Mouldable, thermoplastic, glue-on frog-supportive shoes change hoof kinetics in normal and obese Shetland ponies.

BACKGROUND: Obesity and hyperinsulinaemia are frequently encountered in the equine population and risk factors for the development of laminitis. There are many options for hoof support that claim a beneficial effect, but often the scientific evidence is scarce. OBJECTIVES: To quantify the effect of frog-supportive shoes on hoof kinetics in normal and obese ponies. STUDY DESIGN: Controlled in vivo trial. METHODS: Ten Shetland mares (n = 10) with a normal (n = 5) or obese (n = 5) body condition were led over a dynamically calibrated pressure plate before (T0), immediately after (T1) and 72 h (T2) after application of the shoes. The following locomotor variables were measured: stance duration (StDur), vertical impulse (VI), peak vertical force (PVF), time to PVF and time from PVF to lift off. The hoof print was divided into a toe and heel region and the StDur toe-heel index was calculated. The toe-heel hoof balance curves of the vertical force were plotted throughout the stance phase. RESULTS: The VI and PVF increased significantly 72 h after application of the shoes, when compared with T0 and T1. The StDur toe-heel index and toe-heel balance curves were significantly different between the normal and obese ponies. These variables became more comparable between the groups after application of the frog-supportive shoes. MAIN LIMITATIONS: It would have been interesting to measure the effect of the shoe in patients with acute laminitis. However, this would have had major welfare implications. CONCLUSIONS: The obese ponies moved more carefully than the normal group, demonstrated by a decreased loading of the toe area. The data illustrate that the ponies became more comfortable 72 h after application of the shoes, with a pronounced effect in the obese group. Thus, these results suggest that frog-supportive shoes could be beneficial, especially for obese ponies.

Correlation between surgical success rate and severity of congenital glaucoma.

AIM: To study the correlation between severity of primary congenital glaucoma (PCG) and success of three types of surgery. METHODS: This was a retrospective review of all records of patients diagnosed with PCG up to age 1 year who underwent goniotomy, trabeculotomy, or combined trabeculotomy-trabeculectomy with mitomycin C as initial procedure between 1982 and 2002 at the King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. 532 paediatric glaucoma patients below age 1 year (820 eyes) with a minimum 1 year follow up were identified. The main outcome measures used for the surgeries were postoperative intraocular pressure, stability of the corneal diameter, and maintenance of corneal clarity. Surgical success was defined as a postoperative intraocular pressure of < or = 21 mm Hg without additional medical or surgical therapy, and with decreased corneal oedema, stabilised corneal diameter, and no additional optic nerve damage for at least 1 year after surgery. Complications, time of surgical failure, and follow up were recorded. RESULTS: The eyes were grouped into mild (249), moderate (342), and severe (229) PCG, based on intraocular pressure, corneal diameter, and clarity. All three surgical procedures resulted in high success rates of 81-100% for the mild form of PCG. Eyes classified with moderate glaucoma had a 13%, 40%, and 80% success rate respectively for goniotomy, trabeculotomy, and combined trabeculotomy-trabeculectomy with mitomycin C. The success rate for severe PCG was 10% and 70% for trabeculotomy and combined surgery respectively. Goniotomy was never done for eyes with this condition. CONCLUSION: Clinical classification of PCG is helpful for surgical decision making. The mild form has a high surgical success regardless of the procedure chosen. Combined trabeculotomy-trabeculectomy with mitomycin C gave the best results for moderate and severe cases of PCG.

Homozygous mutations in ARIX(PHOX2A) result in congenital fibrosis of the extraocular muscles type 2.

Isolated strabismus affects 1-5% of the general population. Most forms of strabismus are multifactorial in origin; although there is probably an inherited component, the genetics of these disorders remain unclear. The congenital fibrosis syndromes (CFS) represent a subset of monogenic isolated strabismic disorders that are characterized by restrictive ophthalmoplegia, and include congenital fibrosis of the extraocular muscles (CFEOM) and Duane syndrome (DURS). Neuropathologic studies indicate that these disorders may result from the maldevelopment of the oculomotor (nIII), trochlear (nIV) and abducens (nVI) cranial nerve nuclei. To date, five CFS loci have been mapped (FEOM1, FEOM2, FEOM3, DURS1 and DURS2), but no genes have been identified. Here, we report three mutations in ARIX (also known as PHOX2A) in four CFEOM2 pedigrees. ARIX encodes a homeodomain transcription factor protein previously shown to be required for nIII/nIV development in mouse and zebrafish. Two of the mutations are predicted to disrupt splicing, whereas the third alters an amino acid within the conserved brachyury-like domain. These findings confirm the hypothesis that CFEOM2 results from the abnormal development of nIII/nIV (ref. 7) and emphasize a critical role for ARIX in the development of these midbrain motor nuclei.

Recognized globe perforation during strabismus surgery: incidence, risk factors, and sequelae.

BACKGROUND: Inadvertent perforation of the globe is a well-recognized complication of extraocular muscle surgery. We evaluated the incidence, risk factors, and sequelae of this complication at our institution. METHODS: Medical records of patients who underwent extraocular muscle surgery at King Khaled Eye Specialist Hospital, Saudi Arabia, between September 1983 and April 1997, were reviewed for the occurrence of globe perforation. We documented preoperative visual acuity and refraction, surgical procedure, how the perforation occurred, and immediate management, as well as the sequelae of the perforation, its management, and final outcome. RESULTS: Recognized perforations occurred in 15 of 4886 procedures, for an overall incidence rate of 3/1000. Perforations were 3 times more common in myopic eyes (>-6.00 D, P =.05) and 2 times more common in eyes with previous extraocular muscle surgery. Perforations occurred during muscle reattachment (5 cases), placement of traction sutures at the limbus (4 cases with transient hyphema), muscle disinsertion (3 cases), and placement of sutures at the muscle insertion before disinsertion (3 cases). One patient had a large scleral laceration with uveal prolapse, necessitating scleral patch graft at the time of surgery, and later had retinal detachment surgery with loss of 2 lines of visual acuity. Endophthalmitis, cataract, glaucoma, and phthisis bulbi were not encountered in our review. CONCLUSION: The current incidence of globe perforation is low and only rarely associated with serious sequelae.

Pyramidal anterior polar cataracts.

OBJECTIVE: To document clinical features and subsequent management of pyramidal anterior polar cataracts in children. DESIGN: Retrospective, noncomparative case series and clinicopathologic correlation. PARTICIPANTS: Fifteen patients who presented to the pediatric ophthalmology clinic. INTERVENTION: All patients underwent measurement of visual acuity, assessment of ocular motility, examination of the anterior and posterior segments, and cycloplegic refraction. Amblyopia treatment was instituted when appropriate. When visual impairment occurred from cataract progression or amblyopia or both, cataract removal with or without lens implantation was performed. After surgery, correction of refractive error and treatment of amblyopia were instituted. Several pyramidal opacities were retrieved during cataract extraction and examined by light and electron microscopy. MAIN OUTCOME MEASURES: Visual acuity at initial presentation, size of lens opacity before surgery, amblyopia status, most recent visual acuity after cataract extraction, and histologic examination of lens opacity. RESULTS: Nine children had bilateral and six had unilateral pyramidal cataracts (24 eyes). There was no discernible inheritance pattern. Patients were followed for 27 months on average. Twenty of 24 eyes developed cortical opacification that extended significantly beyond the base of the pyramidal lesion. Nineteen eyes required cataract surgery: 10 eyes underwent lensectomy with anterior vitrectomy and 9 had extracapsular cataract extraction, 8 of which had insertion of a posterior chamber intraocular lens. Amblyopia was present or developed in all six patients with unilateral cataract and in eight of nine patients with bilateral cataract. Visual acuity in many eyes remained poor despite amblyopia therapy. The pyramidal opacities consisted of hyperplastic lens epithelium, which exhibited a loss of polarity and was surrounded by a collagenous matrix. CONCLUSIONS: Pyramidal anterior polar cataracts are present at birth and may represent a variant of anterior polar lens opacities. They may be unilateral or, if bilateral, they may be either symmetric or asymmetric. They consist of hyperplastic lens epithelium in a collagenous matrix. Patients with pyramidal cataracts are likely to develop amblyopia. This can result from either unilateral occurrence or asymmetry of bilateral opacities and is often worsened by surrounding cortical opacification. Many patients require cataract surgery. All infants and young children with anterior polar opacities showing this configuration should be followed for cataract progression and amblyopia.

Combined trabeculotomy and trabeculectomy as an initial procedure in uncomplicated congenital glaucoma.

OBJECTIVE: To review the results of combined trabeculotomy and trabeculectomy as a primary procedure in congenital glaucoma. METHODS: A retrospective review of 100 consecutive eyes in 60 children undergoing surgery from December 30, 1991, to April 17, 1996. Features at initial examination, ie, corneal size and clarity, presence or absence of anterior segment structural abnormalities, and intraocular pressure (IOP), were noted. Data pertaining to perioperative use of mitomycin and the occurrence of complications were collected. After surgery, all patients had IOP, corneal integrity, and any postoperative complication recorded under chloral hydrate sedation. RESULTS: Mean preoperative IOP was 31 mm Hg. Average horizontal corneal diameter was 12.60 mm. Ninety-five eyes had corneal opacification. Twenty-nine eyes had additional anterior segment anomalies, with ectropion uveae (n = 11), Peters anomaly (n = 9), and partial aniridia (n = 7) being the most common. Mitomycin (0.2 or 0.4 mg/mL) was used in 87 eyes. Eleven eyes sustained hyphemas during or just after surgery. Total average follow-up was 304 days. Eyes in which no coexistent anterior segment anomalies were present had a 78% (49 eyes) operative success (IOP, <21 mm Hg); however, in eyes with associated anterior segment anomalies, the success rate was much lower (45% [18 eyes]). The difference in success rates between both groups was statistically significant (P = .03, chi2 test). CONCLUSIONS: Primary combined trabeculotomy and trabeculectomy was a useful initial procedure in uncomplicated congenital glaucoma. This was particularly true where corneal opacification, as in nearly all our eyes, precluded goniotomy, however, where other stigmata of anterior segment dysgenesis coexisted, results were significantly poorer.

Glaucoma in Sturge-Weber syndrome.

BACKGROUND: In glaucoma associated with Sturge-Weber syndrome (SWS), medical treatment often fails to control intraocular pressure, thus requiring surgical intervention that may result in serious complications. METHODS: Eighteen consecutive patients with SWS were reviewed retrospectively at the King Khaled Eye Specialist Hospital. An intraocular pressure less than 20 mm Hg, plus stable optic nerve cup-to-disc ratio and corneal diameter (or visual fields where appropriate), were parameters chosen to indicate that the glaucoma was being controlled. RESULTS: Glaucoma was found in 15 of 18 patients (22 eyes). The mean follow-up time was 62 months (range, 12 to 148 months). Medical treatment alone was successful in 5 patients (7 eyes); the remainder required surgical intervention. The initial surgical procedures included cyclocryotherapy, YAG laser goniotomy, surgical goniotomy, and trabeculotomy or trabeculectomy. Eight eyes required subsequent surgery, 5 with Molteno or Ahmed implants. Early postoperative choroidal effusion and hemorrhage occurred in 4 eyes and resolved spontaneously. Hemorrhagic choroidal detachment with total retinal detachment developed in 2 patients 3 to 5 months after surgery. In 1 patient a recurrent serous choroidal detachment after suture lysis was associated with total optic atrophy. CONCLUSIONS: Glaucoma in SWS is common. Control of glaucoma was successfully achieved with medical treatment in 7 of 22 eyes of our 15 SWS-glaucoma patients, and we consider it the initial treatment of choice. Of the 15 eyes that required surgery, late postoperative complications resulted in loss of vision as a result of persistent postoperative hypotony in 3 eyes that underwent surgical procedures.

Effectiveness and complications of mitomycin C use during pediatric glaucoma surgery.

PURPOSE: To examine the safety of mitomycin C (MMC) use in pediatric glaucoma surgery. DESIGN: Retrospective interventional case series. PARTICIPANTS: One hundred eighty pediatric glaucoma patients younger than 7 years of age (254 eyes) who underwent glaucoma surgery and were followed for at least 1 year participated. INTERVENTIONS: Surgeries consisted of trabeculectomy or combined trabeculotomy-trabeculectomy with adjunctive use of MMC. MAIN OUTCOME MEASURES: Control of intraocular pressure (IOP) and occurrence of complications were measured. An IOP below 21 mmHg without any additional medical or surgical treatment was considered a success. RESULTS: Primary congenital glaucoma was present in 98% of the patients. Sixty percent had a trabeculectomy, and 40% had a trabeculotomy-trabeculectomy. The combined surgery was performed mostly in infants up to 1 year of age. Complications were cystic bleb (19), bleb leak (4), retinal detachment (3), flat anterior chamber (3), cataract (2), and endophthalmitis (1). Children younger than 2 years of age had fewer complications but higher failure rates. The combined procedure in infants up to 2 years of age was moderately more successful (57%) than trabeculectomy alone (39%). Minimal complications seen in this group were more likely related to young age than to the type of surgery. Complications increased with time after surgery, with most occurring 2 years or more after surgery. CONCLUSIONS: Success of MMC-augmented glaucoma filtering surgery increased with age, as did the complication rate. Serious complications were uncommon in the authors' group of pediatric patients up to now. However, complications related to bleb thinning increased with time after surgery, and additional problems can be anticipated with longer follow-up.

Congenital fibrosis of the extraocular muscles type 2, an inherited exotropic strabismus fixus, maps to distal 11q13.

The extraocular fibrosis syndromes are congenital ocular-motility disorders that arise from dysfunction of the oculomotor, trochlear, and abducens nerves and/or the muscles that they innervate. Each is marked by a specific form of restrictive paralytic ophthalmoplegia with or without ptosis. Individuals with the classic form of congenital fibrosis of the extraocular muscles (CFEOM1) are born with bilateral ptosis and a restrictive infraductive external ophthalmoplegia. We previously demonstrated that CFEOM1 is caused by an autosomal dominant locus on chromosome 12 and results from a developmental absence of the superior division of the oculomotor nerve. We now have mapped a variant of CFEOM, exotropic strabismus fixus ("CFEOM2"). Affected individuals are born with bilateral ptosis and restrictive ophthalmoplegia with the globes "frozen" in extreme abduction. This autosomal recessive disorder is present in members of three consanguineous Saudi Arabian families. Genetic analysis of 70 individuals (20 affected individuals) reveals linkage to markers on chromosome 11q13, with a combined LOD score of 12.3 at the single nonrecombinant marker, D11S1314. The 2.5-cM CFEOM2 critical region is flanked by D11S4196/D11S4162 and D11S4184/1369. Two of the three families share a common disease-associated haplotype, suggesting a founder effect for CFEOM2. We hypothesize that CFEOM2 results from an analogous developmental defect to CFEOM1, one that affects both the superior and inferior divisions of the oculomotor nerve and their corresponding alpha motoneurons and extraocular muscles.

Combined intraocular and strabismus surgery.

BACKGROUND AND OBJECTIVE: To study the results of combined intraocular and strabismus surgery. PATIENTS AND METHODS: Combined surgery was done in 14 patients. In 10 of these patients, cataract and strabismus surgery were combined. One had a penetrating keratoplasty, and another required placement of a glaucoma valve implant. In one patient trabeculectomy, pupilloplasty, and lensectomy were done, and one patient needed repair of a leaking bleb. RESULTS: The strabismus of most patients was significantly improved. Eleven patients (79%) were orthophoric +/- 10 prism diopters (PD). Visual outcome was good in patients with no structural abnormalities who were compliant with occlusion therapy, if applicable. CONCLUSIONS: Combined intraocular and strabismus surgery has a success rate comparable with that of standard strabismus surgery.

Topical tissue plasminogen activator appears ineffective for the clearance of intraocular fibrin.

BACKGROUND AND OBJECTIVE: To determine the efficacy of topical tissue plasminogen activator (tPA) for the resolution of postoperative or inflammatory intraocular fibrinous exudates. PATIENTS AND METHODS: Each treatment consisted of drops of 1 mg/ml tPA given 9 times 5 minutes apart. Records were reviewed and the results at 24 and 48 hours were recorded. Sixty-two patients had a total of 94 treatments. RESULTS: Fibrin exudates following intraocular surgery in 34 patients were treated 44 times. In 6 patients there was a positive result. Fibrin associated with intraocular infection was treated in 9 patients. None showed clear improvement. Nineteen patients had a total of 34 treatments for poorly controlled intraocular pressure (IOP) after glaucoma surgery. Five patients showed adequate control of the IOP, 12 did not change, and 2 had a questionable improvement. Eleven patients had adequate IOP control after additional treatment. Seven required suture lysis, 2 ab interno bleb revision, and 2 YAG capsulotomy or iridotomy to reduce the IOP to an acceptable level. CONCLUSIONS: Within the limits of this retrospective study and taking into account that fibrin may resolve spontaneously, it appears that topical tPA drops are not effective for the liquefaction of intraocular fibrin after surgery or in association with intraocular inflammation. They did not improve IOP control after glaucoma surgery.

Pediatric intraocular lens implantation. Surgical results and complications in more than 300 patients.

OBJECTIVE: The study aimed to review pediatric intraocular lens (IOL) implantations performed in the authors' institution for the past 7 years. STUDY DESIGN: The study design was a retrospective chart review. PARTICIPANTS: All children who underwent IOL placement between January 1, 1989, and January 31, 1996, at ages 2 to 16 years were studied. Follow-up was a minimum of 6 months up to 4 years with an average of 13 months. INTERVENTION: Placement of a primary or secondary posterior chamber IOL was performed. MAIN OUTCOME MEASURES: Visual acuity and possible complications were tabulated. RESULTS: Fifty-seven percent of the cataracts were caused by trauma, and 37% were infantile cataracts. Visual acuities of 20/40 or better were attained in 44% of eyes and visual acuities of 20/50 to 20/80 were attained in 27% of eyes. Visual acuities were better in children older than 4 years of age (P = 0.001). Compliance with amblyopia therapy improved vision (P = 0.004). Fibrinous membranes occurred in 41 eyes (13%), and posterior capsule opacification occurred in 120 eyes (39%). There were no significant differences in visual outcome and complications between primary and secondary implants (17%) or between capsular bag and sulcus fixation (27%). The first stable postoperative refraction was predicted accurately in most patients, based on the Sanders-Retzlaff-Kraff II (SRK II) formula and intraoperative corneal curvature and axial length determinations. The mean refraction differed from the goal by only +0.28 diopter and 84% were within +/- 2 diopters. A few patients showed large overcorrections or undercorrections. On average, no myopic shift occurred. CONCLUSIONS: Short-term results of IOLs implanted in children older than 2 years of age were favorable. Visual acuities obtained were better than 20/80 in 71% despite a high prevalence (28%) of penetrating trauma. Major complications were rare.

Secondary posterior chamber intraocular lens implantation in children.

BACKGROUND: Primary intraocular lens (IOL) implantation after cataract aspiration is a widely accepted means of correcting pediatric aphakia. However, little is available in the literature on secondary IOL implantation in children. We present our experience over the past 6 years. METHODS: The charts of 57 aphakic children (61 eyes) who underwent secondary posterior chamber IOL implantation between January 1989 and April 1996 were reviewed. In general, these children were either intolerant of or noncompliant with their contact lenses. An attempt was made to correlate visual outcome with patient variables. Evaluation of the ciliary sulcus structure was made in selected patients by ultrasonographic biomicroscopy to reveal any changes resulting from the presence of the IOL haptic in the sulcus. RESULTS: The age range at the time of surgery was 2 to 16 years (mean 8 y). Mean follow-up was 14 months (range 6 to 48 months). Forty-two percent of the patients had a best-corrected visual acuity of 20/40 or better and 78% saw better than 20/80. Posterior capsular opacification occurred in 10 eyes, 8 of which required neodymium:yttrium-aluminum-garnet laser capsulotomy. No major complications occurred. Ciliary sulcus evaluation by biomicroscopy did not reveal any significant ciliary body or scleral erosion. No changes were noted when the implanted sulcus was compared with the normal contralateral side. CONCLUSION: Although follow-up was short, this review suggests that secondary posterior chamber IOL implantation is a safe alternative when other methods of correcting pediatric aphakia fail.

Treatment of congenital nasolacrimal duct obstruction before and after the age of 1 year.

BACKGROUND AND OBJECTIVES: The treatment of congenital nasolacrimal duct (NLD) obstruction continues to be a subject of controversy. Some authors advocate early probing and irrigation in an office setting, whereas others recommend that the procedure be performed under general anesthesia when the child is at least 1 year old. The focus of this study was to compare the results of probing and irrigation of congenital NLD obstruction among children younger than 1 year of age, those 1 to 2 years of age, and those older than 2 years. PATIENTS AND METHODS: The author reviewed the records of 120 patients, ranging in age from 3 weeks to 30 years, with 153 cases of NLD obstruction. Eighty-five patients (110 cases of NLD obstruction) underwent probing and irrigation. RESULTS: Complications of NLD obstruction occurred in 12 patients; 75% of these patients were younger than 1 year of age. In group 1 (patient age < 1 year) there were 37 probings with 1 failure (3%). Group 2 (patient age = 1-2 years) had 43 probings and 5 failures (12%). In group 3 (patient age > 2 years), 30 NLDs were probed with 2 failures (7%). However, these differences were not significant (P = .13 between groups 1 and 2; P = .42 between groups 1 and 3). CONCLUSION: In this study, the postponement of probing and irrigation for congenital NLD obstruction beyond the age of 1 year did not result in an increased rate of failures or complications.

Long-term outcome of neonatal macular hemorrhage.

BACKGROUND: We studied long-term visual acuity in children who had macular hemorrhages at birth. METHODS: Of 11 involved children, seven had eye examinations at about age 10. Two were contacted by telephone; two were lost to follow up. RESULTS: Of the seven examined children, six had normal visual acuities. One had reduced vision in the eye with the macular hemorrhage, possibly related to deprivation amblyopia secondary to slow resorption of the hemorrhage. The two patients contacted by telephone reported normal vision. CONCLUSION: Although macular hemorrhages generally resolve without any lasting damage, the outcome may be less favorable in some patients.

The anatomy of probing and irrigation for congenital nasolacrimal duct obstruction.

In this study, an easily palpable landmark, the supraorbital notch or foramen, was used to simplify the localization of the nasolacrimal duct during the probing procedure. The notch was palpated in 50 patients of a pediatric clinic. The topographic anatomy of the notch in relation to the lacrimal drainage system was studied in 10 skulls. The supraorbital notch is a convenient landmark for the guidance of a probe into the nasolacrimal canal. This technique should reduce the failure rate of probing without the need for infracturing of the lower turbinate or silicone intubation.

Pediatric IOL implantation: the KKESH experience.

BACKGROUND: Intraocular lens (IOL) implantation is increasingly accepted as a means of correcting pediatric aphakia. However, few large series have been reported. We present our experience over the past 6 years. METHODS: Charts were reviewed of 84 patients (88 eyes) 8 years old or younger who underwent IOL implantation at King Khaled Eye Specialist Hospital between January 1989 and March 1995. An attempt was made to correlate visual outcome with patient variables, and refractive outcome was assessed. RESULTS: Despite a high percentage of patients with penetrating trauma (24%) and a significant level of poor compliance with amblyopia treatment (33%), one third of patients saw 20/40 or better, and 60% had at least 20/80 acuity. Improved visual outcome correlated with later onset and shorter duration of opacity and compliance with occlusion therapy. The posterior capsule was left intact in the majority of cases; opacification occurred in 47 eyes, 25 of which required Nd:YAG capsulotomy. No unexpected complications occurred. Prediction of postoperative pseudophakic refraction was within 2 diopters (D) in 70% of patients. CONCLUSION: IOL implantation in appropriate children can be used as a safe alternative to other methods of correcting pediatric aphakia. Visual outcome often depends on amblyopia management. These patients are appropriately followed by ophthalmologists who are experienced in managing amblyopia and pediatric pseudophakia.

The long-term effects of an accidental injection of depot corticosteroids in an infant eye.

A 4-month-old infant received an accidental intraocular injection of methylprednisolone while undergoing penetrating keratoplasty for congenital, hereditary endothelial dystrophy. This was not discovered until 4 months later, at which time the intraocular pressure (IOP) was increasing and an early cataract was forming. A lensectomy and vitrectomy were performed when the child was 12 months old. The IOP remained higher than that of the fellow eye, but the recovery was otherwise uneventful. This indicates that intraocular depot steroid may be tolerated, except when there is the occurrence of known pharmacologic side effects.

Eye injuries during training exercises with paint balls.

The use of paint balls, increasingly popular for war games and survival games, has recently been introduced for certain military training exercises. We treated two soldiers who had severe permanent ocular damage after being hit by these balls. Both removed their goggles after their vision was obscured with paint from a hit on these protective lenses. They were then hit for a second time, resulting in the eye injury. Based on these cases and on a literature review, we conclude that protective eye gear should be mandatory when paint pellets are used. It is essential that service members participating in such exercises be instructed not to remove their protective goggles under any circumstances.