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Retina and the Department of Defense

Military transformation and retinal care.

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Vitreoretinal surgeons have played a critical role in caring for service members who have suffered injury or illness during the Global War on Terror and other conflicts over the course of a generation. Dozens of surgeons have performed thousands of sight-saving surgeries on our service members, relying on innovations developed in the private sector to serve those who suffer in harm’s way. We aim to highlight these advances, identify the role of the vitreoretinal surgeon in the landscape of the Military Health System for the future, and provide a framework for continued improvements for the next generation.

September 11, 2001, changed the role of nearly every military physician. As military officers, we take an oath to defend and protect the United States from all enemies, foreign and domestic. The surgeons at Walter Reed Army Medical Center and National Naval Medical Center acutely recognized this oath on that day, and began seeing a transition from caring for military retirees and their family members to serving the needs of severely injured service members. A steady stream of patients evacuated from the Middle East arrived by aeromedical transport 2 to 3 times a week, with as many as 15% of them having some form of ocular injury. The severest ocular injuries frequently required hours of consultation and subsequent surgery and careful coordination with the trauma surgeons to ensure postoperative positioning, medication administration, antibiotic usage, and follow-up care was optimized. This coordination was critical to ensuring the best possible care for our patients. Collectively, thousands of vitreoretinal surgical interventions have been performed on our patients at facilities ranging from Walter Reed National Military Medical Center in Washington, DC, and later Bethesda, MD, to San Antonio Military Medical Center in San Antonio, Texas, Naval Medical Center San Diego, Madigan Army Medical Center in Tacoma, Washington, and Tripler Army Medical Center in Honolulu, Hawaii.

With the complex evacuation pattern and long treatment tail necessary to attempt to restore sight in our service members, refinement of surgical techniques was necessary. In the earliest days of conflict, the only diagnostic capabilities included technologies that were not superior to those used in the Vietnam war era — slit lamp biomicroscopy and indirect ophthalmoscopy. Fundus photography was not easy in these immobile and often sedated patients. Surgical capability included 20-gauge vitrectomy on older systems with limited cutting speeds. We transitioned surgery from direct visualization via contact lens to the noncontact visualization early in the war. The first optical coherence tomography (OCT) systems within the military began appearing in 2003, which provided a view of retinal injuries not previously characterized. These enhancements highlighted the potential for innovation and transformation in care that could be possible.

Over the past 10 years, vitreoretinal surgeons in the military have begun applying novel commercially available approaches to treating ocular injuries — endoscopic vitrectomy, intravitreal treatments for the treatment and prevention of proliferative vitreoretinopathy, smaller gauge vitrectomy to preserve the conjunctiva and minimize surgical trauma to severely injured eyes. With few exceptions, application of these approaches has yielded improved outcomes and quality of life for our service members. However, the evacuation patterns, limitations in surgical capability near to the point of injury, and unrealized commercialization of research and development hamper efforts to ensure optimal outcomes.

The primary limitations today include lack of understanding related to the impact of blast on the retina, limited diagnostic modalities at the point of injury to quantify and trend injury, delayed evacuation to definitive vitreoretinal care, and retinal equipment and techniques increasingly optimized for delicate macular work rather than complex polytrauma effecting the eye. We will describe the strategy to improve outcomes by focusing on these topic areas.

Figure 1. From left, ophthalmologists Air Force Colonel Randy Beatty, MD, Air Force Major Lisa Mihora, MD, and Air Force Colonel David Holck, MD, repair an orbital fracture at the Air Force Theater Hospital on Joint Base Balad, Iraq
IMAGE COURTESY OF THE OFFICE OF THE SECRETARY OF DEFENSE PUBLIC AFFAIRS.

STATE OF MILITARY RETINA IN 2019-2024

This is an exciting time to be members of a vitreoretinal team in the military and to work with some of the leading experts on ocular trauma. As the conflict has been winding down in the past few years, we have fortunately been receiving and treating fewer wounded warriors than in the previous decade. This has given time to reflect on the outcomes during the height of the conflict. It was found that posterior-segment injuries led to a higher rate of poor visual outcomes than those involving only the anterior segment. Additionally, recent studies from outside the United States have demonstrated better visual and anatomic outcomes for traumatic retinal detachments that were treated earlier, within 4 days of the injury. Currently, service members are evacuated to Walter Reed National Military Medical Center but are often delayed by systemic injuries that require treatment at Landstuhl Regional Medical Center in Germany. In Germany, there is a wide range of specialties available including general surgery, neurosurgery, and otolaryngology to address the many severe injuries sustained in combat trauma. Often, because treatments can be provided in Germany, the patient is delayed in arriving to the United States while various teams work to help better stabilize the service member for transport. With access to new technology, it is possible for the retina specialist in the United States to evaluate the patient at Landstuhl, Germany utilizing synchronous telecommunication. This allows the retina service, and various other required ophthalmic subspecialties, to plan and coordinate the anticipated surgical care for when the wounded warrior is eventually transported to the United States.

However, with the knowledge that earlier vitreoretinal intervention may help to improve the outcomes in these service members, there is consideration in the next few years of expanding the capabilities of vitreoretinal surgeons to locations outside of the United States and closer to conflicts, for example Landstuhl, Germany. Through earlier intervention, it could be possible to treat and repair injuries with decreased complications such as necrosis of tissues, proliferative vitreoretinopathy, failure of attachment, and phthisis. This is an exciting prospective expansion of vitreoretinal capabilities, but this method also poses many challenges, such as maintaining an adequate number of surgeries for the retina specialist in these locations with fewer ocular injuries and less patient access during times of declining conflict.

Besides focusing primarily on wounded warriors, retina surgeons care for a vast array of patients within the military, including retirees and their dependents. As Congressional appropriations and budgets are directing a transformation of military medicine, we anticipate reductions in staffing, clinics, and operating rooms throughout the Military Health System. This raises questions about how adequate is the experience of surgeons in the military. The retina service has remained demanding and the patient load continues to grow despite the cutbacks. There have been some creative solutions to finding resources to best treat the growing number of patients while decreasing the burden on the reduced military health system. For example, smaller military treatment facilities are being utilized to allow space for more surgical volume. The patients that require monthly visits for injections and management have been assisted in finding civilian retina providers that can handle the demand to prevent long wait times or difficulty with making appointments in limited slot availability. New-patient consults are being scheduled with patients who will require surgery to ensure that patients that need immediate attention are cared for as well as to ensure continued surgical experience for retina specialists without overloading the system. Additionally, novel diabetic telescreening has been implemented to benefit patients by offering an efficient nonmydriatic screening system. This also allows providers to screen many more patients.

The care and treatment of posterior-segment injuries extends beyond the surgical suite. There is strong research collaboration between the various military teaching facilities as well as other large universities. Research is often focused on obstacles that are very prominent in a young, healthy, active-duty population. Recent research includes collaboration to collect and examine the vitreous from patients with proliferative vitreoretinopathy to analyze the characteristics that could help better understand the pathophysiology to guide which patients may be higher risk and eventually lead to treatments.

Lastly, the impact of the vitreoretinal service on managing care for wounded warriors who have been seen at Walter Reed National Military Medical Center has been phenomenal. Witnessing the responsibility of not only treating the ocular injuries but also in coordinating care to ensure that patients are receiving necessary social support, such as blind rehabilitation, was one of the inspirations to pursue retina in the military. The experiences of participating as a member of the entire ophthalmology team in the care for wounded warriors has been a great honor.

MILITARY RETINA IN 2025 AND BEYOND

Looking ahead to 10 to 20 years from now, there are significant changes that will likely affect the vitreoretinal surgeons in the US Military. Research from the current conflicts in Iraq and Afghanistan completed at Walter Reed National Military Medical Center points to the need for vitreoretinal surgeons in theater in a large conflict. Studies of retinal trauma are demonstrating that earlier retinal intervention than the conventional 1-2 weeks is critical. Although current military evacuation from Iraq and Afghanistan is at times less than 72 hours from point of injury to the United States, sometimes it can be delayed longer than 2 weeks.

Due to this possible delay in evacuation, there has been an emphasis on prolonged field care. Two major area of emphasis in retinal trauma are the development of proliferative vitreoretinopathy (PVR) and endophthalmitis. Hopefully, at this time 10 years from now, there will be an oral medication for treatment of PVR that can be given to soldiers with concern for retinal injuries. The rates of endophthalmitis were surprising low in Iraq and Afghanistan due to improved field care. Every deployed soldier that is deployed had a medical kit with moxifloxacin 400 mg. This early access to antibiotics significantly reduced the risk of endophthalmitis compared to previous conflicts.

There are certain other key technological advancements that will likely occur over the next few decades. If retina specialists are deployed into theater, it will be critical to create a portable lightweight vitrectomy and phacoemulsification system. Currently, the platforms for these systems are too large and difficult to maintain to be brought into theater. In addition, a high-quality portable microscope would be key. Although there is not significant incentive to design these systems for domestic use in ambulatory surgical centers or for humanitarian missions, these systems need to be developed.

In addition, it is critical that we develop a portable OCT that can be used at the battalion aid station (first evacuation point) by a medic. Frequently, by the time patients are seen by a retina specialist, they already have a vitreous hemorrhage. Having an OCT of the macula would help retina specialists in their surgical decision making and would give higher resolution than a B-scan. The last critical technological development will be the use of telemedicine by the military. Retinal surgeons from across the globe will be using imaging platforms and an integrated single EHR to communicate with each other and advise emergency and trauma surgeons.

Finally, at-home retinal specialist will still manage a wide range of posterior-segment injuries. However, one critical area that will likely change in 10 to 20 years will be prosthetics or stem cells. One of the amazing advances in the past 10 years has been in extremity prosthesis. Some US service members who have lost a limb in blast trauma have even returned to the Middle East in further deployments. Retinal prosthetics or stem-cell injections may allow soldiers with severe eye injuries to continue to work in the military with different jobs. In addition, retinal surgeons may be implanting prosthetics that go beyond repairing a soldier’s vision to even enhancing their job capacity, such as a helicopter pilot’s night vision or a sniper’s distance vision. RP