Severe ocular trauma due to landmines and other weapons in Cambodia
Thirty-eight patients with ocular trauma due to antipersonnel landmines (29 patients) or other weapons (9 patients) presented to a hospital eye department in Northwest Cambodia between January and September 1994. Fourteen of these patients were bilaterally blind (accounting for 4% of all causes of blindness attending the clinic during this period), and all these cases were due to landmine injury. Twenty-three patients (60%) presented with bilateral injuries, of which 21 were due to landmines. Of the 15 patients with unilateral injuries, eight were due to landmine injury and seven were due to shrapnel, of which five required enucleation. All but two of the patients reported had penetrating ocular injury in at least one eye. Ocular trauma due to war injuries or antipersonnel landmines is a significant cause of ocular morbidity in Cambodia, and predominantly affects young men.
Previous population-based surveys 1, 2and surveys of schools for the blind3,4 in developing countries have not reported ocular trauma as being a significant cause of blindness, although it is regarded as one of the major causes of monocular blindness, especially in children.5,6The relative rarity of these injuries and the high degree of technology often needed for appropriate surgical treatment means that efforts to reduce the incidence of severe ocular trauma are usually directed towards prevention, for instance by promoting education and safety in the workplace.3The incidence of severe ocular injury leading to blindness in countries at war or with high landmine densities has not been formally evaluated, but reports suggest that it is much higher than in countries at peace. Cambodia is the poorest country in South East Asia, with a population of approximately 8.8 million.7Life expectancy is 51 years, and 65% of the adult population is female. Cambodia has been at war for over 25 years, and now has an estimated 4-10 million landmines which cause significant morbidity and mortality to its population of 8.8 million, resulting in one of the highest percentages of amputee’s in the world.8
Patients and methods
In a hospital-based survey in Battambang Province in the Northwest of Cambodia, all patients with ocular trauma attending the eye clinic at the provincial hospital between January and September 1994 were identified. All patients had their visual acuity assessed using a Snellen chart, and were examined using slit lamp biomicroscopy and indirect ophthalmoloscopy. A careful history was taken. Where possible, surgical and/or medical treatment was undertaken to improve the visual outcome.
Thirty-eight patients with ocular trauma due to antipersonnel landmines or other weapons were seen. Thirty-seven (97%) were male, and ages ranged from 9 to 57 years (mean 28 years) (Fig. 1). Ten were soldiers on active military duty and three of these were injured by landmines. Twenty-eight patients were civilians, of which twenty six were injured by landmines.
Twenty-three patients (60%) had bilateral ocular injuries; 21 (91%) of these were due to landmines and two (9%) to misfiring B40 rockets. Of the 15 unilateral injuries, 8 were due to landmines and 7 to shrapnel (grenades and shells). The injuries from shrapnel were usually severe, with 5 of 7 eyes (71%) requiring enucleation.
In all, 61 eyes of 38 patients had ocular trauma, of which 54 (89%) were penetrating injuries. Visual outcome was poor in most cases (Fig. 2). Eleven eyes (18%) achieved 6/12 or better, and 46/61 (75%) had a final visual acuity of <3/60. Fourteen patients were bilaterally blind, accounting for 4% of blindness from all causes, and all of these cases were due to landmine injuries. Other main causes of blindness were cataract (59%), glaucoma (14%) and corneal scarring (12%) (Table 1).
Table 1. Causes of blindness in patients attending a provincial hospital
Twenty-one patients (29 eyes) presented within one week of injury, and of these eleven eyes (38%) achieved 6/12 or better following surgery, accounting for all eyes with good visual outcome. Surgery consisted of primary repair of corneo-scleral lacerations and anterior segment reformation as well as removal of anterior segment or scleral foreign bodies. Cataract surgery was undertaken as a secondary procedure. There were no facilities for posterior segment surgery.
These results indicate that severe ocular trauma due to explosives and other weapons is a significant cause of ocular morbidity and blindness in Cambodia. Of the 38 patients reported here, 14 (37%) were bilaterally blind, which was 4% of blindness from all causes. Eighteen others were blinded (VA<3/60) in one eye; only six (15%) retained vision of >3/60 in both eyes. The type of injury, and those at risk, differed according to the weapon:
Landmines were responsible for 29/38 (76%) of injuries, and 21/29 (72%) were bilateral. Almost half these patients (14/29) were blind due to bilateral penetrating injuries. Twenty six (90%) were civilians engaged in activities such as farming and wood cutting when they were injured. Landmine injuries are essentially blast injuries 9with multiple small high velocity particles (mainly soil and grit) causing injury. Most landmines contain mainly explosive, with only small amounts of metal and plastic (to evade mine detectors), thus making radiological identification of foreign bodies difficult.9The photograph shows a typical blast victim with ‘peppering’ of the face by small fragments (mainly soil and grit), showing how easily bilateral penetrating ocular injuries can occur. The penetrating ocular injuries were frequently caused by small particles rather than the large pieces of shrapnel seen with grenade or rocket injuries, thus preserving the globe in many instances. Vision was lost in many of these cases by delay in hospital treatment leading to infection or other complications. With prompt access to good ophthalmic care to prevent infection and, where appropriate, to remove any intraocular foreign bodies and/or perform reconstructive surgery, it should be possible to improve the final visual outcome in many patients.
Two patients had bilateral non-penetrating injuries as a result of B40 rockets misfiring in their faces. Both had bilateral superficial and deep conjunctival and corneal stromal foreign bodies with marked corneal oedema but no perforation or infection. Both escaped with relatively good visual acuity once accessible foreign bodies had been removed and corneal oedema had resolved. Seven patients were injured by shrapnel from shells, grenades or rockets, and all but two were soldiers. These injuries were all unilateral but usually severe, with five (71%) requiring eventual enucleation.
Injuries are traditionally thought not to be a significant cause of bilateral blindness, either in the developed or the developing world.5,6A population-based survey of 6981 people in Malawi did not report any bilateral blindness due to trauma,1nor did surveys of schools for the blind in Zimbabwe3and Ethiopia.4A population-based survey of 8174 people in The Gambia reported trauma to be responsible for 2% of blindness.2Monocular blindness due to trauma is more common, affecting approximately half a million people worldwide,6and has been described as one of the six major causes of unilateral blindness, especially in children.5,6A population-based survey from Nepal reported that trauma was responsible for 7.9% of blindness in one eye.10The prevalence of bilateral blindness from ocular trauma in countries at war has not been reported.
The incidence of ocular trauma in warfare has been estimated as 20-50 times higher than might be expected from the ocular surface area11and Duke-Elder estimated direct ocular injuries to be 2.0-2.5% of all modern battle casualties.12This appears to be rising as warfare has progressed from the use of simple guns and explosives to more sophisticated and powerful weapons – from 0.65% of all casualties in the Crimean War and 0.57% in the American Civil War 12(reported as mainly bayonet injuries to the face) to 8.1% in the Korean War and 5.6% to 10% in the Arab-Israeli War.10,12,13Landmines add another dimension to this picture. They do not recognise cease-fires and they do not discriminate between civilians and soldiers, resulting in injuries which affect the civilian population of a country long after hostilities have ended. In the Cambodian civil war, all sides continued to rely heavily on the laying of landmines, with the Khmer Rouge knowingly placing antipersonnel mines in civilian areas to terrorise the local population and control their movements.8The use of landmines by all sides in the Cambodian conflict has led to one amputee in 236 of the population (approximately 36,000 people) thought to be affected.8This hospital-based survey shows that landmines are responsible for significant ocular morbidity in Cambodia.
Ocular trauma has been reported to be common in landmine incidents. Of 133 surviving patients with mine injuries seen at a UN hospital in the demilitarized zone between Iraq and Kuwait in autumn 1991, 27 (20%) had significant eye injuries, of which 13 (10%) were penetrating.14Coupland and Korver reported that of 757 patients with injuries from antipersonnel mines treated at two ICRC (International Committee of the Red Cross) hospitals, 8% had penetrating eye injuries.9Khan et al reported 221 Afghan refugees admitted with ocular trauma to a hospital in Peshawar; 93.2% of the injuries were due to bomb or mine blast, and 172 cases involved penetrating eye injuries, with 25 cases being bilateral.15The demography of those blinded by landmine blasts increases the social and economic burden for the affected population. Of the landmine victims reported here, 28 of 29 were male, aged between 15 and 35 years (Fig. 1). In Khan’s report 95% of the 221 Afghan refugees were male, and 68.3% were aged 16-30 years.15The victims of all types of landmine injuries are predominantly young men – a survey of 842 mine victims hospitalised in Cambodia between January and June 1993 showed that 85% were adult males8– thus often depriving families of the main breadwinner. The higher incidence of mine injuries in young men does not appear to be due to their being on active military service. A recent survey showed that 13 out of 16 victims of landmine injury over a 3 week time span were civilians rather than combatants, involved in activities including wood cutting and herding animals.8In this report, only 3 of 29 patients injured by landmines were on active military duty at the time of the injury, compared to 7 of 9 patients injured by other weapons. The numbers of women and children affected seem to be much smaller, possibly due to differences in the division of labour, although it is thought that many children do not survive their initial injuries and, therefore, do not reach hospital.15,16
Few of the cases reported here had prompt access to appropriate ophthalmic care, reflecting the lack of resources of the Cambodian health system. The difficulties of successful surgical treatment of eye injuries, along with the high financial cost of equipment and the need for specialist training, mean that efforts are usually aimed at the prevention of ocular trauma in both developing and developed countries. In Cambodia mines awareness training has begun to teach villagers (especially children) how to avoid the dangers of landmines. Mine clearance programmes continue, but it is estimated that it will take over 100 years to rid Cambodia of landmines at current levels of activity. In addition, mines are still being planted in Cambodia.
This hospital-based survey suggests that severe ocular trauma, in many cases leading to blindness, is a significant burden in Cambodia, affecting predominantly young men. Injuries due to landmines were severe, often bilateral, and were responsible for 4% of all causes of bilateral blindness seen, affecting mainly civilians. The true incidence of ocular trauma due to warfare or landmines leading to blindness in Cambodia is unknown, and a large population-based survey would be necessary to provide a more accurate estimate of the problem. There are few ophthalmologists outside the capital Phnom Penh, although a National Plan for the Prevention of Blindness has been developed and a training programme for ophthalmologists has begun. Efforts must also be directed towards prevention, by education, mine clearance and a cessation of the laying of antipersonnel landmines.
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