Michael J. Mines

Ocular injuries sustained by survivors of the Oklahoma City bombing

OBJECTIVE The purpose of this study is to provide a review of the ocular injuries sustained by survivors of the April 19, 1995, bombing of the Alfred P. Murrah Federal Building in Oklahoma City. DESIGN Retrospective, noncomparative case series. PARTICIPANTS The authors retrospectively evaluated data collected on all surviving persons receiving ocular injuries during the bombing and on all at-risk occupants of the federal building and four adjacent buildings. METHODS Injury data from survivors were collected from multiple sources to include hospital medical records, a physician survey, emergency medical services run reports, written survivor accounts, building occupant survey, telephone interviews, and mail surveys. MAIN OUTCOME MEASURES The types of ocular injuries, the associated systemic injuries, and the location of the injured at the time of the blast were evaluated. RESULTS Fifty-five (8%) of the 684 injured bombing survivors sustained an ocular injury. Persons injured in the Murrah building were more than three times more likely to sustain an ocular injury than other injured persons. Seventy-one percent of ocular injuries occurred within 300 feet of the point of detonation. The most common serious ocular injuries included lid/brow lacerations (20 patients, 23 eyes), open globe injuries (12 eyes), orbital fractures (6 eyes), and retinal detachment (5 eyes). A retained intraocular foreign body accounted for only two of the injuries (4%). Glass accounted for nearly two thirds of the ocular injuries. CONCLUSIONS Blasts involving explosions inflict severe ocular injury, mostly as a result of secondary blast effects from glass, debris, etc. Eye injuries in bombings can probably be prevented by increasing the distance from and orientation away from windows (i.e., by facing desks away from windows). Use of such products as laminated glass, toughened window glazing, and Mylar curtains may reduce glass projectiles in the blast vicinity.

Robotic laser tissue welding of sclera using chitosan films.

To demonstrate the feasibility of scleral wound closure using a novel adhesive made of chitosan film.

The United States Army Ocular Teleconsultation program 2004 through 2009

PURPOSE To describe the United States Army Ocular Teleconsultation program and all consultations received from its inception in July 2004 through December 2009. DESIGN Retrospective, noncomparative, consecutive case series. METHODS All 301 consecutive ocular teleconsultations received were reviewed. The main outcome measures were differential diagnosis, evacuation recommendations, and origination of consultation. Secondary measures included patient demographics, reason for consultation, and inclusion of clinical images. RESULTS The average response time was 5 hours and 41 minutes. Most consultations originated from Iraq (58.8%) and Afghanistan (18.6%). Patient care-related requests accounted for 94.7% of consultations; nonphysicians submitted 26.3% of consultations. Most patients (220/285; 77.2%) were United States military personnel; the remainder included local nationals and coalition forces. Children accounted for 23 consultations (8.1%). Anterior segment disease represented the largest grouping of cases (129/285; 45.3%); oculoplastic problems represented nearly one quarter (68/285; 23.9%). Evacuation was recommended in 123 (43.2%) of 285 cases and in 21 (58.3%) of 36 cases associated with trauma. Photographs were included in 38.2%, and use was highest for pediatric and strabismus (83.3%) and oculoplastic (67.6%) consultations. Consultants facilitated evacuation in 87 (70.7%) of 123 consultations where evacuation was recommended and avoided unnecessary evacuations in 28 (17.3%) of 162 consultations. CONCLUSIONS This teleconsultation program has brought valuable tertiary level support to deployed providers, thereby helping to facilitate appropriate and timely referrals, and in some cases avoiding unnecessary evacuation. Advances in remote diagnostic and imaging technology could further enhance consultant support to distant providers and their patients.

Digital imaging to assist preoperative planning for ipsilateral rotational autokeratoplasty

A 14-month-old child with a central corneal scar underwent rotational autografting of his cornea to clear his visual axis. This was accomplished through eccentric trephination and 180 degree rotation of the central cornea. A preoperative image of the patients cornea was manipulated digitally using a common commercial image-processing software package. This allowed accurate prediction of the best trephine size and location prior to surgery. Digital imaging played an important role in preoperative surgical planning and demonstrates the potential for tele-ophthalmology.

Photorefractive keratectomy in posterior polymorphous dystrophy with vesicular and band subtypes

PURPOSE: To evaluate the safety and efficacy of photorefractive keratectomy (PRK) in patients with posterior polymorphous dystrophy (PPMD) with vesicular and band subtypes. SETTING: Walter Reed Center for Refractive Surgery, Washington, DC, USA. DESIGN: Case series. METHODS: The records of patients with PPMD who had PRK between January 2002 and May 2009 were reviewed. Data for analysis included sex, age, ablation depth, residual stromal bed thickness, manifest spherical equivalent, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, central corneal thickness (CCT), endothelial cell density (ECD), intraocular pressure (IOP), and complications. Preoperative and postoperative results were compared using the Wilcoxon signed‐rank test, with P<.05 considered significant. RESULTS: Fourteen eyes of 7 men (mean age 29.1 years ± 9.1 [SD]; range 21 to 42 years) with at least a 6‐month follow‐up were reviewed. At the final follow‐up (mean 19.5 months; range 6.3 to 58.3 months), all eyes had a UDVA of 20/15 and all eyes were within ±0.50 diopter of emmetropia. The CDVA was unchanged from preoperatively in 71.4% of eyes and improved by 1 line in 28.6%. There were no significant complications. The IOP did not change significantly over the follow‐up (P=.272). At the final visit, the mean ECD (2795.3 ± 366.0 cells/mm2) was unchanged from baseline (2809.1 ± 338.3 cells/mm2) (P=.114). CONCLUSIONS: Photorefractive keratectomy in PPMD patients with vesicular and band subtypes resulted in excellent visual outcomes and a low incidence of adverse effects. Endothelial cell densities did not change significantly in the early postoperative period. Financial disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Telerobotic contact transscleral cyclophotocoagulation of the ciliary body with the diode laser.

To assess the feasibility of using the Robotic Slave Micromanipulator Unit (RSMU) to remotely photocoagulate the ciliary body for the treatment of glaucoma with the diode laser. In fresh unoperated enucleated human eyes, the ciliary body was destroyed either with a standard contact transscleral cyclophotocoagulation ‘by hand’ diode laser technique, or remotely using the RSMU. The treated sections were fixed in formalin, paraffin-embedded, and stained with hematoxylin and eosin. Histological evaluation was performed by a masked observer using a standardized grading system based on the amount of damage to the ciliary body to evaluate effectiveness of treatment. Both methods of contact transscleral cyclophotocoagulation showed therapeutic tissue disruption of the ciliary processes and both the non-pigmented and pigmented ciliary epithelium. Histology examination of remote robotic contact transscleral cyclophotocoagulation and “by hand” technique produced similar degrees of ciliary body tissue disruption. Remote diode laser contact transscleral cyclophotocoagulation of the ciliary body in fresh enucleated human eyes is possible with the RSMU. Therapeutic tissue disruption of the ciliary body was achieved. Additional study is necessary to determine the safety and efficacy of robotically-delivered cyclophotocoagulation in live eyes.

Night firing range performance following photorefractive keratectomy and laser in situ keratomileusis.

OBJECTIVE To investigate the effect of laser refractive surgery on night weapons firing. METHODS Firing range performance was measured at baseline and postoperatively following photorefractive keratectomy and laser in situ keratomileusis. Subjects fired the M-16A2 rifle with night vision goggles (NVG) at starlight, and with iron sight (simulated dusk). Scores, before and after surgery, were compared for both conditions. RESULTS No subject was able to acquire the target using iron sight without correction before surgery. After surgery, the scores without correction (95.9 +/- 4.7) matched the preoperative scores with correction (94.3 +/- 4.0; p = 0.324). Uncorrected NVG scores after surgery (96.4 +/- 3.1) exceeded the corrected scores before surgery (91.4 +/- 10.2), but this trend was not statistically significant (p = 0.063). CONCLUSION Night weapon firing with both the iron sight and the NVG sight improved after surgery. This study supports the operational benefits of refractive surgery in the military.

Periocular Histiocytoid Carcinoma: Potential Diagnostic Challenges

Cutaneous histiocytoid carcinoma can occur as a primary tumor of the periocular region. Morphologically similar histiocytoid carcinomas arising as primary tumors of the breast have a predilection for orbital metastases. They can occasionally contain regions with prominent vacuolated cytoplasm and minimal nuclear atypia, which mimic benign histiocytic lesions. Differentiating nonneoplastic, primary neoplastic, and metastatic histiocytoid lesions involving the periorbita can be challenging for both the clinician and the pathologist, and this distinction has management implications. Herein, we present 3 cases to illustrate the challenges of diagnosing periocular histiocytoid carcinoma.

Teleophthalmology in the United States Army

Delivering timely, cost-effective, quality care to beneficiaries and consultation partners is the goal of all health care systems. The particular challenges of distance, geography, and logistics faced by US Army ophthalmologists as they deliver this care attest to the ever-increasing relevance of telemedicine. Research and implementation of teleophthalmology solutions are providing opportunities to improve care, expand knowledge through training and distance learning, and provide services that were not possible a few short years before. Many of these applications, which are in use today, enable Army ophthalmologists both to assist other health care providers, and to deliver care directly to a geographically diverse beneficiary population. US Army ophthalmologists continue to develop and research new technologies in an effort to shorten the distance between the injured soldier or ill retiree and the ophthalmologist’s exam chair, thereby speeding interventions to preserve ocular health.

Ocular injuries sustained by survivors of the Oklahoma City bombing32The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.33The authors have no financial interest in any product described in this article.

OBJECTIVE The purpose of this study is to provide a review of the ocular injuries sustained by survivors of the April 19, 1995, bombing of the Alfred P. Murrah Federal Building in Oklahoma City. DESIGN Retrospective, noncomparative case series. PARTICIPANTS The authors retrospectively evaluated data collected on all surviving persons receiving ocular injuries during the bombing and on all at-risk occupants of the federal building and four adjacent buildings. METHODS Injury data from survivors were collected from multiple sources to include hospital medical records, a physician survey, emergency medical services run reports, written survivor accounts, building occupant survey, telephone interviews, and mail surveys. MAIN OUTCOME MEASURES The types of ocular injuries, the associated systemic injuries, and the location of the injured at the time of the blast were evaluated. RESULTS Fifty-five (8%) of the 684 injured bombing survivors sustained an ocular injury. Persons injured in the Murrah building were more than three times more likely to sustain an ocular injury than other injured persons. Seventy-one percent of ocular injuries occurred within 300 feet of the point of detonation. The most common serious ocular injuries included lid/brow lacerations (20 patients, 23 eyes), open globe injuries (12 eyes), orbital fractures (6 eyes), and retinal detachment (5 eyes). A retained intraocular foreign body accounted for only two of the injuries (4%). Glass accounted for nearly two thirds of the ocular injuries. CONCLUSIONS Blasts involving explosions inflict severe ocular injury, mostly as a result of secondary blast effects from glass, debris, etc. Eye injuries in bombings can probably be prevented by increasing the distance from and orientation away from windows (i.e., by facing desks away from windows). Use of such products as laminated glass, toughened window glazing, and Mylar curtains may reduce glass projectiles in the blast vicinity.