title: Closed-globe injuries of the ocular surface associated with combat blast exposure.
abstract: OBJECTIVE
  To describe closed-globe conjunctival and corneal injuries and endothelial cell abnormalities associated with blast exposure and their relationships to other closed-globe injuries and blast-event characteristics.
  
  
  METHODS
  Observational cross-sectional study.
  
  
  METHODS
  Veterans with a history of blast-related traumatic brain injury (TBI).
  
  
  METHODS
  History and ocular examination, including slit-lamp biomicroscopy, gonioscopy, specular microscopy.
  
  
  METHODS
  Type and location of blast injuries to the conjunctiva and cornea.
  
  
  RESULTS
  Ocular surface injuries were present in 25% (16 of 65) of blast-exposed veterans with TBI. Injuries included partial-thickness anterior stromal corneal scars (15 eyes), Descemet membrane ruptures (6 eyes), and conjunctival or corneal foreign bodies (7 eyes). Based on normative information from an age-matched comparison group, endothelial cell abnormalities were identified in 37% of participants. Eyes with ocular surface injury were more likely to have lower endothelial cell density, higher coefficient of variation of cell area, and lower percentage of hexagonal cells compared with eyes without injury. Presence of ocular surface injury or endothelial cell abnormalities was associated with elevated rates of other anterior and posterior segment injuries, as well as impairment of visual acuity. We found no relationship between ballistic eyewear use or severity level of TBI and presence of ocular surface injuries from blast.
  
  
  CONCLUSIONS
  Independent of TBI severity or use of protective eyewear, ocular surface injuries and endothelial cell abnormalities were found in significant numbers of veterans with blast-related brain injury. Descemet membrane ruptures from blast exposure were described. Ocular surface trauma was associated with other ocular injuries throughout the globe. Potential mechanisms for the types and locations of ocular injuries seen were discussed. Any corneal or conjunctival injury in a blast survivor should prompt a thorough ocular trauma examination, including gonioscopy and specular microscopy, with appropriate follow-up for associated injuries. Longitudinal studies are required to determine long-term visual outcomes after blast exposure.
authors.affiliation: Department of Ophthalmology, Veterans Administration Palo Alto Health Care System, Palo Alto, California; Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California; Department of Pathology, Stanford University School of Medicine, Palo Alto, California. Electronic address: glenn.cockerham@va.gov.
authors.forename: Glenn C
authors.initials: GC
authors.lastname: Cockerham
authors.affiliation: Program Evaluation & Resource Center, Veterans Administration Palo Alto Health Care System, Palo Alto, California.
authors.forename: Sonne
authors.initials: S
authors.lastname: Lemke
authors.affiliation: Department of Ophthalmology, Veterans Administration Palo Alto Health Care System, Palo Alto, California; Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Rice
authors.affiliation: Department of Ophthalmology, Veterans Administration Palo Alto Health Care System, Palo Alto, California; Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California.
authors.forename: Gloria
authors.initials: G
authors.lastname: Wang
authors.affiliation: Department of Ophthalmology, Veterans Administration Palo Alto Health Care System, Palo Alto, California.
authors.forename: Catherine
authors.initials: C
authors.lastname: Glynn-Milley
authors.affiliation: Department of Ophthalmology, University of Muenster, Muenster, Germany.
authors.forename: Lars
authors.initials: L
authors.lastname: Zumhagen
authors.affiliation: Department of Ophthalmology, Veterans Administration Palo Alto Health Care System, Palo Alto, California; Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California.
authors.forename: Kimberly P
authors.initials: KP
authors.lastname: Cockerham
mesh_terms: D000328:Adult; D001753:Blast Injuries / Q000175:diagnosis / Q000209:etiology*; D001930:Brain Injuries / Q000209:etiology; D002452:Cell Count; D003228:Conjunctiva / Q000293:injuries*; D065306:Corneal Injuries / Q000175:diagnosis / Q000209:etiology*; D003430:Cross-Sectional Studies; D004728:Endothelium, Corneal / Q000473:pathology; D005131:Eye Injuries / Q000175:diagnosis / Q000209:etiology*; D005260:Female; D006068:Gonioscopy; D006801:Humans; D007429:Intraocular Pressure / Q000502:physiology; D008297:Male; D033401:Microscopy, Acoustic; D008875:Middle Aged; D010781:Photography; D014481:United States; D014728:Veterans; D014792:Visual Acuity / Q000502:physiology; D014857:Warfare; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000209:etiology*; D055815:Young Adult