Although we may live thousands of miles away from war zones, we bear witness to its horrific effects through social and news media. This accessibility to information is a powerful connector, giving us insight into the loss of lives, culture and well-being in these war-torn areas. And while there is much reporting on lives lost and serious injuries (like limb amputation) to military personnel, there are other traumatic consequences of war, including ocular damage to both military personnel and civilians. The impacts of these often-overlooked injuries are significant, and they create ongoing social and economic burdens.
Late last year, Syed Abid Hassan Naqvi and colleagues from Rawalpindi, in the Punjab province of Pakistan, reported their findings from an observational study of 210 soldiers who presented with ocular war injuries to the Combined Military Hospital in Peshawar between 2012 and 2016. The paper described demographic details and severity of eye injuries, as well as providing an analysis of prognostic influences to good or poor outcomes.1
They found that more than half (54.3%) of the ocular injuries were caused by a blast from an improvised explosive device, followed by blunt trauma (20%) and road traffic accidents (11.4%). Closed globe injuries occurred most frequently (57.1%). Outcomes were quite evenly distributed, while 29.5% were considered to have a good outcome (20/40 or better), 24.3% were considered fair, 21.9% poor and 24.3% experienced the worst visual outcome. Improvised explosive device blast, open globe injury, injury to Zone III (posterior region) and ocular trauma score grade 1 (most severe injury and 73% probability of no light perception at 6 months follow-up) were poor prognostic features and resulted in significantly higher frequency of poor visual outcome.
These findings are important because they include some of the most commonly used weapons, that despite protective measures are leading to severe eye injuries. Many of the advancements in body armour are aimed at protecting vital organs and the skull and saving lives, leaving troops’ eyes and limbs particularly vulnerable to the blizzard of shrapnel from explosions. Each explosion unleashes large metal shards and thousands of fragments, like tiny missiles. Those fragments are generally innocuous if they hit the protected areas but can have devastating when they make contact with the eye.
Unfortunately, the answer isn’t as simple as wearing protective eyewear. These blasts can hit with a force that has reportedly stripped soldiers of their helmets and goggles or even driven the frame of protective eyewear into the face and eyes. Serious eye injuries are reportedly accumulating at almost twice the rate of wounds requiring amputation and have life-long consequences, as approximately 70% of all sensory perception comes from vision.
Based on this work, the authors advocated that patients presenting with improvised explosive device blast, open globe, zone-III injury and/or an ocular trauma score grade 1 should be suspected to result in a poor visual outcome, therefore meticulous care should be provided to save as much vision as possible, and to minimize the social and economic effects of blindness.
And while the effects of war are debilitating to soldiers, the damage often extends into the civilian community, affecting its youngest residents – children. In Syria, the civil war has deliberately targeted healthcare services, resulting in an additional humanitarian crisis in the devastated war zone. Children’s healthcare has been severely impacted. After hearing reports stating that there was just one pediatrician remaining in Aleppo, Dr. Gerlant van Berlaer, a pediatrician and emergency physician in Belgium with a PhD in disaster medicine, wanted to help.
As Dr. van Berlaer’s current position restricts his travel to war zones, he had to find an alternative way to make an impact. He, along with colleague Abdallah Elsafti, persisted until they found an opportunity. “When the Qatar Red Crescent conducted an immunization campaign with permission from the Syrian Ministry of Health, my colleague and I thought it would be a good opportunity to look into the physical and mental health of these children. We trained the healthcare workers of the campaign to collect our data while they received their vaccinations.”
What they found was shocking – but not entirely unexpected in a war zone. They studied the living conditions of 1,000 Syrian children and published “Children in the Syrian Civil War: The Familial, Educational and Public Health Impact of Ongoing Violence” in Disaster Med Public Health Preparedness 2016. “We found that one in five children did not live in their own house anymore; 5% had deceased or missing parents; more than 50% had dropped out of school; 15% lacked access to safe drinking water; 23% did not have toilets; and 16% did not have healthy food to eat. In addition, 64% could not reach medical care, and 72% lacked proper vaccinations.”
More recently, Dr. van Berlaer and colleagues published their follow-up findings from the Syrian civil war in PLoS One: “Diagnoses, infections and injuries in Northern Syrian children during the civil war: A cross-sectional study.” They found that four years into the conflict, 64% of the studied children suffer from serious infections – 5% of these ocular – while most were from respiratory, neurological or digestive origin.
The authors discuss how these children’s living conditions during the war will impede both their health and opportunities for the future. Dr. van Berlaer explains: “Many Syrian children will possibly bear the consequences of lifelong disability, physically as well as mentally, imposing an extra burden on the country’s future. As physicians we urge to immediately cease attacks on hospitals, schools, and other critical civilian infrastructure, and to respect international humanitarian laws. Urgent coordinated and global action is needed to deal with this complex humanitarian emergency, and to prevent worsening of health threats to this generation of children in Syria, as they are the nation’s only asset for the future.”
Editor’s Note: The group of Pakistani investigators couldn’t have their biographies or photos published due to their military positions and the extreme confidential nature of their work. Dr. van Berlaer, although his work did not have a real eye-related focus, but more about the health crisis resulting from war, was generous enough to contribute to this story.
References:
1 Hassan Naqvi SA, Malik S, Syed ZUD, et al. Visual outcome and its prognostic factors in patients presenting with ocular war injuries at an army hospital in Pakistan. J Pak Med Assoc. 2017;67(12):1853-1856.2 van Berlaer sG, Elsafti AM, Al Safadi M, et al. Diagnoses, infections and injuries in Northern Syrian children during the civil war: A cross-sectional study. PLoS One. 2017;8;12(9):e0182770.
