Delivering Eye Care in Challenging Areas

Providing ophthalmic care in areas affected by conflict or instability presents both logistical and ethical complexity. These environments pose distinct risks to patients and providers and make maintaining the continuity of care challenging. Efforts therefore require careful planning, adaptability, and local coordination.

This article addresses these realities and examines how surgeons and organizations are navigating the provision of medical services where infrastructure is limited or absent. The goal is to use real-world examples from experienced participants to illustrate the operational, clinical, and ethical decisions necessary to prioritize safety and enable the delivery of care.

When it is not possible or practical to be involved in direct deployment, alternative ways to contribute include remote surgical mentorship (see “Scaling Surgical Mentorship Across Borders”), clinical case consultations, equipment support, and funding partnerships (see “How to Get Involved”). Each initiative plays a role in strengthening eye care infrastructure where it is most vulnerable.

Together, these contributions offer insight into how individuals and institutions approach risk, sustainability, and impact in fragile settings—and what these approaches can teach us about broader challenges in access and equity across ophthalmology.

- Cathleen M. McCabe, MD

Content Advisory: This article contains graphic images of war-related trauma.

Triaging Risk

By Daniel M. Anderson, MD

After many years as an active-duty US Air Force ophthalmologist, I now serve in the National Guard and continue to participate in humanitarian missions that I would characterize as traditional, with extensive planning, funding, and resources. During crises, however—especially conflict—humanitarian missions can look very different. One of my deployments while on active duty took me to the Craig Joint Theater (CJT) Hospital at Bagram Air Base, the largest US military installation in Afghanistan, where tens of thousands of personnel were stationed during nearly 2 decades of military operations. Although the base had hardened facilities and towering 20-foot concrete T-walls, we routinely experienced mortar attacks.

DELIVERING TRAUMA CARE AT THE FRONT LINE

CJT Hospital served as the region’s Role 3 trauma center. It had multiple surgical subspecialists, anesthesia providers, nurses, technicians, internists, and a radiologist with imaging capabilities. The hospital also included a pharmacist and a well-stocked pharmacy that operated 24/7. Our mission was either to treat and return service members to duty or to stabilize them for evacuation to the United States for definitive surgical care and rehabilitation.

As the conflict evolved and the US military’s focus shifted to training local Afghan forces, we began to see fewer coalition casualties and a growing number of Afghan patients. Their postoperative care became a serious challenge. I treated a wide variety of ocular injuries, many caused by blast trauma. Shrapnel and foreign bodies easily penetrated soft tissue (Figure 1), and rather than one open globe, I often had to manage bilateral injuries. These cases frequently required several hours in the OR, usually after life-threatening injuries had been addressed.

NAVIGATING CARE AND COMPROMISE IN CONFLICT SETTINGS

There were no local ophthalmic specialists to handle follow-up care, and the situation was further complicated by the immense risk patients faced just to return to CJT Hospital for follow-up. I witnessed countless instances of patients hiding steroid and antibiotic drops or other medications in creative ways just to make it through nearby Taliban checkpoints.

Humanitarian work in conflict zones presents difficult ethical and logistical questions. How do you weigh the risks of entering such an environment?

I had the opportunity to discuss humanitarian work with Dr. Mike Simpson, an emergency physician. As a former Green Beret and part of the elite Joint Medical Augmentation Unit, he continues to work in conflict zones and categorizes areas as either hot or cold. Despite his advanced training, he acknowledged the inherent personal risk.

The resources that were available to me in Bagram cannot be overstated: robust security, food, housing, a fully equipped OR, and general anesthesia. None of these is guaranteed in an active conflict zone.

GUIDANCE FOR PHYSICIANS CONSIDERING HIGH-RISK MISSIONS

If you find yourself in a hot zone—or are considering humanitarian work during conflict—operational security will become just as critical as the medical mission itself. Here is some advice.

Do not self-deploy. Align yourself with a well-established organization that has the resources, infrastructure, and protocols to support you. Get to know the head of security and familiarize yourself with the organization’s evacuation plans.

Know your resources. Transportation can be unreliable, and your supplies may be limited to what you can carry. Be prepared to leave everything behind and walk out if necessary.

Secure your identity. Remove personal effects from your wallet. Consider using a burner phone with no personal information.

Maintain a low profile. Be aware that stamps in your passport and past travel locations can raise concerns at checkpoints. When it comes to appearance, avoid wearing clothing with US flags or tactical gear that might suggest an affiliation with a government agency.

Military or police personnel may be on edge, so it is always best to be direct and honest about your intentions.

Limit digital exposure. As difficult as it may be, refrain from posting on social media until you are safely home. Also, avoid appearing in photographs with unfamiliar individuals; you could unintentionally be associating with a political or paramilitary group.

Prepare a contingency file. Prepare a secure digital file with your photo IDs, passport, medical history, current medications, itinerary, and emergency contacts. Make sure a trusted person has access to this file.

THE ROLE OF OPHTHALMOLOGISTS IN CONFLICT

We ophthalmologists bring essential skills to disaster and conflict response, but it is critical for us to recognize the limitations of operating in a hot zone. In these environments, ophthalmic intervention may have to be deprioritized in favor of life-saving stabilization and evacuation.

Although many of us are experienced in delivering care in austere environments, the conditions of conflict are categorically different from elective humanitarian missions. For most of us, partnering with an organization that can stage care just outside the conflict zone—where patients can be stabilized and safely transported—may be the most meaningful way to contribute without compromising safety.

What Gaza Taught Me About Medicine, Humanity, and Letting Go

By Shehzad Batliwala, DO, MGM

When I volunteered to go to Gaza, I knew the trip would not be easy. What I did not anticipate was how profoundly the experience would reshape my perspective on medicine and people and, honestly, my perception of myself.

My time in Gaza has led me to reflect more deeply on gaps in the health care landscape.

THE RESOURCE GAP—RETHINKING ENOUGH

In Gaza, everything—from supplies to electricity to hours in the day—is limited. I learned to use every drop of OVD carefully. I made sure gowns were reusable. I had to determine what was essential and what was waste.

The experience made me recognize how much I take for granted in the United States and consider how much waste of time, materials, and energy is inherent to our health care system. I returned with a heightened awareness of the luxuries I am afforded, and I now find myself asking: Am I using resources wisely? Am I doing what actually matters for patient outcomes or just adding layers because that is how it has always been done?

THE EDUCATION GAP—HUNGRY STUDENTS, WILLING TEACHERS

If Gaza has one thing, it is hunger—not just for food or stability but also for education. In the United States, we have access to a world-class education and abundant learning resources. Gaza currently has three full-time ophthalmologists to serve nearly 2 million people. The ophthalmologists I met were brilliant, dedicated, and eager to absorb knowledge. What they lacked was not passion or talent but access. Bridging that gap—linking a resource-rich United States with resource-depleted Gaza—is the first step toward building sustainable capacity.

THE INJURY GAP—WHEN EVERYTHING ARRIVES AT ONCE

Blast injuries, penetrating and perforating wounds, and chemical and thermal burns are often superimposed on a backlog of untreated cataracts, diabetic vitreous hemorrhages, and chronic glaucoma. Research suggests that ocular trauma accounts for approximately 15% of war-related injuries. Extrapolated to Gaza’s tens of thousands of wounded, that equates to thousands of vision-threatening cases, with many of these patients awaiting care.

On some nights, nearby explosions were strong enough to rattle the hospital windows. We avoided operating after dark because it was too dangerous for staff to travel safely. Thousands of health care workers in the region have lost their lives during the ongoing conflict. Each morning, we took roll and hoped the team was intact.

THE EMOTIONAL AND ETHICAL GAP—A FACE FOR BURIAL

One story stays with me. A 44-year-old woman was pulled from a collapsed apartment. She had sustained blunt facial trauma, complex lacerations with avulsion, femoral and pelvic fractures, and a ruptured right globe. The patient had just undergone an exploratory laparotomy, and the prognosis was grim.

Her husband asked whether we could “put her face back together” so that, if she died, she could be buried with dignity. Triage protocol said to focus on life-saving work. Humanity dictated we do both.

We removed debris, sutured the lacerations, and closed the globe—minutes that did not influence her chance of survival but that changed everything about her farewell (Figure 2). At that moment, I was not an eye surgeon; I was a human being trying to honor another. The phrase humanitarian ophthalmology struck deep in my heart that day.

THE MINDSET GAP—SURRENDERING CONTROL

Before the trip, I wrote a will and signed a Power of Attorney just in case.

I was scheduled to leave Gaza after 2 weeks, but when conflict flared, my exit was delayed without explanation. Each morning, my colleagues and I packed our belongings with hope for clearance, and each evening, we unpacked with our hearts racing at the sound of shelling.

Sitting with that uncertainty rewired something in me. Confronting the real possibility of not returning home made revenue targets and blurry clinic metrics feel oddly small. I stopped pretending to control everything. Instead, I focused on how fully present I could be for patients, colleagues, and my team.

THE BIG PICTURE

Bridging gaps is not heroic. It is steady, sometimes exhausting human work. I learned the following lessons:

• Use resources as if they are borrowed—because they are;
• Honor the person in the chair, even if you cannot save the eye; and
• Hold plans lightly; hold people tightly.

In Gaza, I did not just operate on open globes but opened my own eyes a bit wider. If that small shift has traveled home with me—and into how I practice, teach, and spend—then perhaps one more gap just became a little narrower.

An Insider’s View of Ophthalmology Practice in Ukraine

By Vasyl Shevchyk, MD, PhD

February 24, 2022, created a clear divide between before and after. Before the war began, Ukraine had a well-developed, independent network of ophthalmology clinics. We ophthalmologists regularly performed anterior segment procedures—laser cataract surgery, physiologic IOP-level procedures, and refractive surgery— with state-of-the-art technologies. Kyiv alone had 15 excimer lasers.

After Ukraine was invaded, our network was nearly destroyed.

THE COLLAPSE OF A SURGICAL ECOSYSTEM

Logistics broke down immediately. Hospitals ran out of essential supplies for ophthalmic surgery. Many of our ophthalmic clinics—including private facilities—have been targeted by missile attacks. Some sustained partial damage from blast waves, whereas others were completely destroyed (Figure 3).

In the first 3 months of the war, much of the country had no electricity or running water, necessitating the cancellation of all scheduled cases. Resources were diverted entirely to emergency care. Four years into the war, the volume of elective procedures remains well below prewar levels owing to the ongoing demand for trauma and reconstructive care.

The evacuation of personnel to safer regions or abroad created a critical shortage of doctors and nurses—just as the number of patients in front-line areas soared.

SHIFTING TO MILITARY EYE SURGERY

We had to pivot from peacetime ophthalmology to military eye surgery. The psychological burden remains severe. We face heartbreaking decisions: whom to treat first, whose care to delay, and—devastatingly—whom we cannot help.

Military medicine, including eye care, follows a different paradigm: do the best for the most, not everything for everyone. Priority is often given to those with less severe injuries—those who can be treated quickly and return to duty.

Modern warfare has introduced high-energy, multifragment injuries. Eye trauma now constitutes 14.6% of all battlefield injuries—compared with just 2.2% during World War II.¹

DELAYS, COMPLICATIONS, AND IMPROVISED CARE

Owing to evacuation delays, patients often have severe eye infections by the time we see them. One of the most pressing challenges in Ukraine is inadequate first aid. The most common error is the application of a tight bandage without a protective eye shield (Figure 4), which increases pressure on the globe, dries the ocular surface, and causes the cotton fabric to adhere to the cornea, iris, or retina, leading to irreversible damage.

With limited staff on hand, when dozens—or even 100—wounded soldiers arrive simultaneously, the quality of initial care drops. Too often, war surgery becomes a procedure full of complications performed by a doctor who is poorly trained—or not trained in surgery at all.

A growing population of patients with retained intraocular foreign bodies must wait months for definitive surgery. Some receive only primary wound closure, while periocular injuries remain untreated. In certain cases—due to limited time, equipment, or surgical expertise—enucleation or evisceration becomes the default intervention.

Compounding these issues is a breakdown in interdisciplinary communication. Our soldiers with head injuries typically undergo immediate CT imaging, and the results are saved to a Secure Digital disk. However, the absence of direct communication between radiologists and ophthalmologists means that intraocular foreign bodies visible on CT scans often go unrecognized by eye care providers. To address this gap, we are developing a new clinical guideline requiring radiologists to flag the presence of ocular foreign bodies directly in evacuation documentation, alerting other specialists to the need for urgent ophthalmic

GAPS IN INFRASTRUCTURE AND EQUIPMENT SUPPORT

The war has decimated technical support capacity. Many biomedical engineers were drafted or fled the country. Obtaining support from European device manufacturers is nearly impossible because dispatching service teams to Ukraine is too dangerous.

Prevention is our most urgent need. Tactical ballistic eyewear could save thousands of eyes. Even in the setting of devastating head injuries, properly shielded eyes can remain intact (Figure 5). Hundreds of thousands of pairs are needed.

A SYSTEM REBUILT—WITH GLOBAL SUPPORT

Despite everything, Ukraine has begun to rebuild its ophthalmic care infrastructure. Military hospitals, public institutions, and private centers currently serve both soldiers and civilians.

The Ministry of Veterans Affairs has launched a rehabilitation program for veterans with eye injuries, implemented through the vision and sustained support of Deputy Minister Ruslan Prykhodko. Specialized centers across Ukraine provide advanced services such as the following:

• Reconstructive eyelid surgery;
• Scar revision;
• Drainage device implantation for traumatic glaucoma;
• Complex cataract surgery;
• Iris reconstruction; and
• Vitreoretinal procedures.

We owe our progress to international partnerships. Organizations such as the AAO, ASCRS, ESCRS, Women in Ophthalmology, Eye Care for Ukraine, the Association of Polish Ophthalmic Surgeons, and Support Hospitals in Ukraine have supported us since the earliest days of the war.

Initially, we received core supplies—suture materials, silicone oil, and trauma kits. Later came phaco machines, surgical microscopes, Ahmed Glaucoma Valves (New World Medical), Nd:YAG lasers, platforms for selective laser trabeculoplasty, artificial irises, and Boston Keratoprostheses (BostonSight).

TRAINING, COLLABORATION, AND HOPE

Perhaps even more valuable than the equipment we have received is the knowledge we have gained. Charitable missions such as Face to Face and Face the Future Ukraine have brought US and European surgeons to operate alongside young Ukrainian doctors, offer hands-on training, and serve as mentors. Our specialists have completed internships at leading centers in the United States and Europe. We have received complimentary registration at professional congresses. Wet labs, simulation centers, and even artificial eyes for training have been donated.

This global demonstration of solidarity has allowed Ukrainian ophthalmology not only to survive but to grow.

A FINAL WORD OF GRATITUDE

On behalf of the Ukrainian ophthalmology community, I extend my sincere thanks to the many individuals and organizations that have stood by us during our darkest hours. They include Jorge Corona, MD; Natalia Danilkova, MD; Vitaliy Dubil; Parag Gandhi, MD, FACS; Roman Kovbasnyk; Tom Ogilvie-Graham, MD, FEBO; Serhiy Lahodych; Bruce Moskowitz, MD; Robert Rejdak, MD, PhD; and Brian True. Their support has helped restore vision, dignity, and hope in our country.

A Story From Java

By Lloyd Williams, MD, PhD

A young man on the island of Java, Indonesia, raises his head and turns toward the sound of my voice. He cannot meet my gaze, although I can look into his eyes. His corneas are scarred beyond the capability of vision, and his heart bears the weight of a decision he made 8 years ago—when a large firecracker, or perhaps a small bomb, given to him by a friend exploded. Fragments from the blast remain embedded in his eyes. The pieces look like small rocks lodged in the cornea and conjunctiva and are surrounded by white, opaque scarring interwoven with dilated blood vessels.

SURGERY, UNCERTAINTY, AND A FIRST LOOK

We agree to attempt a corneal transplant in the eye with viable limbal stem cells. The preoperative discussion includes a frank assessment of his prognosis. I inform him that the epithelium may not heal and the transplant may fail or be rejected but add that, given his current vision—only light perception—the risk of worsening is minimal. I estimate the chances of restoring functional vision at 50%. He cannot shake my hand in agreement, because he lost both hands in the explosion. His despair is evident from his history of multiple suicide attempts over the past 8 years. My heart aches for him, and I silently pray that my surgical skills and his body’s healing capacity will allow him to see again.

During surgery, a dense cataract is discovered with literal rocks embedded in it. The cataract is removed in tandem with the corneal transplant. Surgery proceeds well. Postoperative healing remains the key variable. The next day, the postoperative team cries with the patient and his sister as he sees her for the first time in 8 years. He is not out of the woods, but he is hopeful. By day 4, the corneal epithelium has healed completely—showing resilience beyond my expectations. We celebrate as his vision continues to improve.

The local ophthalmologists, the remarkable Dr. Edy and Dr. Reny, have already arranged the patient’s enrollment in a rehabilitation program for individuals who have lost their hands. He is meeting others who share his challenges. The light is on in his life, and for the first time in years, he looks forward to his future.

WHAT GLOBAL CARE HAS TAUGHT ME

During my 25 years in global eye care, I have treated tens of thousands of patients, yet some individuals stand out in the tapestry of human suffering, healing, and redemption—some of which is my own. I can think of nothing more humanizing than giving of myself purely to help another person, whether next door or across the globe.

Is it too hot? Did I just eat something that made me sick? Did the hospital we worked in last month get attacked and burned down? Are we hungry or tired? Did I just get the middle seat between two linebackers for an 18-hour flight? Maybe. There is also, however, a woman seeing her children after being blind for 29 years and a little boy in South Sudan who is experiencing vision for the first time. These moments shift my perspective outward, and my own complaints grow smaller. In that shift, the joys and burdens of life become lighter.

Surgery in the developing world is difficult. A microscope with an intermediate to poor view increases the complexity of any case. Cataracts here often have all the characteristics—pseudoexfoliation, corneal scarring, band keratopathy, uveitis, a small pupil, a rock-hard white cataract, a deep orbit, and intraoperative bleeding—of the hardest cases I see in the United States in any given year, and they may all be present in the same patient. Combined with unfamiliar equipment, these are real challenges.

I spent years learning from mentors in Nepal and the United States to manage these cases and still provide high-quality care. Patients in places such as Sierra Leone (Figure 6) or South Sudan deserve my best because this may be their only opportunity for restored vision. Many readers may have greater skill than I do; others may be contemplating their first global mission. It is hard. They may suffer. It will challenge their skills and their heart. They will have to learn and improve. It will humble and lift them, but the effort is worthwhile in every way.

I encourage my colleagues to step out of their comfort zone and bring light and sight to a hurting world.