Ophthalmic Injuries by Less-Lethal Kinetic Weapons During the US George Floyd Protests in Spring 2020 | Emergency Medicine | JAMA Ophthalmology | JAMA Network
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Figure.  Number of Residency Programs Reporting Seeing at Least 1 Patient With Ocular Injuries
Number of Residency Programs Reporting Seeing at Least 1 Patient With Ocular Injuries
Table.  Summary of Case Series
Summary of Case Series
1.
Israel and the Occupied Territories: Excessive Use of Lethal Force. Amnesty International. Published October 2000. Accessed October 28, 2020. https://www.amnesty.org/download/Documents/140000/mde150412000en.pdf
2.
Chowaniec  C, Kobek  M, Jabłoński  C, Kabiesz-Neniczka  S, Karczewska  W.  Case-study of fatal gunshot wounds from non-lethal projectiles.   Forensic Sci Int. 2008;178(2-3):213-217. doi:10.1016/j.forsciint.2008.03.020PubMedGoogle ScholarCrossref
3.
Physicians for Human Rights. “Less-lethal” weapons used with excessive force can cause serious injury, disability, and death. Accessed June 2, 2020. https://phr.org/issues/weapons/non-lethal-weapons-used-with-excessive-force/
4.
Ifantides  C, Deitz  GA, Christopher  KL, Slingsby  TJ, Subramanian  PS.  Less-lethal weapons resulting in ophthalmic injuries: a review and recent example of eye trauma.   Ophthalmol Ther. 2020;9(3):1-7. doi:10.1007/s40123-020-00271-9PubMedGoogle ScholarCrossref
5.
Denver Police Department. Operations manual for the police department of the city and county Denver, Colorado. Updated December 2009. Accessed October 29, 2020. http://kpm106.com/LEO/LeoDocs/04-15book.pdf
6.
Fort Lauderdale Police. Authorized less-lethal weapons (policy 113). Revised July 2020. Accessed October 28, 2020. https://www.flpd.org/home/showdocument?id=4060
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    Research Letter
    December 3, 2020

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

    Author Affiliations
    • 1Department of Ophthalmology, University of Colorado, Aurora
    • 2Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
    • 3Department of Surgery, Denver Health Medical Center, Denver, Colorado
    • 4Department of Neurology, University of Colorado, Aurora
    • 5Department of Neurosurgery, University of Colorado, Aurora
    JAMA Ophthalmol. 2021;139(2):242-244. doi:10.1001/jamaophthalmol.2020.5325

    Modern less-lethal weapons, or kinetic impact projectiles (KIPs), may cause ophthalmic morbidity and even mortality1-3; 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).

    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.

    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.

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    Article Information

    Corresponding Author: Prem S. Subramanian, MD, PhD, Sue Anschutz-Rodgers UCHealth Eye Center, University of Colorado School of Medicine, 1675 Aurora Ct, Mail Stop F731, Aurora, CO 80045 (prem.subramanian@cuanschutz.edu).

    Accepted for Publication: October 5, 2020.

    Published Online: December 3, 2020. doi:10.1001/jamaophthalmol.2020.5325

    Author Contributions: Dr Ifantides had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Ifantides, Smith, SooHoo, Subramanian.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Patnaik.

    Administrative, technical, or material support: Ifantides, Deitz, SooHoo, Subramanian.

    Supervision: Ifantides, Christopher, Smith, Subramanian.

    Conflict of Interest Disclosures: Dr Subramanian reports grants from Quark Pharmaceuticals, Santhera Pharmaceuticals, and GenSight Biologics and personal fees from Quark Pharmaceuticals, Horizon Therapeutics, Invex Therapeutics, and GenSight Biologics outside the submitted work. No other disclosures were reported.

    Additional Contributions: We thank Nathan Gelinas, MD (Department of Ophthalmology, University of Colorado), and Taylor Slingsby, MD (Department of Ophthalmology, University of Colorado), for their contributions to this manuscript. No compensation was received by either individual.

    References
    1.
    Israel and the Occupied Territories: Excessive Use of Lethal Force. Amnesty International. Published October 2000. Accessed October 28, 2020. https://www.amnesty.org/download/Documents/140000/mde150412000en.pdf
    2.
    Chowaniec  C, Kobek  M, Jabłoński  C, Kabiesz-Neniczka  S, Karczewska  W.  Case-study of fatal gunshot wounds from non-lethal projectiles.   Forensic Sci Int. 2008;178(2-3):213-217. doi:10.1016/j.forsciint.2008.03.020PubMedGoogle ScholarCrossref
    3.
    Physicians for Human Rights. “Less-lethal” weapons used with excessive force can cause serious injury, disability, and death. Accessed June 2, 2020. https://phr.org/issues/weapons/non-lethal-weapons-used-with-excessive-force/
    4.
    Ifantides  C, Deitz  GA, Christopher  KL, Slingsby  TJ, Subramanian  PS.  Less-lethal weapons resulting in ophthalmic injuries: a review and recent example of eye trauma.   Ophthalmol Ther. 2020;9(3):1-7. doi:10.1007/s40123-020-00271-9PubMedGoogle ScholarCrossref
    5.
    Denver Police Department. Operations manual for the police department of the city and county Denver, Colorado. Updated December 2009. Accessed October 29, 2020. http://kpm106.com/LEO/LeoDocs/04-15book.pdf
    6.
    Fort Lauderdale Police. Authorized less-lethal weapons (policy 113). Revised July 2020. Accessed October 28, 2020. https://www.flpd.org/home/showdocument?id=4060
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