‘If You Can’t See, You Can’t Fight’—Preventing Eye Injuries is One Key to Readiness

Eye injuries can happen in a split-second while service members are on duty and during recreational activities, which highlights the importance of wearing eye protection to guard against life-altering injuries.

Due to the nature of serving in the military, service members are more likely to experience injury, particularly to their vision, than their civilian counterparts, according to the Defense Health Agency’s Vision Center of Excellence.

“If you can’t see, you can’t fight. That really parlays into our motto of ‘Vision Ready is Mission Ready,’” said optometrist U.S. Navy Capt. (Dr.) Kyle Dohm. Dohm is the U.S. Navy and U.S. Marine Corps branch chief in the Tri-Service Vision Conservation and Readiness Program of the Defense Health Agency-Public Health Directorate for Clinical Public Health and Epidemiology in Aberdeen, Maryland.

Military eye protection is not just for combat, Dohm emphasized. “You need to train as you would fight. Wearing appropriate eye protective devices for training and during combat operations is key to reducing the risk of serious ocular injury that could lead to loss of vision and lack of readiness to stay in the fight.”

“You should wear appropriate protective eyewear while playing sports as well,” Dohm said. “There are about 30,000 emergency room visits every year because of sports-related injuries in the United States, with basketball and baseball leading the way for eye injuries, according to a 2016 study in the Journal of the American Medical Association Ophthalmology.”

Service Member Eye Injuries

The VCE oversees the Defense and Veterans Eye Injury and Vision Registry. DVEIVR data give researchers and medical staff accurate information to improve military eye care. Researchers with a CAC may access these data through the CarePoint site.

The most common types of eye injuries in the military “range from relatively mild, superficial foreign bodies in the eye (sand, dust, or other debris) to severe lacerations through the wall of the eyeball endangering the vision of the patient and requiring extensive surgical repair,” said ophthalmologist Dr. David Eliason, deputy chief of the VCE, and supervisor for the Department of Veterans Affairs team at the DOD/VA integrated center.

Eliason said other significant eye injuries military hospitals and clinics see are:
• Fractures of the eye socket
• Lacerations around the eyes
• Blunt trauma to the eyeball

“These injuries typically require the attention of eye care providers either to evaluate the need for surgical repair or examine the eye for internal damage, such as bleeding, or damage to the lens, iris, retina, or other internal structures,” Eliason said. “In many cases, these can also be prevented with wearing appropriate eye protection.”

About half of service member eye injuries are “related to recreational or after-work activities and usually involved being struck in the eye by another person or an object,” he said. “The other half of the eye injuries are evenly divided between altercations and occupational (at-work) activities.”

One of the most common eye problems from active duty service members and veterans is “the visual dysfunction that can result from traumatic brain injury,” said Eliason.

“Some service members who suffer significant TBI may have difficultly focusing, reading, or tracking objects years after their injury. They may also suffer from sensitivity to light, balance problems, and challenges finding glasses that work,” Eliason said. “The origin of these symptoms is sometimes overlooked as the patient has difficulty describing these symptoms, and the physicians (including eye care specialists) may be fooled by what is often a normal eye exam.”

Typical Injuries the VA Sees

“Eye injuries among veterans are no more prevalent than in the general population who engage in similar activities,” said Eliason. “Many veterans have outdoor hobbies or work with cars or in woodshops. Those activities will put them at greater risk of eye injury; however, those injuries can be significantly lessened with use of protective eyewear,” he emphasized.
The most common injuries Eliason’s colleagues see in a general VA eye clinic are “superficial foreign bodies in the eye” from:
• Working beneath cars
• Using a metal grinder
• Operating a grass trimmer during yard work

“A microscopic piece of metal embedded in the eye is invisible to the normal person but can very painful,” Eliason said. “In an eye clinic, the metal piece can usually be removed in a matter of minutes by an optometrist or ophthalmologist,” and the patients “usually recover within a couple of days without lingering effects.”
“In younger veterans, we can see fractures of the eye socket (orbit) and bruising around the eye (“black eyes”) from sports or other outdoor activities,” he said. “Some of these will require surgery to set the bones, but often they will heal on their own, also without any lingering effects.”

Fewer Eye Injuries Thanks to Improved Protective Eyewear

Evidence indicates eye injuries in the military continue to decrease thanks to improvements in protective eyewear. Service members or veterans can choose from a variety of task-specific protective eyewear that meets ballistic-fragmentation criteria and usually is made of high-impact-resistant polycarbonate. They need to review the U.S. Army’s Authorized Protective Eyewear List and use APEL®-approved vendors.

Besides ballistic protection, there are three main areas of focus for continued protective eyewear device enhancements using innovative technology, Dohm said. They are:
• Antifogging capabilities
• Intermediate tints
• Laser protection

“Fogging is not only annoying, but it can be dangerous when it impedes your vision,” he said. “This is true for special operations environments, as well as in cold weather, and in simple routine tasks.”

“Tinted lenses such as a brown or rose color may enhance contrast” more than clear or dark gray lenses. Always looking for improvement, the military is exploring lenses “that would enhance visual performance in different military environments,” Dohm noted.

While contact lenses improve vision, they should not be used for eye protection.

“Contact lenses should not be worn in deployed/field environments due to the risk of contamination and infection,” said U.S. Army Maj. (Dr.) Christiaan Kroesen, an ophthalmologist and refractive surgeon at the Walter Reed National Military Medical Center in Bethesda, Maryland. “Contacts aren’t approved eye protection and could be a liability in a hostile environment. Never sleep in contact lenses either for the same reasons,” he cautioned.

“We are always interested in wearable eye protection that offers no hindrance to the warfighter (no obstruction of view, and no discomfort from wear),” said Eliason. “Ideally, it could be gear service members forget they have on,” he said. “Without a reason to remove this gear, the warfighter is safer in austere environments.”

Eye Injury Evaluation in Training and Combat

Even with protective eye wear, eye injuries can happen quickly and range from minor to severe wounds during field training and combat.
In remote or austere environments, Eliason said the DOD and VA are “activity exploring” telehealth so a medic or corpsman could “consult with a distantly located optometrist or ophthalmologist to aid them in triaging injuries to determine who needs further care.”

“If the situation allows, medics or corpsmen should consult an eye doctor virtually to assist with questionable cases,” Dohm said. “If communication is not available and the field personnel determine that the case is likely an emergency or are in doubt, it’s best to arrange a medical evacuation at that point.”

“Medics and corpsmen are always taught to not touch the eye unless they are confident, they recognize the eye injury and are capable of managing it,” Eliason said.
Medical professionals triage the injury, focus on pain management, administer antibiotics, and cover the eye with a rigid shield that prevents anything from touching the injured area. Current standard procedure is to not pressure patch the eye closed but allow it to open and close underneath the metal shield.

“Training may vary slightly between the services for medical treatment of ocular injuries,” said U.S. Army Maj. (Dr.) John Koehler, of the Tri-Service Vision Conservation and Readiness Program. “The training is changing as the military continues to prepare for future large-scale conflicts in remote areas that will place “increasing demands on all echelons of medical care.”

Eye wounds that merit quick evacuation occur “anytime the eye is impaled or there is a penetrating injury, or suspicion of a penetrating injury,” Dohm explained. The wounded service member “should be evacuated to a higher level of care where ophthalmological surgery is available,” such as a military hospital or specialty clinic.
“If the optic nerve or retina are severely damaged, no surgery can recover vision for the patient,” Kroesen cautioned. “Even if surgeries are ‘successful’, the vision may not recover.”

Staying Focused

There are “two basic lessons” for service members to learn about eye protection, Eliason said. “One, eye protection should be worn any time objects could be flying around the patient, which includes metal and woodwork, and two, these lessons remain relevant after military service.”

Wearing eye protection “is a minor inconvenience that is insignificant compared to the pain of a foreign object embedding itself on (or in) the eye,” he advised.

“Habits develop by intentional routine,” Dohm emphasized. “Just like we all automatically put our seatbelts on when we get in the car to drive, we all should put our protective eyewear on whenever we get ready to do something with a risk of injury to our eyes, whether that be sports, training, combat, or mowing the lawn.”