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indicating an absence of small conjunctival and episcleral blood vessels that left large areas of the sclera bare. In each of these cases there was a history of a severe corneal and perilimbal burn that involved an extensive amount of the perilimbal conjunctiva. This corresponds to Class III injuries in which there is (a) damage to the limbal blood supply, associated with moderate corneal edema, superficial collections of inflammatory cells, with or without superficial corneal vascularization; or (b) ischemic necrosis of the limbal regions, marked and persistent corneal edema, deep corneal inflammatory cells, and deep blood vessel ingrowth into the cornea (vascularization).

The problem of delayed keratitis was neither trivial nor infrequent in the severe injuries. Mann's studies of 84 cases in 1944 showed that an inflammatory keratitis (inflammation of the cornea) developed intermittently in the most severely injured veterans for a period of 17 years after initial exposure (Mann, 1944); however, during the next 7- to 8-year period, a sudden substantial increase in these numbers was observed.

The use of Lewisite as a wartime gas was much less common. A combination of sulfur mustard and Lewisite was reported to have been used in the Japanese attack on Ichang in 1941 (SIPRI, 1971). No medical reports are available to document the short- or long-term effects to the health of survivors. No large-scale reports of pure Lewisite eye injury to humans are noted in the literature.

Medical Therapeutic Exposure

Sulfur mustard has not been used to treat eye disease. However, other alkylating agents, such as cyclophosphamide and chlorambucil, have been shown to be effective in arresting a number of eye diseases, including peripheral ulcerative keratitis, Mooren's corneal ulcer, some ulcerative and nonulcerative scleral diseases, and recalcitrant uveitis (inflammation of the iris, ciliary body, and choroid). Each of these diseases is regarded as, or has been proven to be, an autoimmune process. There are no reports of secondary cancers developing as a consequence of immunosuppression from treatment of eye disease.


Gaps in Knowledge

Limbal Vascular Damage

The whitened appearance of perilimbal ocular tissues after sulfur mustard injury suggested to early investigators that destruction of the limbal vasculature resulted in the disastrous effects on the cornea and

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