To the Editor:

There is an increasing trend of ocular injury in modern conflict. This is compounded by the development of weapons with higher explosive and fragmentation power, resulting in increased severity and morbidity of injury. Explosions cause unique patterns of injury, with the majority a combination of primary and secondary blast mechanisms that are not often seen outside of combat or terror-related attacks [1]. In modern conflict zones up to 15.8% of all medical evacuations have sustained eye injuries [2], and the incidence of ocular trauma is also increased in terror attacks where explosive devices are used (Table 1). In 2019, following a vehicle-borne improvised explosive device detonation in Mogadishu, Somalia ocular injuries were found in 24.6% of survivors [3].

Table 1 Ocular injuries sustained by survivors of terror attacks.

Given the difficulty in managing complex blast injuries and the visual outcomes associated, we aimed to determine the incidence of blast-related ocular injury in modern conflict. We searched PubMed, Web-of-Science and Google Scholar for original studies reporting ocular injury in armed conflict. Key words included ocular, eye, trauma, injury, explosive, conflict, war, armed and combat. A total of 170 titles were identified and 30 were selected for full-text review. Additional relevant articles were identified from the reference lists of articles reviewed and a secondary search of grey literature. We identified 16 studies of ocular injury in modern conflict (Table 2). A total of 13,777 patients with ocular injuries were included in these studies, with a pooled incidence of 78.1% of ocular injuries caused by explosive munitions.

Table 2 Incidence of explosive blast injury in patients presenting with ocular injury during modern conflict.

We show that the majority of eye injury in modern conflict is blast related. Eye protection significantly reduces the incidence and severity of injury and should be encouraged as early as possible in military training and deployments. Enforced use of eye protection in US military convoys in Iraq was shown to reduce eye injuries from a conflict wide incidence of 6–0.5% [4]. Eye protection does not however eliminate risk, nor is there a guarantee troops will be wearing protection; only 11% of British Armed Forces in Iraq or Afghanistan between 2004 and 2008 with eye injuries reported wearing combat eye protection [5]. It is also unlikely that civilians caught in areas of conflict or terror bombings will be suitably protected. It is reported that in Iraq and Afghanistan between 2003 and 2011, eye injuries managed at UK-led military treatment facilities were much less likely to be treated definitively than their US counterparts, reflecting an absence of ophthalmologists [6]. Instead, patients were dependent on rapid aeromedical evacuation taking on average two days. For time-critical injuries delays outside of this window and time to specialist ophthalmic care is likely to affect visual outcomes [7].

Conflict and terror are unpredictable, and it is essential that healthcare professionals are aware of the disproportionate incidence of eye injury, the most common mechanisms and unique patterns of injury that require specialist management. Due to the severity of injury and impact that loss of vision has on quality of life, there must be comprehensive treatment pathways in place, including ensuring availability of specialist surgeons (e.g. ophthalmologists). In many areas rapid evacuation is not possible and there is a need for ophthalmologists, both military and civilian, to be forward deployed to manage patients quickly and effectively. This may involve integration of specialist surgeons into emergency medical teams who are deployed in the aftermath of disaster, outbreak and/or other emergencies [8].