) years, 127 (98%) were male. The mechanism was penetrating in 93 (72%) casualties of which 81 (63%) were due to fragments; 3 injuries were the result of a GSW to the eye. In 6 additional patients the reported mechanism of injury was listed as blast injury but the significant component of the injury was probably the fragments propelled by the blast (secondary blast injury). Blunt injury accounted for 22 (17%) casualties. In 5 patients the eye was injured by thorns or branches. In 6 casualties the mechanism of injury was not recorded. The IDF medical corps CPGs instructs triage of trauma casualties into three categories. Those sustaining injuries resulting in risk to life, limb or function (including eyes) are defined as ‘‘urgent’’ while casualties suffering less severe injuries are defined as ‘‘nonurgent’’. A third category, ‘‘expectant’’, is used mostly in multiple casualty events: it refers to casualties who are deemed non salvageable. In this series of patients suffering ocular injuries, 68 casualties were triaged as ‘‘non-urgent’’ whereas 48 casualties were triaged as ‘‘urgent’’. Three casualties classified as ‘‘expectant’’ died. The cause of death for all three casualties was severe penetrating head injury. One casualty was determined dead before reaching a Medical Treatment Facility (MTF), while the remaining two casualties died after reaching a MTF. Ninety-seven (75%) of the injuries were combat related and the remainder (25%) injuries occurred during training. Demographic data and injury characteristics according to injury setting are presented in Table 1. Distribution of Concomitant injuries is presented in Table 2. Facial injuries were the most common (61.2%), followed by injuries to the extremities (19.4%). Apart from concomitant injury to the face, injuries to extremities were most associated with eye injury. Data relating the specific ocular injury and the resultant medical profile were available for 65 (50%) patients. Of these 65 casualties, 43 (66%) were assigned a MP of 64 or lower precluding further combat duties; 26 (40%) soldiers received a MP of 21 and were discharged from military service. Table 3 lists the diagnosis and appropriate medical profile in the study group. Discussion The incidence of combat eye injury has risen progressively since 1967. During the six-day war in 1967 the ocular injury rate was 5.6% [9]. In Yom Kippur war, 1973, ocular injuries were recorded in 6.7% of all casualties [10] and the same rate 6.8% was noted [11] in the first Lebanon war. In the second Lebanon war in 2006, Israel’s last major high intensity conflict, ocular injury rate was 8% [2]. The ocular injury rate peaked at 11% during Operation ‘‘Cast Lead’’ in 2008 (unpublished data). The higher incidence of ocular injury during the latter two conflicts is probably reflective of the improvement in truncal protective armour as well as in vehicle armour which led to a relative increase in the proportion of ocular injury [11]. Table 2 Distribution of concomitant injuries.a
Combat related
Training
P
97 96/1 22.4 (3.0)
32 31/1 23.61 (6.1)
0.44 0.47
39 49 3 6
9 21 0 2
0.2
17 78 2
13 15 4
0.05
Face Upper extremity Lower extremity Head Chest Burn Abdomen and pelvic Neck Spine a
Count
Column Total N %
79 14 11 9 8 6 4 3 1
61.2% 10.9% 8.5% 7.0% 6.2% 4.7% 3.1% 2.3% .8%
Some casualties had more than one injury.
Please cite this article in press as: Gendler S, et al. Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.01.035
G Model
JINJ-6069; No. of Pages 4 S. Gendler et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx Table 3 Assigned medical profiles and diagnosis. Diagnosis
MP range
N
Retinal injury Corneal erosions CNS injury Facial fractures Visual acuity Lens injury Pupil injury Cranial nerve damage Conjunctivitis
21–82 82 21–24 45–97 21–82 21–82 64 21 64
18 17 10 10 10 9 3 2 2
The scope of this report is unique as it characterizes military related ocular injuries sustained during combat or training over a period of 15 years during which the IDF engaged in both high intensity conflicts and ongoing security missions. Interim periods are characterized by a relatively stable overall incidence of ocular injury (under 5%) interrupted by transient increases in ocular injury incidence during high intensity conflicts. Sixty-six percent (66%) of the patients suffering ocular injuries had their medical profile lowered to a level not suitable for combat duties: 60% of these casualties were discharged from the military service because of the severity of their ocular damage. Although ocular injuries are not considered life threatening, these data emphasize the substantial burden caused by these injuries. Since providing proper assessment of severity of eye injuries and definitive treatment are almost impossible in the pre-hospital settings, the mainstay of first responder eye injury care is shielding, pain control and urgent transport to an appropriate centre for immediate ophthalmologic evaluation and consultation [12]. For Injuries during training, urgent evacuation to a medical facility involves few considerations other than the combatant’s well-being but urgent evacuation during combat entails risks to both the injured soldier and his fellow combatants. According to the IDF-MC all eye injuries should have been classified as urgent. In our series less than 50% of casualties were appropriately triaged as urgent while most were wrongly triaged as non-urgent resulting in an under estimation of the tactical burden that these injuries entail. Considering the economic burden (cost of surgery, compensation claims, disability pensions) and the personal non-economic burdens (aesthetic, quality of life), it is clearly cost-benefit effective to use eye protective gear [13]. Evidence regarding the contribution of protective eyewear (PE) is highly consistent. In the civilian setting, in the U.S., more than 2.5 million eye injuries occur each year resulting in more than 50,000 patients suffering complete or partial loss of vision [14]. In
Fig. 1. Standard IDF CGS.
3
such settings it is estimated that more than 90% of all eye injuries can be prevented with the use of protective eyewear [15,16]. It is also well established that PE significantly reduces both the incidence and the severity of combat related eye injuries. A study on 408 British combatants participating in the war of Iraq and Afghanistan showed that using PE reduced the risk of sustain eye injury by 90% [17]. Among IDF’s casualties of the first Lebanon war, there were no ocular injuries in soldiers who had ballistic protective goggles properly placed over the eyes at the time of injury [18]. In the current series penetrating fragmental wounds accounted for 65% of the injuries. Fragmental penetrating injury is the leading cause of all eye injuries and the second leading cause in training related events. These data are similar to those reported by Ari et al., in an analysis of 207 casualties sustaining eye injury in Iraq in 2004, 82% of the ocular injuries were caused by fragmentary munitions [13]. Given that published data support the beneficial effects of PE on fragment related ocular injuries and since these injuries constitute the most frequent mechanism of eye damage in the IDF, it is clear that special emphasis should be placed on improving ocular protection. In the IDF, prior to 2012, Combat Googles System (CGS Fig. 1 were the eye protection glasses most often used). Adherence to use was inadequate. The reasons soldiers gave for not using PE were: limited field of view, tendency to fog up, easily scratched lenses and especially the shape and style of the frame [19]. In the first year of Operation Iraqi Freedom (OIF) 85% of soldiers sustaining combat related eye injuries were not using PE [20]. Due to the increase in eye injury incidence and combatant’s low compliance in using the standard PE, new alternatives were sought. The Authorized Protective Eye Wear (APEL) is the US army approved list for Ballistic Protective eyewear of qualified products that was assembled to encourage soldiers to use PE [21]. The approved commercial eyewear provides ballistic fragmentation as well as ultraviolet protection, and is available with both clear and grey lenses. The IDF adopted APEL’s PE standard. Accordingly in November 2012 the IDF purchased the Smith Optics Aegis (Smith Optics Inc., Idaho, Fig. 2) and since then it issued this eyewear to all combatants upon their recruitment. The IDF’s new protective spectacle consists of a plastic frame with interchangeable polycarbonate lenses. The frame and lens assembly weighs 43 g (3 times lighter than the CGS). The highimpact system exceeds U.S. military ballistic impact requirements for spectacles [22]. Tactical commanders are required to encourage and enforce the use (both in combat and in training) of this protective eyewear. The
Fig. 2. Smith Optic Aegis.
Please cite this article in press as: Gendler S, et al. Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.01.035
G Model
JINJ-6069; No. of Pages 4 S. Gendler et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
4
combatants’ compliance is essential for the prevention and mitigation of ocular injuries. Until 2013, it was not obligatory to record the casualty’s use of protective eyewear in the ITR. For that reason, although we can assume that the majority of casualties sustaining injury from fragments munitions were not wearing PE, it cannot be determined with certainty. In order to assess the effectiveness of the currently used PE, it is obligatory to record the use of PE in the latest version of the ITR. PE use in the IDF, in training as well as in combat is stressed through all echelons of command and as part of the IDF comprehensive approach towards improving casualty care. Considering that 108 soldiers suffered eye injuries in non-military (occupational or recreational) activities, the use of protective eye wear should be encouraged in these ‘‘civilian’’ situations as well. Finally, since data collection ended shortly after the introduction of the new IDF protective spectacles, further studies will be needed in order to describe the severity and incidence of eye injury in the IDF following the implementation of the new eye protective gear. Conclusion Despite optimal medical care, military eye injuries are a significant cause of substantial disability as the majority of these injuries result in incompatibility with combat duties in previously healthy soldiers. Penetrating fragmental wounds are the most prevalent cause of combat related eye injuries. They are potentially preventable by appropriate protective eyewear. Lessons learned from the data presented led the IDF to modifications in doctrine, procurement and training. Ongoing data acquisition and analysis serves as the basis for improvement in combat casualty care as well as injury prevention. Financial support None. Conflict of interest None.
References [1] Weichel ED, Coyler MH, Ludlow SE, Bower KS, Eiseman AS. Combat ocular trauma visual outcomes during operations Iraqi and enduring freedom. Ophthalmology 2008;115(12):2235–45. [2] Barak A, Elhalel A, Pikkel J, Krauss E, Miller B. Incidence and severity of ocular and adnexal injuries during the Second Lebanon War among Israeli soldiers and civilians. Graefes Arch Clin Exp Ophthalmol 2011;249(12):1771–4. [3] Scott R. The injured eye. Philos Trans R Soc Lond B Biol Sci 2011;366(1562): 251–60. [4] Buckingham RS, Whitwell KJ, Lee RB. Cost analysis of military eye injuries in fiscal years 1988–1998. Mil Med 2005;170(3):196–200. [5] Negrel AD, Thylefors B. The global impact of eye injuries. Ophthalmic Epidemiol 1998;5(3):143–69. [6] Thomas R, McManus JG, Johnson A, Mayer P, Wade C, Holocomb JB, et al. Ocular injury reduction from ocular protection use in current combat operations. J Trauma 2009;66(4 Suppl.):S99–103. [7] Cotter F, La Piana FG. Eye casualty reduction by eye armor. Mil Med 1991;156(3):126–8. [8] Chaiter Y, Palma E, Machluf Y, Yona A, Cohen A, Pirogovsky A, et al. Quality control and quality assurance of medical committee performance in the Israel defense forces. Int J Health Care Qual Assur 2010;23(5):507–15. [9] Treister G. Ocular casualties in the six-day war. Am J Ophthalmol 1969;68(4): 669–75. [10] Belkin M. Ocular war injuries in the Yom Kippur war. J Ocul Ther Surg 1983; 2:40–9. [11] Schwartz D, Glassberg E, Nadler R, Hirschhorn G, Marom OC, AharonsonDaniel L, et al. Injury patterns of soldiers in the second Lebanon war. J Trauma Acute Care Surg 2014;76(1):160–6. [12] American College of Surgeons. Pre hospital life support. Military 7th ed. 2011. [13] Ari AB. Eye injuries on the battlefields of Iraq and Afghanistan: public health implications. Optometry 2006;77(7):329–39. [14] Owens PL, Mutter R. Emergency Department visits related to eye injuries, 2008: statistical brief #112. In: Healthcare Cost and Utilization Project (HCUP) statistical briefs; 2006. Rockville, MD. [15] American Academy of Ophthalmology and American Society of Ocular Trauma. United States Eye Injury Registry summary report, 1998–2002. [16] National Institute for Occupational Safety and Health (NIOSH). Healthy people 2010.Vision. Fact sheet: Eye safety at work is everyone’s business 2014. www. cdc.gov/Features/dsworkPlaceEye/ [last accessed February 2014].. [17] Blanch RJ, Scott RA. Military ocular injury: presentation, assessment and management. J R Army Med Corps 2009;155(4):279–84. [18] Belkin M, Treister G, Dotan S. Eye injuries and ocular protection in the Lebanon War, 1982. Isr J Med Sci 1984;20(4):333–8. [19] Weichel ED, Colyer MH. Combat ocular trauma and systemic injury. Curr Opin Ophthalmol 2008;19(6):519–25. [20] Thach AB, Ward TP, Dick 2nd JS, Bauman WC, Madigan Jr WP, Goff MJ, et al. Intraocular foreign body injuries during Operation Iraqi Freedom. Ophthalmology 2005;112(10):1829–33. [21] Soldier PEO. Authorized protective eyewear list; 2010, Available from: https:// peosoldier.army.mil/equipment/eyewear/. [22] Soldier PEO. Authorized spectacles: Smith Optics Aegis; 2014, Available from: http://www.peosoldier.army.mil/equipment/eyewear/smithopticsaegis.asp.
Please cite this article in press as: Gendler S, et al. Eye injury in the Israeli Defense Force: ‘‘An ounce of prevention is worth a pound of cure’’. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.01.035