Ophthalmic Trauma Care and Major Incident Management: Lessons from Beirut Port Explosion reported in JAMA

The report brings into sharp focus the calamity that results when medical infrastructure is at ground zero, and the innovations and adaptations—including reliance on ocular triage, damage control ophthalmology principles, and regression to past practices— necessary to navigate the ensuing chaos.

The rate of ophthalmic injury, affected 22 of 500 individuals (4.4%) presenting to the American University of Beirut Medical Center in the immediate aftermath of the explosion.

The authors also reported ocular chemical injuries, although they do not specify the exact numbers or severity. Ocular chemical injuries are not often featured in reports of blast injuries but are the most time critical of all ophthalmic traumas and must not be overlooked in the busy aftermath of a major incident, being best dealt with at the front door of the emergency department, without delay for ophthalmic consultation.

More than half of the patients who were injured had combined globe injury with oculoplastic or neuro-ophthalmic injury, which are well-recognized markers of injury severity but also indicative of complex ophthalmic polytrauma, with injuries simultaneously affecting anterior and posterior segments of the globe, ocular adnexa, and optic nerve. This is typical of blast injuries and increases the complexity of immediate and long-term management. Ophthalmic polytrauma often accompanies major systemic multiple trauma, such as craniomaxillofacial injury, further complicating management. Closed globe injuries also figured prominently, which are sometimes subclinical conditions carrying long-term risk requiring surveillance. That 23% of injuries were bilateral is also typical for blast injuries, and this may make patients who would otherwise be walking wounded unable to self-extract from crisis conditions.

The authors rightly focused on providing timely care to the most urgent eye injuries (postponing repair of eyelid lacerations), which certainly will have contributed to the many good visual health outcomes that they report, recognizing that timing matters in the management of open globe injuries. This reflected appropriate application of ocular triage and damage control ophthalmology principles, key aspects of any mass casualty scenario.

The report also highlighted the need for and utility of organized ocular trauma systems, with layers or echelons of capabilities that are integrated with the larger trauma system. The skill sets of ophthalmologists also matter because it is important that the care received is timely and expert. Internationally, increasing subspecialization and centralization of trauma care, which may contribute to improved individual patient outcomes, is anecdotally deskilling ophthalmic surgeons in the management of ophthalmic trauma in some smaller units. These skill sets can only be maintained by regular practice and participation in trauma on call rotas.

The level of response required in Beirut could not have been provided by a single centralized trauma clinician. With 48 simultaneous open globe injuries across the city, a conservative estimate of 2 to 3 hours of operating time per repair would require 100 to 150 total hours of operating, and to meet this within the recommended 24 hours would require at least 6 operating theaters running continuously for ophthalmic trauma alone. Therefore, centralized and subspecialized ophthalmic trauma management should be balanced by measures to maintain ophthalmic trauma knowledge and skills in smaller units peripheral to major trauma centers so that they remain able to contribute effectively to major incident management.

The authors reported that mild injuries were turned away at the door but did not report the extent to which the 39 patients presenting in the months after the blast injury had been turned away on the day of injury by initial triage or the extent to which this may have affected outcome.

Ophthalmic injury falls out of some triage tools, with patients with isolated eye injuries being classified as the walking wounded. The authors reported the activation of their disaster code, a major incident plan that all large health care institutions should maintain. Many such plans make provisions for patients turned away from the overwhelmed emergency department's front door as walking wounded or having minor injuries to be routed elsewhere. Thus, well-constructed ocular trauma systems can run both ways for the benefit of all, with less severe injuries being sent down the echelon to appropriately capable smaller units when higher-order facilities themselves are overwhelmed. This is also a consideration for the international humanitarian response to such incidents, which often focuses on getting physicians and equipment to the incident. It may be less expensive, easier, and safer to move appropriate ophthalmic casualties to other facilities distant from the incident, easing pressure on local resources. Considerations for all clinicians are of what to do if essential technologies fail, such as electronic patient record systems; computed tomography scanners; or modern, sophisticated, powered, and automated ophthalmic surgical equipment, and what to do if there is a need to operate in nonophthalmic surgical suites.

The authors did not report secondary surgeries or long-term outcomes, focusing on the immediate assessment, but the follow-up of these 400 patients with ophthalmic injury across the city would require major long-term health care resources for years to come. Also, if blast-associated open globe injuries receive only initial repair without vitreoretinal surgical reconstruction, then around 50% of patients develop severe proliferative vitreoretinopathy. The provision of high-quality initial care of ophthalmic trauma often will need subsequent access to experts who can manage secondary, often complex, retina procedures. Additionally, future reports on the potential of postblast traumatic brain injury– associated vision dysfunctions should be of value.

Source: Richard J. Blanch; Robert A. Mazzoli; Keith Porter; JAMA Ophthalmology

doi:10.1001/jamaophthalmol.2021.2707