Ophthalmic Injuries by Less-Lethal Kinetic Weapons During the US George Floyd Protests in Spring 2020

Abstract

This study investigates the experience of academic ophthalmology residency programs to assess less-lethal weapon eye trauma after the George Floyd protests in Denver, Colorado.

Modern less-lethal weapons, or kinetic impact projectiles (KIPs), may cause ophthalmic morbidity and even mortality^1,2,3; we recently published a detailed description of KIP types and properties.⁴ Herein, we highlight devastating consequences of KIPs, investigate the experience of other United States–based academic ophthalmology residency programs, review current law enforcement KIP-use policies, and recommend policy changes that may prevent further injuries.

Method

Exemption from institutional review board review and waiver of consent and Health Insurance Portability and Accountability Act authorization under exempt category 4 (secondary data use for research under 45 CFR 164.501) was obtained from the Colorado Multiple Institutional Review Board; patient data are protected by hospital privacy safeguards.

A nonvalidated survey was distributed via email to 115 ophthalmology residency program directors using the database of the Association of University Professors of Ophthalmology from June to July 2020. Programs were queried about the total number and types of injuries seen without details of clinical course or outcomes. Consecutive individuals who sustained ophthalmic injuries during the George Floyd protests in Denver, Colorado, were identified, and clinical course and outcomes were collected.

Results

Surveys were emailed to 115 programs, and 82 (71%) responded. Twenty-two programs (27%; 95% CI, 22%-32%) noted caring for patients with ophthalmic injuries related to the protests; 16 (20%; 95% CI, 15%-24%) indicated at least 1 injury was KIP-related. A total of 41 KIP-related injuries were reported (range, 1-10 per program, with 9 reporting only 1 patient each). The most common injuries were hyphema (reported by 12 programs), orbital fractures (11 programs), and ruptured globe (10 programs) (Figure).

Figure. Number of Residency Programs Reporting Seeing at Least 1 Patient With Ocular Injuries.

Projectiles retrieved from local protest sites (>1000 attendees) included rubber baton rounds, foam grenades, and pepper balls. In particular, our institution cared for 6 unique patients who sustained ophthalmic injuries from suspected KIPs. Four (patients 2-5) reported being struck by projectiles fired by law enforcement; 2 could not identify the source (Table). No patients with KIP injuries unassociated with the protests were identified.

Table. Summary of Case Series.

Patient No.	Projectilea	Presenting VA	Globe rupture	OTS	Presenting physical examination findings	Treatment	Prognosis
1	Rock/projectile	Unknown	No	Unknown	• Extraocular injuries: frontal and temporal subarachnoid hemorrhages, subdural hematoma, orbital hematoma, multiple craniofacial fractures with optic canal involved • Anterior segment injuries: conjunctival chemosis • Posterior segment injuries: none	Observation	Good; VA: 20/20
2	Impact projectile	LP	Yes	1	• Extraocular injuries: periorbital edema, ecchymosis, 1-cm upper eyelid abrasion • Anterior segment injuries: hemorrhagic chemosis, radial scleral laceration ×2 extending posterior to equator • Posterior segment injuries: disorganized contents	Incomplete open globe repair due to posterior extension	Poor (NLP)
3	Foam grenade	20/20	No	5	• Extraocular injuries: multiple forehead, brow, and eyelid lacerations and abrasions • Anterior segment injuries: multiple conjunctival abrasions • Posterior segment injuries: far peripheral commotio retinae	Skin laceration repair, erythromycin ointment	Good
4	Pepper ball	HM	No	3	• Extraocular injuries: disruption of prior left upper eyelid laceration, periorbital edema • Anterior segment injuries: subconjunctival hemorrhage, 2-3 mm layered hyphema with ≥4 suspended red blood cell counts • Posterior segment injuries: commotio retinae	Prednisolone 4 times per d; cyclopentolate 2 times per d; hyphema precautions	Guarded; VA: 20/25
5	Unknown	NLP	Yes	1	• Extraocular injuries: fractures of all right orbital walls, tense periorbital edema and ecchymoses, pneumocephalus • Anterior segment injuries: grossly deformed, disorganized anterior segment with full-thickness stellate corneal laceration extending to sclera past equator, uveal extrusion • Posterior segment injuries: equatorial scleral rupture, uveal prolapse, hemorrhage	Attempted open globe repair, unable to fully repair posterior portion of laceration	Poor; enucleated
6	Unknown	HM	No	3	• Extraocular injuries: periorbital hematoma, brow and nasal bridge lacerations • Anterior segment injuries: 2-mm layered hyphema, ≥4 anterior chamber cell, traumatic mydriasis, angle recession, cyclodialysis cleft • Posterior segment injuries: vitreous hemorrhage	Skin lacerations repaired	Guarded; VA: 20/40

Abbreviations: HM, hand motions; LP, light perception; NLP, no light perception; OTS, Ocular Trauma Score; VA, visual acuity.

^aSuspected.

Discussion

In addition to our own experience, survey results showed that 20% of other US academic programs also saw patients for ophthalmic injuries that occurred during the George Floyd protests and were suspected to be KIP-related.

Written policies typically forbid firing less-lethal weapons at close range and at vulnerable areas of the body. The Denver Police Department’s operational manual confirms: “an officer shall not intentionally deploy the less lethal shotgun projectile…to the head, eyes, throat, neck, breasts of a female, genitalia, or spinal column” or “from a range of less than ten (10) feet.”⁵ Furthermore, “when any person is struck by the projectile from a less lethal shotgun…immediate evaluation by medical personnel is required.”⁵ Similar regulations direct officers to aim at the head or neck area “only if deadly force becomes necessary.”⁶ The trauma seen in Denver, Colorado, and other US cities highlights the need for law enforcement agencies to revisit operational manuals regarding proper use of less-lethal kinetic weapons.

Limitations of this study should be considered. We were unable to identify specific KIPs in each case with certainty and deduced type and source from patient descriptions and photographs. At times, no KIP was recovered. Additionally, some KIPs (ie, pepper balls) shatter on impact, making identification even more difficult. Although we had a good response rate (71%) on the nonvalidated survey, the majority (80%) did not encounter KIP-related trauma. We do not know if nonrespondent programs cared for KIP-injured patients; however, protests did occur in close proximity to all residency programs. Our survey also did not collect specific information beyond injury type. Finally, long-term sequelae of the injuries remain to be seen.