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Purpose To document the types and causes of ocular and ocular adnexal injuries treated by United States Army ophthalmologists serving in Iraq during the Iraqi Insurgency. Design Prospective hospital-based observational analysis of injuries. Participants All coalition troops, enemy prisoners of war, and civilians with severe ocular and ocular adnexal injuries. Methods We prospectively examined severe ocular and ocular adnexal injuries that were treated at the 31st Combat Support Hospital during the portion of the Iraqi Insurgency that took place from January 20 through September 12, 2004. Main Outcome Measures Incidences and characteristics of ocular and ocular adnexal injuries. Results During the time observed, 207 patients suffered severe ocular or ocular adnexal injuries, including 132 open globes. Blast fragmentation from munitions caused 82% of all injuries. The most common single cause of injury was the improvised explosive device (IED), which caused 51% of all injuries. Of 41 eye excisions, 24 were caused by IEDs. Conclusions During the portion of the Iraqi Insurgency covered in our report, munitions fragments were the most common cause of ocular and ocular adnexal injuries. The single most common cause of injury was the IED, which produced devastating ocular and ocular adnexal injuries. The authors' findings indicate that polycarbonate ballistic eyewear could have prevented many, but not all, of the ocular injuries we report.

Retinal vasculitis is an ocular finding that may represent a primary syndrome; may be part of an isolated ocular syndrome, such as birdshot chorioretinopathy; or may be a component of a systemic disease, such as Wegener's granulomatosis or multiple sclerosis. Regardless of the cause of the retinal vasculitis, there are some generalized treatment concepts that should be kept in mind. This article describes the authors' approach to the management of patients with retinal vasculitis. These general guidelines may somewhat vary depending on the underlying cause of the retinal vascular inflammation. As with other forms of uveitis, a stepwise treatment approach is offered. Not all patients with retinal vasculitis require therapeutic intervention. Therapy is probably indicated in a patient exhibiting any of the following symptoms: vision-limiting vitritis, capillary destruction around the foveal avascular zone, broad areas of capillary dropout, or cystoid macular edema. The following methods are discussed: observation, nonsteroidal antiinflammatory preparations, corticosteroids, and immunosuppressive agents. The role of surgical intervention is discussed, as well as some newer innovative approaches to the treatment of ocular inflammation. Certain conditions may vary from these generalized guidelines, and these are discussed later in the article. Before embarking on the use of any immunomodulating therapy, it is imperative for the clinician to have thoroughly evaluated the patient for the possibility of an infectious cause. This should have been done as part of the patient's history and ocular examination, as well as through the use of serologic studies, radiographs, and, if indicated, vitreous humor analysis. Bear in mind that the laboratory evaluation should be carefully guided by the results of a detailed medical history and review of organ systems. If this detailed history is negative then only a limited number of tests should be ordered.8 In most cases the laboratory "shotgun" approach will be both diagnostically unrewarding and expensive. If a specific infectious agent is identified, then specific antimicrobial therapy is indicated. If no infectious agent is found, then immunomodulating approaches may be indicated.

Background: Inflammation of the retinal vasculature without an infectious etiology, systemic disease association, or concomitant ocular disease is termed primary retinal vasculitis, and can result in severe and permanent vision loss. Patients with primary retinal vasculitis usually are subjected to an extensive but unrewarding diagnostic evaluation. This study was undertaken to determine the value of such a diagnostic workup, and to determine whether systemic diseases develop in these patients during the course of their illness. Methods: The clinical records of 25 patients seen between 1984 and 1994 with the referring diagnosis of primary retinal vasculitis were reviewed retrospectively. Recorded data included patient age, sex, race, medical history, medications, visual acuity, extent of retinal disease, and the results of their diagnostic evaluations. Results: On presentation, none of the patients had an underlying systemic disease attributable as the cause of their retinal vasculitis. Review of systems was suggestive of an underlying systemic disease in 1 of 25 patients. Diagnostic evaluation in this patient showed a positive antinuclear antibody value and a double-stranded DNA, suggestive of systemic lupus erythematosus. Subsequently, systemic lupus erythematosus was diagnosed based on the development of other diagnostic criteria. The review of systems was not suggestive of an underlying systemic disease in 24 of 25 patients. False-positive diagnostic test results were obtained in 5 (20.8%) of these 24 patients. No underlying systemic disease associated with the patients' retinal vasculitis subsequently developed in any of these five patients (mean follow-up, 4 years). Conclusion: Few diagnostic tests should be ordered in patients with retinal vasculitis in the absence of a medical history suggestive of underlying systemic disease.

Purpose To determine whether corneal topical application of mitomycin-C (MMC) results in measurable plasma levels of systemic absorption. Setting Madigan Army Medical Center, Refractive Surgery Center, Fort Lewis, Washington, and Micro-Constants Laboratory, San Diego, California, USA. Design Case-control study. Methods The study comprised male and female active-duty soldiers having excimer laser photorefractive keratectomy with MMC. Patients who met inclusion criteria were asked to provide a blood sample immediately after being treated with MMC 0.2 mg/mL (0.02%) for 30 seconds. Human plasma samples were evaluated by liquid chromatography mass spectrometry to determine whether MMC was present. Results Thirty samples were submitted for evaluation. There was zero detection of MMC in the submitted samples. The quantifiable limit was greater than 10.0 ng/mL. All samples were below this. Conclusions In this study of 30 patients with topical application of MMC for refractive surgery, there was no measurable evidence of systemic absorption. Although systemic absorption has been found with use in larger quantities, it was not known whether MMC toxicity concerns could be extrapolated to the refractive surgery population. This information allows counseling of patients on the extremely low likelihood of systemic absorption or toxicity following current techniques for refractive surgery. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Purpose To document the incidence and treatment of patients with severe ocular and ocular adnexal injuries during Operation Iraqi Freedom. Design Retrospective hospital-based observational analysis of injuries. Participants All coalition forces, enemy prisoners of war, and civilians with severe ocular and ocular adnexal injuries. Methods The authors retrospectively examined severe ocular and ocular adnexal injuries that were treated by United States Army ophthalmologists during the war in Iraq from March 2003 through December 2005. Main Outcome Measures Incidence, causes, and treatment of severe ocular and ocular adnexal injuries. Results During the time data were gathered, 797 severe eye injuries were treated. The most common cause of the eye injuries was explosions with fragmentation injury. Among those injured, there were 438 open globe injuries, of which 49 were bilateral. A total of 116 eyes were removed (enucleation, evisceration, or exenteration), of which 6 patients required bilateral enucleation. Injuries to other body systems were common. Conclusions Severe eye injuries represent a significant form of trauma encountered in Operation Iraqi Freedom. These injuries were most commonly caused by explosion trauma.

PURPOSE: To report a case of lower eyelid herniation of orbital fat occurring after periocular corticosteroid injection. DESIGN: Interventional case report. METHODS: A 44-year-old man with asymmetrical pars planitis complicated by right cystoid macular edema was treated with multiple right orbital floor injections of triamcinolone through the lower eyelid. RESULTS: Right lower eyelid orbital fat herniation occurred during the course of the treatment. CONCLUSION: A herniation of orbital fat may complicate the injection of corticosteroid through the lower eyelid.

PURPOSE: To study the treatment of uveitis that has not responded to immunosuppressive medication. Intravenous immunoglobulin (IVIg) effectively treats a variety of autoimmune diseases, but it has not been adequately studied in the treatment of uveitis. METHODS: The trial included patients who satisfied criteria that included noninfectious uveitis, active inflammatory disease, and a failure to respond adequately to immunosuppressive medication. We treated two patients with IVIg (0.5 gm/day, 3 days/mo initial dosage) as a pilot study and then treated an additional eight patients with a similar dosage as part of a formal but uncontrolled protocol. RESULTS: Patients on the protocol have been followed for a median of 11 months and have received a median of 7.5 treatment cycles. Five of 10 patients have had a clinically important and sustained improvement in visual acuity, and two of eight protocol patients have markedly reduced their immunosuppressive medication. CONCLUSIONS: Intravenous immunoglobulin can benefit some patients with uveitis that is otherwise refractory to immunosuppressive therapy. Although our preliminary experience is encouraging, the use of IVIg for uveitis should be limited because of cost, toxicity, the requirement for repeated administration, and the absence of controlled trials that demonstrate efficacy.

A patient developed progressive, severe, recurrent bilateral iridocyclitis, retinal vasculitis, and hemorrhagic infarction of the retina that led to blindness despite immunosuppressive therapy. Histopathology of an enucleated blind and painful eye revealed marked nongranulomatous uveitis with a predominantly CD4+ T-lymphocytic infiltration, as well as B-cell and plasma cell aggregation. Extensive expression of adhesion molecules on vascular endothelial cells were found. This finding suggests that adhesion molecules play an important role in the vasculitic process, the trademark of Behcet's disease. The ocular pathology and the therapeutic approach to Behcet's disease are briefly reviewed.