Frontline Ophthalmology Needs a New Strategy

Many EuroTimes readers will know the experience of working in an emergency room, having to triage patients based on traumatic injuries. It’s a chaotic, stressful environment for doctor and patient alike.

Now imagine doing it on a battlefield as artillery rains down, all while tiny drones zip overhead looking for targets, their high-pitched whine somehow more terrifying than the booming shells.

This situation is the reality of modern combat in Ukraine, where doctors and medics on the front line are deliberately targeted as they try to extricate wounded Ukrainian soldiers. Under these conditions, preserving vision amid combat trauma is particularly challenging.

“Several factors working simultaneously make modern weapons so dangerous,” said Volodymyr Salamashchak MD. “Shock waves cause catastrophic damage to the eye’s structure, often causing multiple intraocular foreign bodies along with thermal and chemical burns and infection.”

In one survey involving 128 patients under Dr Salamashchak’s care, open eye injuries accounted for 72% and closed eye injuries accounted for 28% of trauma cases. The majority of patients (76%) experienced craniocerebral and facial injuries; 9% of cases were bilateral, and another 9% involved ‘eye ruin.’

The key to maximising outcomes for these patients is extracting them from the front lines as quickly as possible, ideally within the ‘golden hour’ of 24 hours. Dr Salamashchak explained this is very difficult, and not just for geographical reasons. For example, Dr Salamashchak is based in Lviv, more than 1,000 km away from the frontline city of Kramatorsk.

“Unfortunately, we can’t reach this ‘golden hour’ at the moment due to the extreme difficulty of removing the patient from the battlefield. The enemy has control of the airspace and uses drones to specifically target medical personnel,” Dr Salamashchak said.

He says the key factors in maximising outcomes under these conditions are stabilising vital functions in a timely manner, protecting the injury with a shield or antibiotic prophylaxis, and coordinating evacuation. This often relies on telemedicine via consulting an ophthalmic surgeon to determine triage priorities.

“Our basic principle is to repair now, refine later; to seal, then reconstruct. The main thing is to quickly restore the integrity of the eye, ensure its tightness, and prevent the loss of internal structures,” Dr Salamashchak said.

“If the patient is stable, then it’s ideal to perform surgery and reconstruction of the posterior segment within 24 hours after injury, but this can take weeks in Ukraine. Each day of delay worsens the patient’s outcome.”

The war in Ukraine is unlikely to abate in the near future, meaning these highly challenging conditions will persist for some time. Dr Salamashchak is working on a series of protocols to improve patient outcomes in the meantime, a strategy that includes an improved triage system for patients with ocular injuries.

ESCRS members and others in ophthalmology can contribute by providing training programmes for vitreoretinal surgeons. There’s also an equipment gap, and institutions working to treat patients in Ukraine urgently need more supplies.

“We need to implement rapid consultations via telemedicine for ophthalmic surgeons, as this will help us to rapidly coordinate our actions in the field,” Dr Salamashchak said. “Ultimately, we need a unified system of knowledge, skills, and standards to provide care for our soldiers who have experienced combat trauma.”

Dr Salamashchak presented at the 2025 Society of Ukrainian Ophthalmic Surgeons Congress in Kyiv.

Volodymyr Salamashchak MD holds the rank of major in the Armed Forces of Ukraine and is an oculoplastics specialist and surgeon based at the Military Medical Clinical Centre of Lviv.volodymyrua89@gmail.com