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Eye Care in Disaster Preparedness

  • Date: Nov 06 2007
  • Policy Number: 200713

Key Words: Disasters, Eye Care Disorders, Vision Care

Recent global health threats and natural disasters necessitate that communities, states, and regions develop contingency plans outlining appropriate action when public health emergencies arise.1 Contingencies, whether for natural disasters, accidents, or terrorist attacks, demand that emergency medical teams be organized to respond rapidly.2 These teams provide emergent care to save lives and reduce loss of limb and vision.2 During an emergency, this team is responsible for fulfilling several functions, such as triage, patient stabilization, medical evacuation, patient education, vaccination, and distribution of medication and personal protective equipment including safety eyewear.3 The emergency roles of providers should match their professional skills and licensure.4

Disaster preparedness teams often find that eye injuries are among the most commonly encountered morbidities in responding to contingencies.5–12 For example, after the September 11, 2001, attacks on the World Trade Center, the incidence rate for eye injury was higher than any other diagnosis, with a rate of 59.7 injuries per 100 worker-years.13 Penetrating eye injuries,14–19 metallic corneal foreign bodies,20 chemical exposures,21–25 hyphemas,26 retinal detachments,27 and orbital and ocular trauma9,28–30 are all diagnoses typically generated by natural disasters, explosions, and terrorist attacks for which these teams are designed to respond. The presentation of these conditions can be subtle, and it is often difficult to diagnose and appropriately triage these eye conditions during the acute phase.24,31–33 They each can have symptoms that appear to improve in the short term or are below the threshold for many patients to self-refer for care.24,32 However, during this quiescent time, the condition is often insidiously exacerbating.9,17,23,34–37 All of these conditions can lead to permanent vision loss that can be minimized or prevented given prompt, appropriate medical intervention.14,15,38,39 

The eye is particularly vulnerable in exposure events such as fires; chemical plant explosions; disasters at hazardous waste dumps; train derailments; volcano eruptions; or terrorist attacks involving biological,40 chemical,5,21–25 or radiological agents.35 In the 1995 Tokyo subway sarin attack, an eye condition was present in 99% of the patients (miosis); in addition, eye pain was present in 45% of the patients.5 Exposure to certain weapons of mass destruction (WMD) causes characteristic ocular signs and symptoms whose patterns can be subtle initially.41 Visual impairment can result unless prompt and appropriate sight-saving measures are initiated.24 Including emergency personnel who are more capable of recognizing the ocular signs and symptoms of WMD-related exposure, as well as manage and treat WMD victims, would be a valuable first step in saving the sight of exposed individuals.41 Optometrists42 and ophthalmologists,43 by virtue of their clinical training, are well suited for this role and should be an integral part of the relief team.44 

The typical makeup of disaster response teams (federal, state, municipal and industrial) has insufficient capacity to perform its primary function of triage, stabilization, and evacuation in the realm of eye care.44,45 More specifically, teams generally do not include a designated optometrist or ophthalmologist.2 In addition, teams are equipped with negligible ophthalmic equipment and pharmaceutical assets, making eye care more difficult for the physicians currently staffing the teams. Training for ocular emergencies among members of emergency relief teams is limited, especially at the emergency medical technician and the paramedic levels.46 The training of prehospital care providers regarding ocular conditions consists of knowledge of anatomy and physiology of the eye, mechanisms of injury, and common medical eye disorders, as well as three basic procedures: gentle irrigation, application of eye patches, and application of eye cones.46 Physicians have greater training but are much more comfortable in their role saving life or limb as opposed to vision.44,47–50 Inadequate personnel and equipment assets to detect and stabilize vision-threatening conditions needlessly risk permanent vision loss.44

Ophthalmologists43 and optometrists42 are specifically trained in the detection, diagnosis, and treatment of eye disease. Triage, stabilization, and appropriate referral of ocular issues is in their primary sphere of responsibility.51 Disaster management teams often have other specialists assigned to address specific frequent diagnoses such as mental health professionals or respiratory technicians.2 Given the significant incidence of vision-threatening conditions in disaster management situations, consideration should be given to incorporating an optometrist or ophthalmologist on disaster response teams.

Eye care treatment needs are generated in high volume in disasters, particularly in cases of terrorism or the use of WMD.5–13,21–25,35,40 The current disaster management teams are ill equipped and are not ideally prepared to deal with the predictable outcomes.2,44–49 In assembling teams to protect the public, it is our public health responsibility to use the data we have from previous episodes to anticipate and prepare for predictable future needs. Although all are vulnerable to these threats, residents of cities and users of mass transit are disproportionately affected. This population includes the historically underserved. 

Optometry and ophthalmology professional associations and their local and state affiliates should be contacted for recruitment of volunteer providers for emergency response teams. Many communities also have optometry schools, medical schools, clinics, and hospitals with eye care professionals who could also complement staffing needs. 

Therefore the American Public Health Association— 

  1. Strongly recommends that the federal government, states, municipalities, and industry include dedicated eye care professionals when devising their disaster preparedness plans to facilitate appropriate triage and stabilization of vision threatening conditions due to the emergent nature of ocular injuries. 
  2. Encourages eye care professionals to volunteer on emergency response teams. 
  3. Recommends that the American Optometric Association and American Academy of Ophthalmology co-develop, in consultation with the American Academy of Emergency Medicine, American College of Emergency Physicians, and other appropriate associations, a manual of Eye care first aid in the model of the successful Psychological First Aid Manual. Taking into account personnel limitations and the likely scenarios the disaster response team will face, the manual should address the following:
    1. A recommended inventory list
    2. A system of ocular triage prioritizing interventions that assures timely resolution of eye injuries
    3. Appropriate actions to stabilize anticipated casualties
    4. Patient education forms specific to diagnosis to distribute to the walking wounded to ensure they are educated regarding their ocular prognosis and their recourse for follow-up care
    5. A training plan to incorporate the knowledge in the manual into the disaster response team’s training program
  4. Strongly recommends that federal governments, states, municipalities, and industry provide education on preposition eye protection53,54 and other personal protective equipment for use by disaster response teams, search and rescue participants, and all other workers in the disaster area to reduce the incidence of eye injury.
  5. Strongly recommends that federal, state, municipal, and industry participate in data collection in alignment with United States Eye Injury Registry55 and state registries regarding the incidence and disposition of eye related conditions in contingency situations. 

References

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