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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2012  |  Volume : 19  |  Issue : 1  |  Page : 153-157  

Cluster bomb ocular injuries

1 Department of Ophthalmology, American University of Beirut and Rafic Hariri University Hospital, Beirut, Lebanon
2 Department of Ophthalmology, American University of Beirut, Beirut, Lebanon
3 Department of Ophthalmology, Hammoud Hospital University Medical Center, Saida, Lebanon
4 Department of Ophthalmology, Nabatieh Government Hospital, Nabatieh, Lebanon

Date of Web Publication20-Jan-2012

Correspondence Address:
Ahmad M Mansour
Department of Ophthalmology, AUB, 3 Daghammarskjold Plaza, 8th floor, New York, NY 10017-2303, USA

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-9233.92133

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Purpose: To present the visual outcomes and ocular sequelae of victims of cluster bombs.
Materials and Methods: This retrospective, multicenter case series of ocular injury due to cluster bombs was conducted for 3 years after the war in South Lebanon (July 2006). Data were gathered from the reports to the Information Management System for Mine Action.
Results: There were 308 victims of clusters bombs; 36 individuals were killed, of which 2 received ocular lacerations and; 272 individuals were injured with 18 receiving ocular injury. These 18 surviving individuals were assessed by the authors. Ocular injury occurred in 6.5% (20/308) of cluster bomb victims. Trauma to multiple organs occurred in 12 of 18 cases (67%) with ocular injury. Ocular findings included corneal or scleral lacerations (16 eyes), corneal foreign bodies (9 eyes), corneal decompensation (2 eyes), ruptured cataract (6 eyes), and intravitreal foreign bodies (10 eyes). The corneas of one patient had extreme attenuation of the endothelium.
Conclusions: Ocular injury occurred in 6.5% of cluster bomb victims and 67% of the patients with ocular injury sustained trauma to multiple organs. Visual morbidity in civilians is an additional reason for a global ban on the use of cluster bombs.

Keywords: Cluster Bomb, Corneal Decompensation, Evisceration, Intraocular Foreign Body, Penetrating Keratoplasty, Vitrectomy

How to cite this article:
Mansour AM, Hamade H, Ghaddar A, Mokadem AS, El Hajj Ali M, Awwad S. Cluster bomb ocular injuries. Middle East Afr J Ophthalmol 2012;19:153-7

How to cite this URL:
Mansour AM, Hamade H, Ghaddar A, Mokadem AS, El Hajj Ali M, Awwad S. Cluster bomb ocular injuries. Middle East Afr J Ophthalmol [serial online] 2012 [cited 2021 Oct 18];19:153-7. Available from: http://www.meajo.org/text.asp?2012/19/1/153/92133

   Introduction Top

Cluster bombs are standard munitions for many nations. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Cluster bombs are produced by 34 countries and have been used by 23 countries. Cluster bombs have been used by the United States (US) in Laos in 1973, by Russia in 1995 during the First Chechen War, by NATO in Yugoslavia in 1999, and by the US in Afghanistan in 2001. [5] In the 2006 war between Hezbollah and Israel, one million cluster bombs rained down upon the fields of South Lebanon. An estimated 35% failed to detonate. [4] Laos, Cambodia, Kosovo, Nepal, Thailand, Afghanistan, Iraq and Lebanon [4] are countries that have experienced significant bombardment with cluster bombs.

Medical reports of cluster bomb injuries are scarce and originate from Croatia [1] (45 cardiothoracic injuries) and Afghanistan [2] (117 cluster bomb victims). Out of 72 cases of war-related ocular trauma in Croatia, Plestina-Borjan et al., [3] treated 4 cases that were due to cluster bombs. We present the ocular findings in a consecutive series of 18 patients reported to the registry of ocular injury due to cluster bombs in Lebanon over a period of 3 years after the war in the year 2006.

   Materials and Methods Top

This was a retrospective, multicenter case series of cluster bomb injuries reported to the registry of cluster bomb eye injuries (ophthalmologists were invited to contribute their cases) and to the Information Management System for Mine Action (IMSMA) for a period of 3 years after the start of the war in Lebanon in July, 2006. Data were gathered from August 2006 onwards. The study received Institutional Review Board approval from Rafic Hariri University Hospital.

Representative case report (Case 1)

A 20-year-old farmer sustained bilateral penetrating ocular injuries while farming. At presentation, the visual acuity was of barely light perception bilaterally. This patient underwent bilateral suturing of corneal lacerations and of multiple posterior scleral lacerations past 6 mm from the limbus along with suturing of bilateral eyelid lacerations. One week postoperatively, the corneas were severely edematous and tiny stones were fully embedded in much of the cornea and there were ruptured cataracts [Figure 1]. B-scan revealed bilateral funnel retinal detachments, expulsive choroidal hemorrhage, and metallic intraocular foreign bodies. The patient consented to sequential surgery. The globes were extremely hypotonous bilaterally. Injection of viscoelastic substance into the anterior chamber allowed recovery of tone and facilitated subsequent maneuvers. Temporary keratoprosthesis, pars plana lensectomy, pars plana vitrectomy, removal of intraocular foreign bodies, and penetrating keratoplasty were performed one week apart starting with the right eye. The left eye had additional temporal retinotomy and heavy silicone oil injection. Histopathology of the excised corneas revealed near complete loss of endothelium [Figure 2]. Twelve months after presentation, best corrected visual acuity was 6/12 in the right eye and hand motion in the left eye. The corneal graft stayed clear [Figure 3]. Postoperatively, the retina was flat in the right eye. However there was phthisis bulbi in the left eye with retinal detachment and proliferative vitreoretinopathy. Twenty four months after presentation, the patient underwent removal of heavy silicone oil and best corrected visual acuity was 20/60. Three years after presentation, raised intraocular pressure caused corneal decompensation and best corrected visual acuity was 20/200.
Figure 1: (Case 1). Appearance of the left eye two weeks after the injury due to a cluster bomb showing diffuse foreign bodies embedded in an edematous cornea

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Figure 2: (Case 1). Clear corneal graft in the right eye eight months after the injury

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Figure 3: (Case 1) The right cornea was markedly thickened with absent endothelium (H and E stain)

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   Results Top

Data from the Information Management System for Mine Action (IMSMA) and Lebanon Mine Action Center revealed a total of 308 victims since the August 2006 ceasefire. There were 36 fatalities (2 with ocular lacerations) and 272 injured individuals (18 with ocular injuries) [Table 1]. All patients with ocular injuries who were still alive were examined and/or underwent surgery by the authors at 3 tertiary centers. The list of patients with ocular injuries was identical using either the ocular registry of cluster bomb injuries or data from IMSMA). All subjects were young males (mean age 24; range 9 to 46 years) and included one deminer and 17 young civilians (13 farmers and 4 adolescents). The right eye was injured in 5 patients, the left eye in 7 patients, and injury to both eyes occurred in 5 patients, and the right orbit and eyelids in 1 patient.
Table 1: Clinical findings in 18 cases with ocular cluster bomb injuries

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The ocular findings included corneoscleral lacerations (16 eyes; evisceration in 3 eyes), corneal foreign bodies (9 eyes), irreversible corneal decompensation (penetrating keratoplasty in 2 eyes), ruptured cataract (6 eyes underwent cataract removal), intravitreal metallic foreign bodies (10 eyes underwent vitreoretinal surgery with 2 eyes with vitreal stones), and eyelid lacerations (4 patients). In 10 patients with more than 1 month of follow-up, median initial visual acuity improved from hand motion to 6/12. Histopathology of both corneas in one patient indicated extreme attenuation of the endothelium. Twelve patients had systemic involvement: burns in 4 patients; injuries in 10 patients with arm or finger loss in 8 patients; facial injuries in 6 patients and; abdominal injuries in 6 patients.

   Discussion Top

Nearly 80 million cluster bombs dropped on Laos by the US military during the Vietnam war failed to detonate on contact and continue to kill and maim to date. In Laos, unexploded bombs from the Vietnam war are being scavenged to sell as scrap metal and 12,000 casualties have been reported since 1973.

Each cluster bomb is composed of 200 to 700 bomblets. When each bomblet explodes, it fragments into approximately 300 pieces of jagged steel, sending out virtual blizzards of deadly shrapnel. Individuals are decapitated; arms, legs, hands and feet are severed. Each bomblet is activated by an internal fuse, and is set to explode above ground, on impact, or can be time-delayed. The smaller bombs are designed to explode near the time of impact. However, 10 to 30% fail to explode at the set time [5] due to release at a low altitude, hitting soft ground, poor storage conditions, and production faults. Consequently, unexploded bombs litter every target area, silent and nondescript until picked up by an unfortunate child or accidentally kicked by a passerby.

According to military experts, [9] rifle bullets have an initial velocity of 750 m/s, while the explosive charges within cluster bombs (and hand grenades) [10] have an initial velocity of 2500 m/s. By the time the intended target, a human body, is reached, the combination of kinetic energy and explosive power makes a wound 30 times larger than the projectile (cluster bomb) itself. This explains the cause of serious bodily injury due to cluster bombs (landmines and hand grenades) [10] which are more damaging than automatic rifle bullets.

Unlike landmine victims who can usually be identified by injuries below the waist, cluster bombs usually inflict injury to the upper body, a result of victims bending forward to pick up the bomb, rather than stepping on it. We found 6.5% of cluster bomb injuries involved the ocular system and 67% of the patients with ocular injuries had other bodily injuries especially to the face and hands. Tragically, children were especially drawn to the cluster bombs due to the small size and interesting shapes. A quarter of all cluster bomb victims are children - children with missing upper limbs, blind, deaf and scarred for life. As unexploded ordinances are usually more visible than landmines, these injuries may be more amenable to prevention through targeted educational messages. [6] Prevention strategies should focus on high-risk groups and changing risky behaviors, such as tampering with explosive devices by children thinking that they are toys. [7]

Case 1 is a unique clinico-pathologic report of an injury by cluster bomb demonstrating the devastating effect of cluster bombs on ocular structures, especially the cornea (air-blast injury from powerful air wave plus direct injury from penetration of foreign bodies). Reconstruction of the anterior and posterior segments of the eye after massive injury required a multidisciplinary approach. Penetrating keratoplasty combined with vitrectomy using a temporary keratoprosthesis was an effective method in treating severe ocular injury from the cluster bomb. The results of combined surgery with penetrating keratoplasty in eyes that would otherwise be untreatable [11] can be limited by anterior segment complications, mainly secondary graft failure, ciliary body malfunction, secondary glaucoma, [11] or proliferative vitreoretinopathy. [11] The pathophysiology of the corneal injury relates to 4 mechanisms causing cumulative damage to the endothelium: primary injury by the initial blast wave, secondary injury caused by projectiles (intra-corneal foreign bodies), tertiary injury caused by the blast wind, and lastly, thermal injuries.

Well after armed conflicts have ceased, cluster bombs continue killing or maiming children and farmers worldwide. The process of locating and removing unexploded bomblets is very costly. The visual and physical rehabilitation is a long, arduous process (especially when the ocular damage is severe) that includes medical care, physical rehabilitation, psycho-social support and socio-economic reintegration. Therefore, we urge all countries to join the ban [8] on the use of cluster munitions signed in December 2008 in Oslo, Norway by representatives of some 100 countries.

   References Top

1.Biocina B, Sutliæ Z, Husedzinoviæ I, Rudez I, Ugljen R, Letica D, et al. Penetrating cardiothoracic war wounds. Eur J Cardiothorac Surg 1997;11:399-405.  Back to cited text no. 1
2.Bilukha OO, Brennan M, Woodruff BA. Death and injury from landmines and unexploded ordnance in Afghanistan. JAMA 2003;290:650-3.  Back to cited text no. 2
3.Plestina-Borjan I, Medvidovic-Grubisic M, Zuljan I, Lakos V, Miljak S, Markovic I, et al. Wartime open globe eye injuries. Graefes Arch Clin Exp Ophthalmol 2010;248:305-12.  Back to cited text no. 3
4.Dyer O. Cluster bombs remain in Lebanon. BMJ 2006;333:412.  Back to cited text no. 4
5.Mannion S, Chaloner E. Potential health hazards of cluster bombing in the Shomali Valley, Afghanistan in October-November 2001. Mil Med 2003;168:756-7.  Back to cited text no. 5
6.Bilukha OO, Tsitsaev Z, Ibragimov BS, Anderson M, Brennan M, Murtazaeva E. Epidemiology of injuries and deaths from landmines and unexploded ordnance in Chechnya, 1994 through 2005. JAMA 2006;296:516-8.  Back to cited text no. 6
7.Surrency AB, Graitcer PL, Henderson AK. Key factors for civilian injuries and deaths from exploding landmines and ordnance. Inj Prev 2007;13:197-201.   Back to cited text no. 7
8.Freckelton I. Cluster munitions: Public health and international law perspectives. J Law Med 2008;15:481-2.  Back to cited text no. 8
9.Wallsten S. High-tech cluster bombs. Nature 2004;428:121-2.  Back to cited text no. 9
10.Sobaci G, Akýn T, Mutlu FM, Karagül S, Bayraktar MZ. Terror-related open-globe injuries: A 10-year review. Am J Ophthalmol 2005;139:937-9.   Back to cited text no. 10
11.Dong X, Wang W, Xie L, Chiu AM. Long-term outcome of combined penetrating keratoplasty and vitreoretinal surgery using temporary keratoprosthesis. Eye (Lond) 2006;20:59-63.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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