Page 81 - JSOM Spring 2018

Ocular Injuries and Cultural Influences in Afghanistan
During 5 Months of Operation Enduring Freedom

David A. Paz, MD*; Karin E. Thomas, MD; Denis G. Primakov, MD

ABSTRACT
In support of Operation Enduring Freedom, American, North the NATO Role 3 Multinational Medical Unit (MMU) at Kan-
American Treaty Organization (NATO) Coalition, and Afghan dahar Air Field (KAF), Afghanistan. This article examines the
forces worked together in training exercises and counterinsur- cross-cultural dynamics that must be deployed to understand
gency operations. While serving at the NATO Role 3 Mul- the importance of eyes in Afghan culture and the effect of cul-
tinational Medical Unit, Kandahar, Afghanistan, numerous ture on use of eye protection among Afghan security forces,
patients with explosive blast injuries (Coalition and Afghan and demonstrates several of the resultant ocular injuries.
security forces, and insurgents) were treated. A disparity was
noted between the ocular injury patterns of US and Coalition Methods
forces in comparison with their Afghan counterparts, which
were overwhelmingly influenced by the use, or lack thereof, of Local national patients seen at the NATO Role 3 MMU in
eye protection. Computed tomography imaging coupled, with Kandahar, Afghanistan, who suffered blast-related injuries
a correlative clinical examination, demonstrated the spectrum were screened for orbital injuries and seen by a US Navy ra-
of ocular injuries that can result from an explosive blast. Pa- diologist and a ophthalmologist. Computed tomography (CT)
tient examination was performed by Navy radiologists and scans were compared with clinical findings retrospectively. A
an ophthalmologist. A cultural analysis by was performed to literature review, which included anecdotal observations, was
understand why eye protection was not used, even if available performed to understand how eyewear is perceived in Afghan
to Afghan forces, by the injured patients in hope of bridging culture and its effect on eye protection compliance among Af-
the gap between Afghan cultural differences and proper opera- ghan security forces. A cross-cultural synopsis was compiled
tional risk management of combat forces. to attempt to link the clinical importance of eye protection
with the Afghan traditions.
Keywords: ocular injury; culture; explosive blast injury
Results
Clinical presentation of ocular injuries was evaluated by a
Introduction
US Navy ophthalmologist on admission to the NATO Role 3
Since 2001, the United States, along with several North At- MMU at KAF. Coalition and Afghan security forces with eye
lantic Treaty Organization (NATO) countries, has been injuries most commonly had injury due to foreign bodies that
providing guidance to the country of Afghanistan via what resulted in corneal abrasions and lacerations. An open globe
eventually evolved into the International Security Assistance was considered present when full-thickness injury to the cor-
Force (ISAF). Part of this entailed training and modernizing nea, sclera, or both existed. Many open globes presented and
the Afghan police, army, and security forces to prevent the re- several emergent ophthalmologic surgeries were performed,
turn of the Taliban government that was removed from power. primarily on Afghan security forces—patients who, in retro-
At the NATO medical facility in Kandahar, the patients treated spect, were found to not have worn eye protection.
may be from ISAF, local nationals, or Afghan military working
alongside Coalition forces. Some of the most severe cases of Aggressive and proactive ophthalmologic evaluation in the
survivable trauma have been reported during the combat op- setting of combat trauma revealed that of the 276 combat ca-
erations in Afghanistan, such as triple amputations secondary sualties requiring surgical intervention from September 2012
to injuries caused by improvised explosive devices (IEDs), with through January 2013, there were 45 patients seen at the
some patients requiring massive blood transfusions to keep the NATO Role 3 MMU KAF for ocular injury. Of the 276 com-
in-hospital mortality rate as low as 4.45%. 1 bat casualties, 48 were Afghan patients, the remaining 228
were Coalition forces or contractors. Of the 45 patients with
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US Army personnel are required to wear issued eye protection ocular injuries due to IED blast and indirect gunfire, 24 were
to mitigate combat theater eye injuries seen during the initial wearing eye protection. Although the eye protection was usu-
phases of this IED-laden war. However, although members of ally either damaged severely or the blast wave blew the eye-
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the Afghan military are issued eye protection when working wear off the patient’s face, only one patient who was wearing
alongside the ISAF, it is infrequently worn, as evidenced by the eye protection had an open globe, with rocks embedded into
extensive eye injuries seen in conjunction with blast victims at the deep temporal sclera. Despite these orbital injuries, after
*Address correspondence to 710 Cabrillo Ave, Coronado, CA 92118; or dpazmd@gmail.com
Drs Paz, Thomas, and Primakov are with the NATO Role 3 Multinational Medical Unit, Kandahar, Afghanistan.

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