Journal Pre-proof Ocular Injuries and Blindness Caused by Crowd Control Measures In Civil Protests Christine Lum, Julie Schallhorn, MD, MS, Flora Lum, MD, Saras Ramanathan, MD, Julius Oatts, MD, Alejandra G. de Alba Campomanes, MD, MPH, Gerami Seitzman, MD PII: S0161-6420(20)30783-1 DOI: https://doi.org/10.1016/j.ophtha.2020.08.005 Reference: OPHTHA 11426 To appear in: Ophthalmology Received Date: 4 August 2020 Revised Date: 6 August 2020 Accepted Date: 7 August 2020 Please cite this article as: Lum C, Schallhorn J, Lum F, Ramanathan S, Oatts J, de Alba Campomanes AG, Seitzman G, Ocular Injuries and Blindness Caused by Crowd Control Measures In Civil Protests, Ophthalmology (2020), doi: https://doi.org/10.1016/j.ophtha.2020.08.005. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. 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Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc. on behalf of the American Academy of Ophthalmology 1 Ocular Injuries and Blindness Caused by Crowd Control Measures In Civil Protests 2 Christine Lum, Julie Schallhorn, MD, MS, Flora Lum, MD, Saras Ramanathan, MD, Julius Oatts, 3 MD, Alejandra G. de Alba Campomanes, MD, MPH, Gerami Seitzman, MD 4 Financial Support: None 6 Interests: 7 Christine Lum: None 8 Julie Schallhorn: Carl Zeiss Meditec (Consultant), Long Bridge (Equity Owner), Stroma (Equity 9 Owner), Vanda (Consultant) -p ro of 5 Flora Lum: None 11 Saras Ramanathan: None 12 Julius Oatts: None 13 Alejandra G. de Alba Campomanes: None 14 Gerami Seitzman: Dompe (Consultant) lP na Running Head: Ocular Injuries and Blindness During Civil Protests Jo 17 ur 15 16 re 10 18 Address for Reprints: 19 Flora Lum, MD 20 American Academy of Ophthalmology 21 655 Beach Street 22 San Francisco, CA 94109 23 Abstract 24 25 Thirty cases of ocular injuries during civil protests were identified, with 27% suffering a ruptured 26 globe, 23% with an orbital fracture, 20% with a resultant macular hole, and 33% with permanent 27 blindness in the involved eye. Jo ur na lP re -p ro of 28 29 Ocular Injuries and Blindness Caused by Crowd Control Measures In Civil Protests 30 During protests in the United States in the late spring of 2020, police departments across the 32 country have utilized crowd control and dispersal techniques, including tear gas, pepper spray, 33 batons, shields, and rubber bullets. Concern has been raised by protestors, activists, and health 34 care organizations over the use of these devices, especially during peaceful protests. Rubber 35 bullets, in particular, have been associated with ocular trauma and subsequent vision loss.1-4 In 36 one large review, 2.7% of those struck by rubber bullets subsequently died from their injuries 37 and 15.1% developed a permanent disability.5 Reports from the news media from Chile, 38 Venezuela, Hong Kong, and the United States recount the loss of sight in one or both eyes due 39 to rubber bullet use against both protestors and journalists. re -p ro of 31 lP 40 The University of California, San Francisco (UCSF) and the American Academy of 42 Ophthalmology (Academy) undertook a joint venture to capture the scope of eye trauma related 43 to these protests. We report the findings of these efforts and review the published literature 44 pertaining to eye injuries from crowd dispersion techniques. ur Jo 45 na 41 46 A web-based survey using Google Forms (Google, Mountain View, CA) was developed to 47 capture cases of ocular trauma related to civil unrest. No identifying patient information was 48 obtained. The name and contact information of the physician submitting the case were required. 49 The form asked for the following information: whether this was related to a civil protest, date of 50 injury, patient role in protest, city and state, laterality of eye, presenting visual acuity, age, 51 gender, type of injury, mechanism(s) of injury, and treatment(s) rendered. The submitting 52 ophthalmologists were all contacted for completion of data and follow-up visual outcome, if 53 patients returned for evaluation. The link to the form was disseminated starting on June 3rd, 2020, via social media and multiple ophthalmic society list-servs and newsletters, including the 55 Association of University Professors in Ophthalmology, Ophthalmology Moms Group, the 56 Cornea Society, the American Association for Pediatric Ophthalmology and Strabismus, and the 57 American Academy of Ophthalmology. Cases entered by July 1, 2020 were included in this 58 article. A web search for eye trauma related to the protests surrounding the death of George 59 Floyd was conducted using these terms: ocular injuries, civil protests, rubber bullets, and tear 60 gas. Cases of eye trauma from the news media were cross-referenced with the web-based 61 survey and included if they identified a unique injury. This study was approved by the UCSF 62 institutional review board, and no patient identifiable information was collected. -p ro of 54 63 A literature search was conducted using PubMed to identify case series reports or review 65 articles in English for ocular injuries from rubber bullets and tear gas between January 1, 1990 66 and July 1, 2020. The search strategy used the following MeSH Terms and text words: 67 (((("eye injuries"[MeSH Terms] OR ("eye"[All Fields] AND "injuries"[All Fields])) OR "eye 68 injuries"[All Fields]) OR ("ocular"[All Fields] AND "injury"[All Fields])) OR "ocular injury"[All 69 Fields]) AND (((("rubber"[MeSH Terms] OR "rubber"[All Fields]) OR "rubbers"[All Fields]) OR 70 "rubberised"[All Fields]) OR "rubberized"[All Fields]) AND (("bullet"[All Fields] OR "bullet s"[All 71 Fields]) OR "bullets"[All Fields] OR ((((("tear gases"[Pharmacological Action] OR "tear 72 gases"[MeSH Terms]) OR ("tear"[All Fields] AND "gases"[All Fields])) OR "tear gases"[All 73 Fields]) OR ("tear"[All Fields] AND "gas"[All Fields])) OR "tear gas"[All Fields]). The initial 74 search yielded 109 results, and 7 articles matched the criteria and were selected for the 75 literature review. Jo ur na lP re 64 76 77 A review of the scientific literature revealed the most common serious ocular injuries from rubber bullets are open globe trauma, retinal/vitreous hemorrhage, hyphema, iridodialysis, and 79 orbital fracture (Table S1, available at www.aaojournal.org). Ocular injuries caused by tear 80 gases included conjunctivitis, corneal epithelial defects, and corneal opacities. Surgical 81 treatments from projectiles included enucleation, evisceration, orbital floor repair, retinal 82 detachment repair, and eyelid laceration repairs. The most severe outcomes included loss of an 83 eye, and temporary or permanent vision loss. One study showed that 33% had no light 84 perception in the injured eye.2 of 78 ro 85 The survey collected 30 cases in total, 23 reported by ophthalmologists and 7 identified by news 87 stories. The average age of the affected individuals was 31.4 ± 11.7 years, with a range of 20 to 88 59 years. Of the reported cases, 22 were male and 8 were female. Injuries were reported in 13 89 states as well as the District of Columbia. lP re -p 86 90 A list of reported injuries is provided in Table 2. Patients could have more than one injury. 92 The most common injury was a ruptured globe (8/30 injuries, 27%). The most common 93 mechanism was a kinetic projectile, which could include rubber bullet, bean bag, wooden 94 bullet and foam bullet. (Table S3, available at www.aaojournal.org) At least 7 individuals (20%) 95 underwent enucleation, all related to a kinetic projectile injury. Patients could receive more 96 than one type of treatment. Supportive, non-surgical therapy was provided to one third of the 97 patients. (Table S4, available at www.aaojournal.org) The final visual acuity was not available 98 for most injuries because of a lack of follow-up, but 10 patients (33%) had no light perception 99 vision after their injury was addressed. Jo ur na 91 100 101 Our survey identified serious ocular sequelae associated with rubber bullets and other non- 102 lethal projectiles, including ruptured 103 globes, retinal detachments and macular holes. Approximately one-third of injuries resulted in 104 near 105 immediate and complete loss of vision in the involved eye. This is consistent with prior reports in 106 the peer-reviewed 107 literature. 108 References 110 1. Balouris CA. Rubber and plastic bullet eye injuries in Palestine. Lancet. 1990;335:415. 111 2. Jaouni ZM, O'Shea JG. Surgical management of ophthalmic trauma due to the ro Palestinian Intifada. Eye (Lond). 1997;11 :392-397. 3. Lartizien R, Schouman T, Raux M, et al. Yellow vests protests: facial injuries from rubber bullets. Lancet. 2019;394:469-470. re 114 -p 112 113 of 109 4. Lavy T, Asleh SA. Ocular rubber bullet injuries. Eye (Lond). 2003;17:821-824. 116 5. Haar R, Iacopino V, Ranadive N, Dandu M, Weiser S. Death, injury and disability from na lP 115 kinetic impact projectiles in crowd-control settings: a systematic review. BMJ Open. 118 2017;7:E018154. Jo ur 117 na lP of ro re -p Injury Ruptured Globe Orbital Fracture Lid Laceration Canalicular Involvement No Canalicular Involvement Hyphema Macular Hole Vitreous Hemorrhage Commotio Retinae Retinal Detachment Iridodialysis Traumatic Optic Neuropathy Submacular Hemorrhage Corneal Abrasion Chemical Burn Optic Canal Fracture Number (%) 8 (27%) 7 (23%) 7 (23%) 3 (10%) 4(13%) 6 (20%) 6 (20%) 4 (13%) 3 (10%) 2 (6.7%) 2 (6.7%) 2 (6.7%) 2 (6.7%) 2 (6.7%) 1 (3.3%) 1 (3.3%) Jo ur Table 2: Reported injuries during civil unrest in the United States, May-June 2020.