Ocular Blast Injuries inMass-Casualty IncidentsThe Marathon Bombing in Boston Massachusetts and theFertilizer Plant Explosion in West Texas

Yoshihiro Yonekawa MD12345 Henry D Hacker MD6 Roy E Lehman MD6 Casey J Beal MD7

Peter B Veldman MD145 Neil M Vyas MD8 Ankoor S Shah MD PhD1345 David Wu MD PhD145

Dean Eliott MD145 Matthew F Gardiner MD15 Mark C Kuperwaser MD2 Robert H Rosa Jr MD6

Jean E Ramsey MD MPH8 Joan W Miller MD145 Robert A Mazzoli MD910 Mary G Lawrence MD10

Jorge G Arroyo MD MPH2

Purpose To report the ocular injuries sustained by survivors of the April 15 2013 Boston Marathon bombingand the April 17 2013 fertilizer plant explosion in West Texas

Design Multicenter cross-sectional retrospective comparative case seriesParticipants Seventy-two eyes of 36 patients treated at 12 institutions were included in the studyMethods Ocular and systemic trauma data were collected from medical recordsMain Outcome Measures Types and severity of ocular and systemic trauma and associations with

mechanisms of injuryResults In the Boston cohort 164 of 264 casualties were transported to level 1 trauma centers and 22

(134) required ophthalmology consultations In the West cohort 218 of 263 total casualties were transported toparticipating centers of which 14 (64) required ophthalmology consultations Boston had significantly shortermean distances to treating facilities (16 miles vs 536 miles P frac14 0004) Overall rigid eye shields were more likelynot to have been provided than to have been provided on the scene (Plt0001) Isolated upper body and facialwounds were more common in West largely because of shattered windows (750 vs 136 P frac14 0001)resulting in more open-globe injuries (429 vs 45 P frac14 0008) Patients in Boston sustained more lowerextremity injuries because of the ground-level bomb Overall 278 of consultations were called from emergencyrooms whereas the rest occurred afterward Challenges in logistics and communications were identified

Conclusions Ocular injuries are common and potentially blinding in mass-casualty incidents Systemic andocular polytrauma is the rule in terrorism whereas isolated ocular injuries are more common in other calamities Keylessons learned included educating the public to stay away from windows during disasters promoting use of rigideye shields by first responders the importance of reliable communications deepening the ophthalmology callalgorithm the significance of visual incapacitation resulting from loss of spectacles improving the rate of earlydetection of ocular injuries in emergency departments and integrating ophthalmology services into trauma teamsas well as maintaining a voice in hospital-wide and community-based disaster planning Ophthalmology 2014-1e7 ordf 2014 by the American Academy of Ophthalmology

Supplemental material is available at wwwaaojournalorg

On April 15 2013 2 improvised explosive devices (IEDs)were detonated 13 seconds apart at 249 PM near the BoylstonStreet finish line of the 117th Boston Marathon1 Improvisedexplosive devices are homemade bombs created anddetonated outside of conventional military use commonlyused in terrorist attacks and guerrilla warfare Mass-casualty incidents caused by IEDs are rare in the UnitedStates civilian setting Two hundred sixty-four runners andspectators sustained injuries during the Boston bombing and3 died at the scene2 The marathon was halted medical tentswere converted to mass-casualty triage units and emergencymedical services (EMS) transported the victims to nearbyadult and pediatric trauma centers

2014 by the American Academy of OphthalmologyPublished by Elsevier Inc

Two days later on April 17 at 750 PM an ammoniumnitrate explosion at a fertilizer plant in West Texas injured263 and killed 15 people3 A fire preceded the explosionwhich resulted in (1) the most severe injuries occurring inthe first responders who were attending the fire resultingin incapacitation of the primary EMS teams and (2) apreponderance of glass shard injuries to locals who wereobserving the fire from behind windows at the time of theexplosion Neighboring emergency services were mobilizedand transported the victims to hospitals but the closesthealthcare facility was 25 miles away

The 2 mass-casualty tragedies occurred 52 hours apartand resulted in similar numbers of injuries but with

1ISSN 0161-642014$ - see front matterhttpdxdoiorg101016jophtha201404004

Table 1 Distance from Mass Casualty Site to Treating Facilities

Boston MarathonBombing Miles

West Fertilizer PlantExplosion Miles

Massachusetts Eye andEar

13 Hillcrest Baptist MedicalCenter

246

Boston Medical Center 13 Providence Health Center 262Massachusetts GeneralHospital

14 Scott amp White MemorialHospital

559

Beth Israel MedicalCenter

18 McLane Childrenrsquos Hospital 575

Boston ChildrenrsquosHospital

18 Childrenrsquos Medical Centerof Dallas

780

Brigham and WomenrsquosHospital

19 Parkland Hospital 796

Mean (SD) 16 (03) Mean (SD) 536 (240)

SD frac14 standard deviationP frac14 0004

Ophthalmology Volume - Number - Month 2014

different mechanisms geographic settings and local medi-cal response networks The Boston Marathon bombing wasan intentional planned and relatively low-energy explosionthat took place in a densely populated urban center but withnumerous level 1 trauma centers within a 2-mile radius TheWest incident was a high-energy accidental open-field ex-plosion in a relatively rural setting Both blasts caused se-vere ocular injuries and provide valuable lessons for bothophthalmic and trauma communities in disaster readinessand response planning As the ophthalmic consultants forthe 2 tragic incidents we report and discuss the ocular in-juries sustained by the survivors and the insight gained byophthalmologists involved in these events

Methods

This study was a multicenter cross-sectional retrospectivecomparative case series of victims of the Boston Marathonbombing on April 15 2013 and the West fertilizer plant explosionon April 17 2013 For the Boston cohort patients were identifiedfrom inpatient or emergency department consultation records at theBeth Israel Deaconess Medical Center Boston Childrenrsquos HospitalBoston Medical Center Brigham and Womenrsquos Hospital Massa-chusetts General Hospital and Massachusetts Eye and Ear In-firmary Tufts Medical Center is not included in the study becauseophthalmology consultations were not required but the number ofpatients transported to Tufts is included in the denominator of totalcasualties For the West cohort patients were identified fromconsultation and billing records from Childrenrsquos Medical Center ofDallas Hillcrest Baptist Medical Center McLane ChildrenrsquosHospital Parkland Hospital Providence Health Center and Scottamp White Memorial Hospital Excluded were ophthalmology con-sultations that occurred during the bombing or explosion for pa-tients unrelated directly to the events Also excluded were ocularinjuries seen only by emergency department personnel withoutophthalmology consultations Distances between incident sites andhospitals were determined using Google Maps (wwwmapsgooglecom retrieved January 21 2014) Data collection of demographicswas kept to a minimum to assure the confidentiality of patientidentification (for example patients were reported as adult or pe-diatric with no specified age gender or ethnicity and systemicinjuries were recorded intentionally without laterality) Presentingvisual acuity provision of rigid eye shields ocular injuries treat-ment provided and associated systemic injuries were noted Forthe Boston cohort we also noted whether the patients were runnersor spectators and for the West cohort whether the patients wereoutdoors or indoors at the time of injury Categorical variableswere analyzed using the Fisher exact test and the ManneWhitneyU test was used to compare nonparametric continuous variablesThe binomial test was used to test proportions Statistical tests were2-tailed and significance was defined as Plt005 Statistical anal-ysis was performed using Stata software version 90 (StataCorpLP College Station TX) The institutional review boards of eachinstitution approved the study except for Providence Hospitalwhich opted to approve the study as part of a quality improvementinitiative This study complied with the Health Insurance Porta-bility and Accountability Act of 1996 and conformed to the tenetsof the Declaration of Helsinki

Results

Boston Marathon Bombing

The distances from the first IED detonation site to the respectiveinstitutions are shown in Table 1 The 2 IEDs injured 264 people2

2

with 164 transported to surrounding level 1 trauma centers12 Threevictims did not survive the blasts and were pronounced dead on thescene2 All patients transported to trauma centers survivedincluding 19 who were critically injured45 Twenty-two patients(134) required ophthalmology consultations that were requestedfrom emergency rooms during trauma or orthopaedic surgeries orafter surgery in intensive care units or inpatient floors Twenty-onepatients (955) were spectators and 1 was a runner No patientswere provided with rigid eye shields at the point of injury

Fourteen (636) consultations were requested from the oper-ating room or intensive care units during or immediately after life-sustaining interventions whereas only 3 (136) were requestedfrom the emergency room (Table 2) Periocular injuries were seenin 19 patients (864) conjunctival or corneal injuries were seen in13 patients (591) posterior segment injuries were seen in 3patients (136) and an open-globe injury was seen in 1 patient(45 Fig 1 available at wwwaaojournalorg) Lodged ocular orintracranial foreign bodies were found in 6 patients (273) Allocular and systemic foreign bodies were shrapnel such as BBpellets and nails Of 20 patients with ocular injuries 19 (950)had bilateral injuries and 12 (600) had ocular polytrauma(multiple ocular injuries)

One hundred percent of patients had concomitant systemic in-juries Of note 18 patients (818) had lower limb injuries ofwhich 16 patients (727) required surgical interventions Incomparison head and neck or upper extremity injuries were foundin 13 patients (591) of which only 3 such cases occurred inisolation without lower extremity injuries Burns involving theperiocular region were found in 17 patients (773) and tympanicmembrane perforations were diagnosed in 11 patients (500)during this acute setting

West Fertilizer Plant Explosion

The distances from the fertilizer plant to the respective treating in-stitutions are listed in Table 1 A total of 263 injured patients weretreated at local and regional hospitals 45 were seen at HillRegional and John Peter Smith Hospitals which did not take partin the current study There were 15 reported deaths5 Of the 218patients from the participating institutions 14 (64) requiredophthalmology consultations and are summarized in Table 3There were 17 other patients with presumed ocular injuries triagedand treated by emergency departments and coded as superficialcorneal injuries who were excluded from our analysis The ocularinjury rate increased to 142 if these patients were included

Table 2 Ocular Injuries in the Boston Marathon Bombing

PatientNo

Adult orPediatric

ConsultationLocation

FoxShield

Visual Acuity(Right EyeLeft Eye) Ocular Injuries Systemic Injuries

1 Adult Floor No 2020 2025 SL both eyes SCHK abrasion left eye Headneck FB2 Adult ER No LP 2025 IOFB (z II)VHtotal RD right eye LE shrapnel3 Adult OR No d SLchemosis both eyes UE FB LE amp compartment syndrome4 Adult OR No d SLchemosis both eyes UELE open fx5 Adult OR No d SLchemosis both eyes TMP LE open fx6 Adult OR No d SLchemosis both eyes LE ampopen fx7 Adult OR No HM 2020 Orbital roof defectsclopetariaRD right eye Intracranial FBheme LE open fx8 Adult ICU No d SLchemosis both eyes UE shrapnel LE open fx9 Adult OR No 2060 2040 SL both eyes conj lacK lacK FB right eye TMP LE open wounds10 Adult ICU No 2020 2020 Lid erythema both eyes TMP UELE FB11 Adult ER No 2020 2020 Normal exam both eyes TMP LE open wounds12 Adult ER No 2020 2020 SL both eyes TMP UELE FB13 Adult Floor No 2020 2020 SL both eyes lid lac right eye Facial FB TMP LE open wounds14 Adult ICU No 2030 2030 Normal exam both eyes TMP LE open wounds sepsis15 Adult Floor No 2020 2020 SL both eyes subconj FB left eye Head wounds16 Adult Floor No 2020 2020 Lid abrasions both eyes VH right eye Abdominal FB17 Adult ICU No d Lid abrasionsSLchemosis both eyes K

abrasion right eyeTMP UE wound LE amp

18 Pediatric ICU No 2025 2025 SLPEE both eyes Pulmonary contusions LE open wounds19 Pediatric ICU No FampF SL both eyes Open head wounds ICH TMP LE FB20 Pediatric ICU No d Lid edemaSLchemosisPEE both eyes TMP abdominal burns LE open wounds21 Pediatric ICU No d SL both eyes conj FBchemosisPEE both

eyesEar lac UE burns diffuse FB LE amp

22 Pediatric Floor No 2025 2030 SLconj gunpowerSCHK FB both eyes TMP facialUE FB

amp frac14 amputation conj frac14 conjunctiva ER frac14 emergency room FampF frac14 fixes and follows FB frac14 foreign body (all shrapnel) fx frac14 fractureheme frac14 hemorrhage HM frac14 hand movements ICH frac14 intracranial hemorrhage ICU frac14 intensive care unit IOFB frac14 intraocular foreign body K frac14 cornealac frac14 laceration LE frac14 lower extremity LP frac14 light perception OR frac14 operating room PEE frac14 punctate epithelial erosions RD frac14 retinal detachmentSCH frac14 subconjunctival hemorrhage SL frac14 singed lashes (all associated with facial burns) subconj frac14 subconjunctival TMP frac14 tympanic membraneperforation UE frac14 upper extremity VH frac14 vitreous hemorrhage z frac14 zone d frac14 not availableAll open fractures and open wounds were associated with shrapnel

Yonekawa et al Boston Marathon Bombing and Texas Explosion

Seven (500) consultations were requested from emergencyrooms Seven (583) of 12 patients with available data were insideat the time of the explosion All of these patients sustained injuriesfrom window glass shards and accounted for 5 (833) of 6 patientswith open-globe injuries Rigid eye shields were provided for only 1patient with available data (rigid eye shields more often were notprovided in either cohort thanwere provided [Plt0001]) Periocularinjurieswere seen in 9 (643) of 14 patients conjunctival or cornealinjuries were seen in 7 (500) of 14 patients posterior segmentinjuries were seen in 5 (357) of 14 patients and open-globe in-juries were seen in 6 (429) of 14 patients (compared with 45 inthe Boston cohort P frac14 0008 Fig 1 available atwwwaaojournalorg) Lodged ocular or periocular foreign bodieswere found in 5 patients (357) Bilateral injuries were seen in 8patients (571) and 8 patients (571) had ocular polytrauma

Two patients had isolated ocular injuries whereas the remain-ing 12 patients (857) had nonocular injuries Of nonocular in-juries lacerations or embedded foreign bodies were seen in 9patients (643) all of which were glass Injuries limited to thehead neck upper extremities or abdomen without involvement oflower extremities were seen in 9 (75) of 12 patients with non-ocular injuries (compared with 136 in the Boston cohort P frac140001) There were no cases of traumatic amputations or openfractures in the West ocular injury cohort

Ophthalmic Operative Treatment

In the Boston cohort patient 2 underwent open-globe repair withpars plana vitrectomy (PPV) endoscopic removal of a large

intraocular BB pellet and retinal detachment repair Patient 7 un-derwent a negative globe exploration and subsequently 2 parsplana vitrectomies for repair of retinal detachment and proliferativevitreoretinopathy associated with sclopetaria (this patient is alsopart of a case series of sclopetaria-associated retinal detachments6)In the West cohort patients 29 30 33 34 35 and 36 underwentrepair of open-globe injury injuries of which patients 33 34 and36 also had intraocular foreign bodies (all glass shards)

Discussion

Ocular blast injuries are well documented from militaryexperiences7e10 but mass-casualty blasts are rare in thecivilian setting in the United States Victims of blast injuriesoften sustain multisystem polytrauma11 Explosions result ininstantaneous rise in air pressure surrounding the blastepicenter causing primary blast injuries from the baricoverpressure12 Secondary blast injuries are caused byshrapnel and debris carried by the blast wind which oftendictates the types of injuries that are sustained13 Tertiaryinjuries are those caused by being displaced by the blastwind such as concussions and orthopedic injuries fromhitting hard surfaces Quaternary injuries are flash burnscaused by heat produced by the explosion and quinaryeffects are inhalation of toxins and components of theblast cloud (vaporized explosive residue sand dirt) thatmay have lingering effects The most severe ocular

3

Table 3 Ocular Injuries in the West Fertilizer Plant Explosion

PatientNo

Adult orPediatric Location

ConsultationLocation

FoxShield

Visual Acuity(Right EyeLeft Eye) Ocular Injuries Systemic Injuries

23 Adult Outside Floor No 2020 2020 K abrasion right eye FacialUELE lacs24 Pediatric d ER No d Lid lacs right eye None25 Adult Inside ER No d Brow lac left eye UE abrasions and ecchymoses26 Adult Outside ER No d Conj dustPEE left eye None27 Adult d ER No d K abrasions both eyes LE FB28 Adult Outside Floor d d Lid lacs both eyes Cervical fx lung contusion29 Adult Inside ER d 2030 NLP Commotio retinae right eye OGI left

eye (z III)Facechestabdominal lacs

30 Adult Outside Floor d d Periorbital FBK abrasion right eyeOGI left eye (z IIIIII)

UE fx neckUE burns

31 Adult Outside Floor No d Orbital floor fx left eye FacialchestUELE lacs resp failure32 Adult Inside Floor No 2050 20100 Brow lacintraorbital radiopaque FB

left eyeFacialneck lacs

33 Pediatric Inside OR Yes d Lid lacsFBs both eyes IOFB right eye(z II) OGI left eye (z I)

Facial lacs UE FB (glass)lacs

34 Pediatric Inside OR d d Brow lacs both eyes K abrasion lefteye IOFB left eye (z II)

Open cranium fx esophageal FBfacialUELE lacs

35 Adult Inside ER No HM CF Lid lacsOGI right eye (z III) lidlacSCHVHOGI left eye (z III)

Facial lacs

36 Adult Inside ER No d Lid lacsSCHOGI right eye (z I)Lid lacSCHIOFB left eye (z IIIIII)

Facial lacs

CF frac14 counting fingers conj frac14 conjunctiva ER frac14 emergency room FB frac14 foreign body fx frac14 fracture K frac14 cornea HM frac14 hand movements IOFB frac14intraocular foreign body lac(s) frac14 laceration(s) LE frac14 lower extremity NLP frac14 no light perception OGI frac14 open globe injury OR frac14 operating room PEE frac14punctate epithelial erosions resp frac14 respiratory SCH frac14 subconjunctival hemorrhage UE frac14 upper extremity z frac14 zone d frac14 not available

Ophthalmology Volume - Number - Month 2014

injuries in Boston and West were caused by secondaryinjuries shrapnel in Boston and shattered glass in West

Ocular injuries are common in mass-casualty in-cidents1314 In the Boston bombing 13 of patients trans-ferred to level 1 trauma centers had ocular involvementsuspicious enough to warrant ophthalmology consultationsIn the West cohort 14 had ocular injuries triaged byemergency departments and 6were seen by ophthalmologyteams In the April 19 1995 bombing of the Federal OfficeBuilding in Oklahoma 55 (8) of 684 injured survivorssustained ocular injuries14 During the World Trade Centertragedy on September 11 2001 in New York City mostvictims directly affected by the collapsed buildings did notsurvive but ocular injuries were the second most commoninjuries for which disaster relief personnel were treated(inhalation injuries were the most common) Keratitissecondary to smoke and chemicals corneal abrasions orforeign bodies were the leading causes1516

Point of Injury

In Boston BB pellets nails and other shrapnel wereimplanted in a pressure cooker IED The bomb was placed atground level resulting in many lower extremity injuries Anopen-globe injury was seen in 1 patient but more would haveoccurred if the bombs had been situated in an elevatedlocation In West the prominent secondary injuries werefrom window glass Many victims were standing by theirwindows to observe the fertilizer plant fire when it abruptlyexploded Facial and upper body injuries were more com-mon which translated into higher rates of open-globe

4

injuries Communities should be made aware that facingwindows during disasters is potentially vision and lifethreatening This was also seen in the Oklahoma bombing Asignificant number the injuries were the result of shatteredglass and there was a high rate of open-globe injuries (22)60 of these patients were facing a window during the ex-plosion Historically the Halifax Disaster of 1917 also had asimilar mechanism After a collision in the harbor a muni-tions ship caught fire and while residents looked out theirwindows the ship exploded and caused significant ocularinjuries from shattered glass resulting in 249 enucleations17

Quaternary (thermal) injuries were more common inBoston Injury patterns depend on the energy of the explo-sion and the distance from the epicenter the explosion inBoston was smaller but the bomb was detonated in themiddle of a crowd compared with the explosion in Westthat was larger but approximately 150 m away from theclosest residential buildings where most victims werelocated West experienced an open-field blast where rela-tively predictable Friedlander physics apply more than theconfined urban canyon of Boston where blast waves alsoreflect off surfaces causing phase adding and subtracting

Prehospital Care

Many factors contributed to the efficient and effective careprovided in Boston predeployed police and EMS personnelfor a major event that decreased response times cleared citystreets for the marathon bystanders who acted as first re-sponders and assisted medical personnel effectively 6 level1 trauma centers within 2 miles of the bombing site and an

Yonekawa et al Boston Marathon Bombing and Texas Explosion

explosion that took place during hospital changes of shiftsresulting in personnel from 2 shifts being present and thusdoubling the available medical personnel5 Although thereare no substantiating data sunglasses worn by runnerstheoretically are protective against ocular injuries also

The West victims received prompt and expert care butfaced different challenges in the relatively rural setting Theexplosion incapacitated the initial responders which requiredthe robust surrounding regional EMS services to be mobi-lized The closest medical facility was 25 miles away andsome casualties required helicopter transportation for urgentevacuation Some patients self-transported or were sent to thenearest medical care facility which might not have had theproper capabilities for required treatment For example pa-tient 33 had open-globe injuries that were repaired at thethird hospital to which he or she was transferred

The use of rigid eye shields was alarmingly low in bothcities First responders should be aware of potential ocularinjury scenarios in polytrauma patients should be providedwith readily available rigid eye shields and should bemindful to use them in all suspected ocular trauma patientsThe military has instituted this in a clinical practice guide-line with better success and this should be applied in thecivilian sector as well (Mazzoli RA et al Use of rigid eyeshields (Fox shields) at the point of injury in AfghanistanPoster presented at Military Health System ResearchSymposium August 12e15 2013 Fort Lauderdale)

Trauma Teams

Ocular injuries are assessed during the advanced trauma lifesupport secondary survey which is usually performed in theemergency room In Boston many casualties had life-threatening injuries and secondary surveys took place inthe operating room for a number of patients Neverthelessophthalmology consultations were requested from theemergency departments for only 14 of patients in Bostonand for 50 of patients in West the remaining 86 and50 of consultations respectively occurred afterward Ofthe 7 patients with open-globe injuries in both cohorts 4consultations were requested from emergency roomswhereas 3 consultations occurred afterward in the operatingroom or inpatient units Eye injuries are part of the blastpolytrauma complex but may escape early detectioncompared with other life-threatening nonocular injuriesLife support obviously is the primary goal of trauma carebut ocular issues should be considered in overall preopera-tive planning For example some potential consequencesinclude additional iatrogenic ocular trauma resulting fromunawareness of an open globe during patient manipulationand transportation inadvertent taping of an eye with anopen-globe injury and forgoing orbital cuts in the traumapan-computed tomography scan Time also is required toarrange transportable microscopes or transfer to anophthalmic operating room

Coordination and Communication

We found that reliable communication methods are essentialfor coordinating care Cellular networks were overwhelmedduring the first few hours of the Boston explosion such that

communication between our team members had to be madeon landlines and via paging systems Disaster-readinessorganizations indicate that text messaging is also an effec-tive means of communication when network traffic ishigh18

Manpower can become an issue especially where 1ophthalmologist may be on call for multiple facilities orextended geographic regions In Boston ophthalmologyresidents across several institutions were mobilized strate-gically while coordinating with faculty to cover facilitieswith the most need This went beyond the usual call algo-rithm The emergency patients may have disrupted normalclinic and operating room flow but the bombing took placeon a holiday when there were no scheduled clinics or routinesurgeries In West the operative cases also were dividedamong facilities albeit across further distances Werecommend that a 2- or 3-tiered disaster plan be put in placefor all ophthalmic practices to accommodate high-volumemass casualty incidents The flow of care for polytraumapatients may be disrupted if there are not enough ophthal-mologists integrated into the trauma team

Access to subspecialty ophthalmic expertise also isessential Similar to the systemic polytrauma seen in patientswith blast injuries the eyes of such patients often also haveocular polytrauma Each type of injury requires sub-specialized attention Of note vitreoretinal surgeries wererequired in both Boston and West We recommend thatophthalmic communities be aware of the inventory ofspecialized equipment in their home institutions such asendoscopes for bypassing media opacities19 and foreignbody forceps and magnets for intraocular foreign bodyremoval20 If immediate access to subspecialty services isnot available the military experience has shown that so-called damage control surgery is an effective approach inwhich open globes are closed stabilized and prepared fortransfer to collaborators at tertiary care centers910

Preparations for the Future

Basic provisions that eye centers take for granted may not beavailable during emergencies Computed tomography im-aging is routine for head and neck trauma but ocular in-juries must be identified during the secondary survey toassure that orbital cuts are included in the scans Patientswith polytrauma invariably are situated in general surgeryoperating rooms and portable microscopes ideally aretransported into the rooms Patients also are on generalsurgery beds with limited space around the head for theophthalmologistrsquos leg positioning In such cases patientseither can be positioned as superiorly as possible or can bepositioned backward with the head at the foot of the bedwhere there is more leg space The ophthalmologist alsomust be prepared to work with general surgery techniciansand nurses who may have limited experience withophthalmology cases

In Texas eye-care providers have anecdotally indicatedthat many of their patients became visually incapacitatedbecause of the loss of their spectacles from the impact of theblast Survivors of the Tohoku earthquake in Japan21 andHurricane Katrina22 also had similar experiences

5

Ophthalmology Volume - Number - Month 2014

Navigating a disaster-struck environment while visuallyimpaired increases the risk of more serious but preventablephysical injuries particularly at night or if power andinfrastructure are disrupted We recommend that stocks ofspectacles be available as early as possible during disasterrelief efforts

In many cities preparation for mass-causality incidentsbecame a priority after 911 Because of this response theBoston trauma centers were well prepared2 West also hadsimilar discussions after the fertilizer plant explosion3

However the number of ocular casualties is not consideredor planned for routinely Therefore ophthalmologists mustremain in the discussions and medical response planningmoving forward because ocular injuries are commonand potentially blinding for survivors of civilian blastinjuries

The limitations of this report include inherent biases in itsretrospective cross-sectional design The numbers of mildocular injuries are unknown because of triaging of patientswith less-severe injuries to community facilities and self-treatment The data gathered is skewed toward inpatientswith severe systemic and polytrauma injuries who hadocular manifestations beyond the capacity of primary teamsData collection purposely was limited after discussion withinstitutional review boards to be more conservative thanusual in protecting patient anonymity in light of high mediacoverage so we do not present age gender ethnicity orlaterality of systemic injuries The cross-sectional design didnot allow presentation of follow-up data which is importantin these patients whose traumatized eyes are susceptible toboth acute23 and chronic7 sequelae Of note seeminglybenign ocular injuries such as corneal abrasions may be abellwether of other occult ocular trauma with significantlong-term implications such as angle recession

Additional natural disasters manmade calamities andintentional and unintentional mass-casualty incidents un-doubtedly will occur in the future Many survivors ofmultisystem trauma will sustain blast-related ocular injuriesand ophthalmologists must be seamlessly integrated intoregional trauma teams and their preparations

References

1 Kotz D Injury toll from Marathon bombs reduced to 264Boston Globe April 24 2013 Available at httpwwwbostonglobecomlifestylehealth-wellness20130423number-injured-marathon-bombing-revised-downwardNRpaz5mmvG-quP7KMA6XsIKstoryhtml Accessed April 7 2014

2 FEMA Lessons Learned Information Sharing Boston Mara-thon bombings hospital readiness and response Available athttpswwwllisdhsgovsitesdefaultfilesBoston20Marathon20Bombings20Hospital20Readiness20and20Responsepdf Accessed January 24 2014

3 Zuzek C The night West blew up Tex Med 201310941ndash54 Gebhardt MC Guest editorial Patriotsrsquo Day at the Boston

Marathon Clin Orthop Relat Res 20134712045ndash65 United States Senate Committee on Homeland Security and

Government Affairs One Hundred Thirteenth Congress FirstSession Lessons learned from the Boston Marathon

6

bombings preparing for and responding to the attack July 102013 Available at httpswwwhsdlorgviewampdidfrac14740471Accessed January 24 2014

6 Papakostas TD Yonekawa Y Wu D et al Retinal detachmentassociated with traumatic chorioretinal rupture (sclopetaria)Ophthalmic Surg Lasers Imaging Retina In press

7 Cockerham GC Rice TA Hewes EH et al Closed-eye ocularinjuries in the Iraq and Afghanistan wars N Engl J Med20113642172ndash3

8 Thach AB Johnson AJ Carroll RB et al Severe eye injuriesin the war in Iraq 2003e2005 Ophthalmology 2008115377ndash82

9 Colyer MH Chun DW Bower KS et al Perforating globeinjuries during operation Iraqi Freedom Ophthalmology20081152087ndash93

10 Weichel ED Colyer MH Ludlow SE et al Combat oculartrauma visual outcomes during operations Iraqi and EnduringFreedom Ophthalmology 20081152235ndash45

11 Thach AB Eye injuries associated with terrorist bombings InThach AB ed Ophthalmic Care of the Combat CasualtyWashington DC Office of the Surgeon General at TMM Publ2003421ndash9 Lounsbury DE ed-in-chief Textbooks of MilitaryMedicine Available at httpwwwcsameddarmymilbordenPortletaspxIDfrac144503a58c-5b6c-43f9-afef-0adb36fcc635 Acc-essed April 7 2014

12 Wolf SJ Bebarta VS Bonnett CJ et al Blast injuries Lancet2009374405ndash15

13 Morley MG Nguyen JK Heier JS et al Blast eye injuries areview for first responders Disaster Med Public Health Prep20104154ndash60

14 Mines M Thach A Mallonee S et al Ocular injuries sustainedby survivors of the Oklahoma City bombing Ophthalmology2000107837ndash43

15 Injuries and illnesses among New York City Fire Departmentrescue workers after responding to the World Trade Centerattacks JAMA 20022881581ndash4 Reprinted from MMWRMorb Mortal Wkly Rep 200251(Spec Issue)1e5 Availableat httpwwwcdcgovmmwrpreviewmmwrhtmlmm51SPa1htm Accessed April 7 2014

16 Kurup SK Que ET Kauffmann Jokl DH The World TradeCenter disaster a brief on-site report from Ground Zero ArchOphthalmol 2002120395ndash6

17 McAlister CN Murray TJ Lakosha H Maxner CE TheHalifax disaster (1917) eye injuries and their care Br JOphthalmol 200791832ndash5

18 Federal Emergency Management Agency Ready Get techready Available at httpwwwreadygovget-tech-readyAccessed February 15 2014

19 Yonekawa Y Papakostas TD Marra KV Arroyo JG Endo-scopic pars plana vitrectomy for the management of severeocular trauma Int Ophthalmol Clin 201353139ndash48

20 Soheilian M Abolhasani A Ahmadieh H et al Managementof magnetic intravitreal foreign bodies in 71 eyes OphthalmicSurg Lasers Imaging 200435372ndash8

21 Tanaka Y Yamato A Yaji N Yamato M A simple stock ofoptical glasses for a catastrophic disaster eyewear donationsafter the 2011 Pacific Coast Tohoku earthquake Tohoku J ExpMed 201222793ndash5

22 Ridenour ML Cummings KJ Sinclair JR Bixler DDisplacement of the underserved medical needs of HurricaneKatrina evacuees in West Virginia J Health Care Poor Un-derserved 200718369ndash81

23 Stryjewski TP Andreoli CM Eliott D Retinal detachmentafter open globe injury Ophthalmology 2014121327ndash33

Yonekawa et al Boston Marathon Bombing and Texas Explosion

explosion that took place during hospital changes of shiftsresulting in personnel from 2 shifts being present and thusdoubling the available medical personnel5 Although thereare no substantiating data sunglasses worn by runnerstheoretically are protective against ocular injuries also

The West victims received prompt and expert care butfaced different challenges in the relatively rural setting Theexplosion incapacitated the initial responders which requiredthe robust surrounding regional EMS services to be mobi-lized The closest medical facility was 25 miles away andsome casualties required helicopter transportation for urgentevacuation Some patients self-transported or were sent to thenearest medical care facility which might not have had theproper capabilities for required treatment For example pa-tient 33 had open-globe injuries that were repaired at thethird hospital to which he or she was transferred

The use of rigid eye shields was alarmingly low in bothcities First responders should be aware of potential ocularinjury scenarios in polytrauma patients should be providedwith readily available rigid eye shields and should bemindful to use them in all suspected ocular trauma patientsThe military has instituted this in a clinical practice guide-line with better success and this should be applied in thecivilian sector as well (Mazzoli RA et al Use of rigid eyeshields (Fox shields) at the point of injury in AfghanistanPoster presented at Military Health System ResearchSymposium August 12e15 2013 Fort Lauderdale)

Trauma Teams

Ocular injuries are assessed during the advanced trauma lifesupport secondary survey which is usually performed in theemergency room In Boston many casualties had life-threatening injuries and secondary surveys took place inthe operating room for a number of patients Neverthelessophthalmology consultations were requested from theemergency departments for only 14 of patients in Bostonand for 50 of patients in West the remaining 86 and50 of consultations respectively occurred afterward Ofthe 7 patients with open-globe injuries in both cohorts 4consultations were requested from emergency roomswhereas 3 consultations occurred afterward in the operatingroom or inpatient units Eye injuries are part of the blastpolytrauma complex but may escape early detectioncompared with other life-threatening nonocular injuriesLife support obviously is the primary goal of trauma carebut ocular issues should be considered in overall preopera-tive planning For example some potential consequencesinclude additional iatrogenic ocular trauma resulting fromunawareness of an open globe during patient manipulationand transportation inadvertent taping of an eye with anopen-globe injury and forgoing orbital cuts in the traumapan-computed tomography scan Time also is required toarrange transportable microscopes or transfer to anophthalmic operating room

Coordination and Communication

We found that reliable communication methods are essentialfor coordinating care Cellular networks were overwhelmedduring the first few hours of the Boston explosion such that

communication between our team members had to be madeon landlines and via paging systems Disaster-readinessorganizations indicate that text messaging is also an effec-tive means of communication when network traffic ishigh18

Manpower can become an issue especially where 1ophthalmologist may be on call for multiple facilities orextended geographic regions In Boston ophthalmologyresidents across several institutions were mobilized strate-gically while coordinating with faculty to cover facilitieswith the most need This went beyond the usual call algo-rithm The emergency patients may have disrupted normalclinic and operating room flow but the bombing took placeon a holiday when there were no scheduled clinics or routinesurgeries In West the operative cases also were dividedamong facilities albeit across further distances Werecommend that a 2- or 3-tiered disaster plan be put in placefor all ophthalmic practices to accommodate high-volumemass casualty incidents The flow of care for polytraumapatients may be disrupted if there are not enough ophthal-mologists integrated into the trauma team

Access to subspecialty ophthalmic expertise also isessential Similar to the systemic polytrauma seen in patientswith blast injuries the eyes of such patients often also haveocular polytrauma Each type of injury requires sub-specialized attention Of note vitreoretinal surgeries wererequired in both Boston and West We recommend thatophthalmic communities be aware of the inventory ofspecialized equipment in their home institutions such asendoscopes for bypassing media opacities19 and foreignbody forceps and magnets for intraocular foreign bodyremoval20 If immediate access to subspecialty services isnot available the military experience has shown that so-called damage control surgery is an effective approach inwhich open globes are closed stabilized and prepared fortransfer to collaborators at tertiary care centers910

Preparations for the Future

Basic provisions that eye centers take for granted may not beavailable during emergencies Computed tomography im-aging is routine for head and neck trauma but ocular in-juries must be identified during the secondary survey toassure that orbital cuts are included in the scans Patientswith polytrauma invariably are situated in general surgeryoperating rooms and portable microscopes ideally aretransported into the rooms Patients also are on generalsurgery beds with limited space around the head for theophthalmologistrsquos leg positioning In such cases patientseither can be positioned as superiorly as possible or can bepositioned backward with the head at the foot of the bedwhere there is more leg space The ophthalmologist alsomust be prepared to work with general surgery techniciansand nurses who may have limited experience withophthalmology cases

In Texas eye-care providers have anecdotally indicatedthat many of their patients became visually incapacitatedbecause of the loss of their spectacles from the impact of theblast Survivors of the Tohoku earthquake in Japan21 andHurricane Katrina22 also had similar experiences

5

Ophthalmology Volume - Number - Month 2014

Navigating a disaster-struck environment while visuallyimpaired increases the risk of more serious but preventablephysical injuries particularly at night or if power andinfrastructure are disrupted We recommend that stocks ofspectacles be available as early as possible during disasterrelief efforts

In many cities preparation for mass-causality incidentsbecame a priority after 911 Because of this response theBoston trauma centers were well prepared2 West also hadsimilar discussions after the fertilizer plant explosion3

However the number of ocular casualties is not consideredor planned for routinely Therefore ophthalmologists mustremain in the discussions and medical response planningmoving forward because ocular injuries are commonand potentially blinding for survivors of civilian blastinjuries

The limitations of this report include inherent biases in itsretrospective cross-sectional design The numbers of mildocular injuries are unknown because of triaging of patientswith less-severe injuries to community facilities and self-treatment The data gathered is skewed toward inpatientswith severe systemic and polytrauma injuries who hadocular manifestations beyond the capacity of primary teamsData collection purposely was limited after discussion withinstitutional review boards to be more conservative thanusual in protecting patient anonymity in light of high mediacoverage so we do not present age gender ethnicity orlaterality of systemic injuries The cross-sectional design didnot allow presentation of follow-up data which is importantin these patients whose traumatized eyes are susceptible toboth acute23 and chronic7 sequelae Of note seeminglybenign ocular injuries such as corneal abrasions may be abellwether of other occult ocular trauma with significantlong-term implications such as angle recession

Additional natural disasters manmade calamities andintentional and unintentional mass-casualty incidents un-doubtedly will occur in the future Many survivors ofmultisystem trauma will sustain blast-related ocular injuriesand ophthalmologists must be seamlessly integrated intoregional trauma teams and their preparations

References

1 Kotz D Injury toll from Marathon bombs reduced to 264Boston Globe April 24 2013 Available at httpwwwbostonglobecomlifestylehealth-wellness20130423number-injured-marathon-bombing-revised-downwardNRpaz5mmvG-quP7KMA6XsIKstoryhtml Accessed April 7 2014

2 FEMA Lessons Learned Information Sharing Boston Mara-thon bombings hospital readiness and response Available athttpswwwllisdhsgovsitesdefaultfilesBoston20Marathon20Bombings20Hospital20Readiness20and20Responsepdf Accessed January 24 2014

3 Zuzek C The night West blew up Tex Med 201310941ndash54 Gebhardt MC Guest editorial Patriotsrsquo Day at the Boston

Marathon Clin Orthop Relat Res 20134712045ndash65 United States Senate Committee on Homeland Security and

Government Affairs One Hundred Thirteenth Congress FirstSession Lessons learned from the Boston Marathon

6

bombings preparing for and responding to the attack July 102013 Available at httpswwwhsdlorgviewampdidfrac14740471Accessed January 24 2014

6 Papakostas TD Yonekawa Y Wu D et al Retinal detachmentassociated with traumatic chorioretinal rupture (sclopetaria)Ophthalmic Surg Lasers Imaging Retina In press

7 Cockerham GC Rice TA Hewes EH et al Closed-eye ocularinjuries in the Iraq and Afghanistan wars N Engl J Med20113642172ndash3

8 Thach AB Johnson AJ Carroll RB et al Severe eye injuriesin the war in Iraq 2003e2005 Ophthalmology 2008115377ndash82

9 Colyer MH Chun DW Bower KS et al Perforating globeinjuries during operation Iraqi Freedom Ophthalmology20081152087ndash93

10 Weichel ED Colyer MH Ludlow SE et al Combat oculartrauma visual outcomes during operations Iraqi and EnduringFreedom Ophthalmology 20081152235ndash45

11 Thach AB Eye injuries associated with terrorist bombings InThach AB ed Ophthalmic Care of the Combat CasualtyWashington DC Office of the Surgeon General at TMM Publ2003421ndash9 Lounsbury DE ed-in-chief Textbooks of MilitaryMedicine Available at httpwwwcsameddarmymilbordenPortletaspxIDfrac144503a58c-5b6c-43f9-afef-0adb36fcc635 Acc-essed April 7 2014

12 Wolf SJ Bebarta VS Bonnett CJ et al Blast injuries Lancet2009374405ndash15

13 Morley MG Nguyen JK Heier JS et al Blast eye injuries areview for first responders Disaster Med Public Health Prep20104154ndash60

14 Mines M Thach A Mallonee S et al Ocular injuries sustainedby survivors of the Oklahoma City bombing Ophthalmology2000107837ndash43

15 Injuries and illnesses among New York City Fire Departmentrescue workers after responding to the World Trade Centerattacks JAMA 20022881581ndash4 Reprinted from MMWRMorb Mortal Wkly Rep 200251(Spec Issue)1e5 Availableat httpwwwcdcgovmmwrpreviewmmwrhtmlmm51SPa1htm Accessed April 7 2014

16 Kurup SK Que ET Kauffmann Jokl DH The World TradeCenter disaster a brief on-site report from Ground Zero ArchOphthalmol 2002120395ndash6

17 McAlister CN Murray TJ Lakosha H Maxner CE TheHalifax disaster (1917) eye injuries and their care Br JOphthalmol 200791832ndash5

18 Federal Emergency Management Agency Ready Get techready Available at httpwwwreadygovget-tech-readyAccessed February 15 2014

19 Yonekawa Y Papakostas TD Marra KV Arroyo JG Endo-scopic pars plana vitrectomy for the management of severeocular trauma Int Ophthalmol Clin 201353139ndash48

20 Soheilian M Abolhasani A Ahmadieh H et al Managementof magnetic intravitreal foreign bodies in 71 eyes OphthalmicSurg Lasers Imaging 200435372ndash8

21 Tanaka Y Yamato A Yaji N Yamato M A simple stock ofoptical glasses for a catastrophic disaster eyewear donationsafter the 2011 Pacific Coast Tohoku earthquake Tohoku J ExpMed 201222793ndash5

22 Ridenour ML Cummings KJ Sinclair JR Bixler DDisplacement of the underserved medical needs of HurricaneKatrina evacuees in West Virginia J Health Care Poor Un-derserved 200718369ndash81

23 Stryjewski TP Andreoli CM Eliott D Retinal detachmentafter open globe injury Ophthalmology 2014121327ndash33

Ophthalmology Volume - Number - Month 2014

Navigating a disaster-struck environment while visuallyimpaired increases the risk of more serious but preventablephysical injuries particularly at night or if power andinfrastructure are disrupted We recommend that stocks ofspectacles be available as early as possible during disasterrelief efforts

In many cities preparation for mass-causality incidentsbecame a priority after 911 Because of this response theBoston trauma centers were well prepared2 West also hadsimilar discussions after the fertilizer plant explosion3

However the number of ocular casualties is not consideredor planned for routinely Therefore ophthalmologists mustremain in the discussions and medical response planningmoving forward because ocular injuries are commonand potentially blinding for survivors of civilian blastinjuries

The limitations of this report include inherent biases in itsretrospective cross-sectional design The numbers of mildocular injuries are unknown because of triaging of patientswith less-severe injuries to community facilities and self-treatment The data gathered is skewed toward inpatientswith severe systemic and polytrauma injuries who hadocular manifestations beyond the capacity of primary teamsData collection purposely was limited after discussion withinstitutional review boards to be more conservative thanusual in protecting patient anonymity in light of high mediacoverage so we do not present age gender ethnicity orlaterality of systemic injuries The cross-sectional design didnot allow presentation of follow-up data which is importantin these patients whose traumatized eyes are susceptible toboth acute23 and chronic7 sequelae Of note seeminglybenign ocular injuries such as corneal abrasions may be abellwether of other occult ocular trauma with significantlong-term implications such as angle recession

Additional natural disasters manmade calamities andintentional and unintentional mass-casualty incidents un-doubtedly will occur in the future Many survivors ofmultisystem trauma will sustain blast-related ocular injuriesand ophthalmologists must be seamlessly integrated intoregional trauma teams and their preparations

References

1 Kotz D Injury toll from Marathon bombs reduced to 264Boston Globe April 24 2013 Available at httpwwwbostonglobecomlifestylehealth-wellness20130423number-injured-marathon-bombing-revised-downwardNRpaz5mmvG-quP7KMA6XsIKstoryhtml Accessed April 7 2014

2 FEMA Lessons Learned Information Sharing Boston Mara-thon bombings hospital readiness and response Available athttpswwwllisdhsgovsitesdefaultfilesBoston20Marathon20Bombings20Hospital20Readiness20and20Responsepdf Accessed January 24 2014

3 Zuzek C The night West blew up Tex Med 201310941ndash54 Gebhardt MC Guest editorial Patriotsrsquo Day at the Boston

Marathon Clin Orthop Relat Res 20134712045ndash65 United States Senate Committee on Homeland Security and

Government Affairs One Hundred Thirteenth Congress FirstSession Lessons learned from the Boston Marathon

6

bombings preparing for and responding to the attack July 102013 Available at httpswwwhsdlorgviewampdidfrac14740471Accessed January 24 2014

6 Papakostas TD Yonekawa Y Wu D et al Retinal detachmentassociated with traumatic chorioretinal rupture (sclopetaria)Ophthalmic Surg Lasers Imaging Retina In press

7 Cockerham GC Rice TA Hewes EH et al Closed-eye ocularinjuries in the Iraq and Afghanistan wars N Engl J Med20113642172ndash3

8 Thach AB Johnson AJ Carroll RB et al Severe eye injuriesin the war in Iraq 2003e2005 Ophthalmology 2008115377ndash82

9 Colyer MH Chun DW Bower KS et al Perforating globeinjuries during operation Iraqi Freedom Ophthalmology20081152087ndash93

10 Weichel ED Colyer MH Ludlow SE et al Combat oculartrauma visual outcomes during operations Iraqi and EnduringFreedom Ophthalmology 20081152235ndash45

11 Thach AB Eye injuries associated with terrorist bombings InThach AB ed Ophthalmic Care of the Combat CasualtyWashington DC Office of the Surgeon General at TMM Publ2003421ndash9 Lounsbury DE ed-in-chief Textbooks of MilitaryMedicine Available at httpwwwcsameddarmymilbordenPortletaspxIDfrac144503a58c-5b6c-43f9-afef-0adb36fcc635 Acc-essed April 7 2014

12 Wolf SJ Bebarta VS Bonnett CJ et al Blast injuries Lancet2009374405ndash15

13 Morley MG Nguyen JK Heier JS et al Blast eye injuries areview for first responders Disaster Med Public Health Prep20104154ndash60

14 Mines M Thach A Mallonee S et al Ocular injuries sustainedby survivors of the Oklahoma City bombing Ophthalmology2000107837ndash43

15 Injuries and illnesses among New York City Fire Departmentrescue workers after responding to the World Trade Centerattacks JAMA 20022881581ndash4 Reprinted from MMWRMorb Mortal Wkly Rep 200251(Spec Issue)1e5 Availableat httpwwwcdcgovmmwrpreviewmmwrhtmlmm51SPa1htm Accessed April 7 2014

16 Kurup SK Que ET Kauffmann Jokl DH The World TradeCenter disaster a brief on-site report from Ground Zero ArchOphthalmol 2002120395ndash6

17 McAlister CN Murray TJ Lakosha H Maxner CE TheHalifax disaster (1917) eye injuries and their care Br JOphthalmol 200791832ndash5

18 Federal Emergency Management Agency Ready Get techready Available at httpwwwreadygovget-tech-readyAccessed February 15 2014

19 Yonekawa Y Papakostas TD Marra KV Arroyo JG Endo-scopic pars plana vitrectomy for the management of severeocular trauma Int Ophthalmol Clin 201353139ndash48

20 Soheilian M Abolhasani A Ahmadieh H et al Managementof magnetic intravitreal foreign bodies in 71 eyes OphthalmicSurg Lasers Imaging 200435372ndash8

21 Tanaka Y Yamato A Yaji N Yamato M A simple stock ofoptical glasses for a catastrophic disaster eyewear donationsafter the 2011 Pacific Coast Tohoku earthquake Tohoku J ExpMed 201222793ndash5

22 Ridenour ML Cummings KJ Sinclair JR Bixler DDisplacement of the underserved medical needs of HurricaneKatrina evacuees in West Virginia J Health Care Poor Un-derserved 200718369ndash81

23 Stryjewski TP Andreoli CM Eliott D Retinal detachmentafter open globe injury Ophthalmology 2014121327ndash33

Yonekawa et al Boston Marathon Bombing and Texas Explosion

Footnotes and Financial Disclosures

Originally received February 24 2014Final revision March 31 2014Accepted April 8 2014Available online --- Manuscript no 2014-2951 Department of Ophthalmology Massachusetts Eye and Ear InfirmaryHarvard Medical School Boston Massachusetts2 Department of Ophthalmology Beth Israel Deaconess Medical CenterHarvard Medical School Boston Massachusetts3 Department of Ophthalmology Boston Childrenrsquos Hospital HarvardMedical School Boston Massachusetts4 Department of Ophthalmology Brigham and Womenrsquos Hospital HarvardMedical School Boston Massachusetts5 Department of Ophthalmology Massachusetts General Hospital HarvardMedical School Boston Massachusetts6 Department of Ophthalmology Scott amp White Eye Institute Texas AampMHealth Science Center College of Medicine Temple Texas7 Department of Ophthalmology University of Texas Southwestern Med-ical Center Dallas Texas

8 Department of Ophthalmology Boston Medical Center Boston Univer-sity School of Medicine Boston Massachusetts9 Department of Defense and Veterans Administration Vision Center ofExcellence Bethesda Maryland10 Department of Ophthalmology Uniformed Services University of theHealth Sciences Bethesda Maryland

Presented at American Academy of Ophthalmology Annual MeetingNovember 2013 New Orleans Louisiana

Financial Disclosure(s)The author(s) have no proprietary or commercial interest in any materialsdiscussed in this article

Abbreviations and AcronymsEMS frac14 emergency medical services IED frac14 improvised explosive device

CorrespondenceJorge G Arroyo MD MPH Department of Ophthalmology Beth IsraelDeaconess Medical Center Harvard Medical School 330 BrooklineAvenue Shapiro Fifth Floor Boston MA 02215 E-mail jarroyobidmcharvardedu

7

Figure 1 Pie charts showing types of ocular injuries sustained in (A) theBoston Marathon bombing and the (B) West fertilizer plant explosionPatients with multiple injuries are listed for each injury type

Ophthalmology Volume - Number - Month 2014

7e1