Race and Medicine
Race and Medicine
Issue: July 2020
Source/Disclosures
Source: Healio Interviews
Disclosures: Goel and Natarajan report no relevant financial disclosures.
July 09, 2020
6 min read
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Answering the call of AAO, ophthalmologists campaign to ban rubber bullets, tear gas

The US call has reached India, revamping advocacy for the elimination of pellet guns in Kashmir.

Issue: July 2020
Source/Disclosures
Source: Healio Interviews
Disclosures: Goel and Natarajan report no relevant financial disclosures.
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Rubber bullets and tear gas may sound innocuous and offer a false sense of security. In reality, these nonlethal weapons can cause permanent eye damage, eye injury, discomfort, pain, loss of vision and blindness.

Ravi D. Goel, MD, a cataract surgeon in Cherry Hill, New Jersey, and clinical spokesman for the American Academy of Ophthalmology, actively joined the AAO #NoRubberBullets #NotOneMoreEye campaign to end the use of rubber bullets to control or disperse crowds because “while classified as nonlethal, they are not non-blinding.”

Sundaram Natarajan, MD head shot and quote

“When the protests started and we saw on Twitter and Instagram that people had lost their eyes, I reacted by writing a blog post on safety in my ProtectingSight.com website, including pearls on self-protection and basic eye care for protesters,” he said.

Ravi D. Goel, MD

When the AAO published its official statement, Goel took to social media as an effective way of reaching people and educating them on how they should protect themselves.

The call of AAO traveled far and fast to India, where Sundaram Natarajan, MD, immediate past president of the All India Ophthalmological Society, made the statement circulate on social media, , mentioning his role as an experienced vitreoretinal surgeon tackling ocular trauma. Now he is analyzing the results of the world’s largest study on pellet ocular trauma, which will be published in an international peer-reviewed journal.

“I took the chance to step into the blog and say to the government, ‘take action now.’ Don’t wait for these riots to happen again before you think of ways to protect people,” he said.

When pellet guns caused injuries to thousands of protesters in Kashmir in 2016, Natarajan operated on more than 200 victims and got deeply involved in campaigning to prevent pellet ocular trauma. Natarajan wrote to the then Minister for Home Affairs in 2016 about pellet ocular trauma and taking measures to prevent blindness.

“They questioned me, everywhere, also on television: Why should a doctor take political sides and tell the police how to behave? I have come to save lives, I answered, let me work as a doctor. I am concerned about everyone’s safety, including the police and Army. I don’t take sides. I suggest doing prevention. That’s why I have the duty to speak up,” said Natarajan, who is president of the Asia Pacific Ophthalmic Trauma Society, immediate past president of the Ocular Trauma Society of India and a board member of the International Society of Ocular Trauma.

His work to protect sight was reported at the time in an interview with The New York Times and referenced in the AAO’s June 3 press release, “Nation’s ophthalmologists condemn use of rubber bullets.”

Precautions, emergency interventions

There is no way of being 100% safe when joining a protest. Even remaining in the back of the crowd, leaving the crowd or being a bystander can be a risk.

“From the point of view of prevention, the safest thing to do is stay at home. Otherwise, my advice is to protect the eyes with goggles or shatterproof glasses and avoid wearing contact lenses and makeup,” Goel said.

Tear gases cause a variety of chemical injuries to the eye, ranging from hyperemia to epithelial defects, pseudopterygium, corneal neovascularization, corneal opacities and reduced visual acuity.

“They are not harmless as many people think and can produce long-term effects on the cornea, as well as severe pulmonary sequelae,” Goel said.

In addition, canisters exploding near the eye can cause open globe injuries, as it happened to Balin Brake, a 21-year-old student who lost his eye during the George Floyd protest in Indiana.

Three things should be immediately done when tear gases are used to disperse crowds: Leave the situation, find higher ground and use clean water to rinse the eyes, pouring it from the inside corner to the outside corner. Contact lenses should be removed and eyes should not be rubbed, but frequent blinking might help.

Rubber bullets cause severe eye injuries, from orbital fractures to open globe and penetrating injuries. Quoting George Williams, MD, in an interview with The Wall Street Journal, it is like “taking a grape and hitting it with a hammer.”

“Again, the basic rules are not to rub or even touch the eye. Some kind of protection and tape should be used to secure a hard shield around the eye, like a Styrofoam cup or goggles. The injured person should be kept upright and taken to an emergency room without delay,” Goel said.

In collaboration with the University of California, San Francisco, the AAO is gathering a database of people who have been affected by tear gas and rubber bullets. There are currently 20 reported cases, many of which are severe injuries leading to blindness. And the numbers are probably underreported.

Hundreds of victims in Kashmir

Kashmir is the only state in India where the use of pellet guns as well as tear gases is allowed to disperse crowds. When protests broke out in July 2016 against Indian military presence in Kashmir, Natarajan flew from Mumbai to join the team of ophthalmologists taking care of the many hundreds of people sent to the Sri Maharaja Hari Singh Hospital in Srinagar with ocular injuries.

“In the first 3 days, I did 47 vitreoretinal surgeries to repair the pellet trauma, working from early morning to almost midnight,” he said. “From July to November, more than 1,000 ocular injuries were seen, and more than 600 vitreoretinal surgeries were performed.”

“Pellet guns fire multiple small pellets spreading over a wide range, like a shower. When an eye is injured, they tear through the tissue and go through layers of the retina,” Natarajan said.

Many of the eyes in which the pellets had pierced through the side could be saved, but when the shot had hit the eye frontally, the bullets perforated the cornea, the lens and the macula, and vision was lost.

“The nearer the shot, the worse the effect. I remember a girl with no perception of light. I discussed the case with Ferenc Kuhn. Then I did the surgery, and I got her light perception in one eye but could do nothing for the contralateral eye,” Natarajan said.

Managing perforating injuries

When dealing with an eye traumatized by pellets or rubber bullets, the first intervention is crucial and should be done as early and accurately as possible.

“Approach those eyes with confidence and positive thinking, repair the anatomy, clear the ground as much as possible and close the eye. Second surgery should be performed by a vitreoretinal surgeon with experience in ocular trauma, but the first stage is extremely important. Many times with perforating injuries there is little chance of recovering vision, but if you repair as much anatomy as possible, the patient will at least not be disfigured,” Natarajan said.

Secondary intervention should be performed within the following 6 days. Waiting longer would cause the hemoglobin to damage the function of the retina. Sometimes multiple surgeries are needed.

“As long as the optic nerve is functioning and I feel I can anatomically repair the retina and get the macula attached, I keep trying. Salvaging the unsalvageable is the motto of trauma surgeons,” he said.

Managing trauma involves helping patients to accept loss of vision in many cases, and this means time spent with them before and after surgery.

“Being a good ‘vitreoretinal psychologist’ is as important as developing your surgical skills. I never miss this part. I kept in touch with all the patients I operated on in Kashmir. They still write to me and ask for my support and advice,” Natarajan said.

He warned about the false sense of security eye protection might give to protesters.

“Protective goggles may protect you from a rubber bullet, but likely not from pellets that are larger and multiple, and not from an exploding canister. As long as these weapons are used, there is no way of being safe in a demonstration. Truly harmless methods of crowd control should be discussed,” he said.

Spreading awareness

The AAO campaign not only found large national and international resonance, but also brought about real changes, according to Goel.

“I am encouraged by the government level reactions to the tear gas and rubber bullet issue. And I hope that the #NoRubberBullets campaign is helping in this mission of protecting sight. Numerous jurisdictions have already enacted bans or restrictions, among them Denver, Portland, Seattle and San Francisco. Other jurisdictions are considering doing the same, and these include Philadelphia, Allegheny County, San Jose, Austin, Minneapolis, as well as the District of Columbia and the states of California and Texas,” he said.

Public awareness is growing through social media networking and the national press. Ophthalmologists have been quoted in The New York Times, Washington Post and The Wall Street Journal.

“It takes time to lay the groundwork for effective public advocacy and for influencing decision-makers. However, this is part of our mission, ‘protecting sight and empowering lives.’ Even if we save just one eye, the efforts will be worthwhile,” Goel said.

For more information:

Ravi D. Goel, MD, can be reached at Regional Eye Associates, 741 Marlton Pike West, Cherry Hill, NJ 08002; email: rdgoel@gmail.com.

Sundaram Natarajan, MD, can be reached at Aditya Jyot Eye Hospital, Plot No. 153, Road No. 9, Mumbai, Maharashtra 400031, India; email: prof.drsn@gmail.com.