Ocular Injury After Thermal Blast Ocular Injury After Thermal Blast from a Propane Tank from a Propane Tank

Aruoriwo Oboh-Weilke, MDAruoriwo Oboh-Weilke, MDFlorian A. Weilke, MDFlorian A. Weilke, MD

The authors have no financial interest in this subject matterThe authors have no financial interest in this subject matter

PURPOSEPURPOSE

We report a case of a patient who suffered We report a case of a patient who suffered second degree burns to his face and presented second degree burns to his face and presented with significant foreign body deposits in his with significant foreign body deposits in his conjunctiva, epithelial, sub-epithelial and stromal conjunctiva, epithelial, sub-epithelial and stromal layers of his cornea after a propane tank fire layers of his cornea after a propane tank fire related blast injury. The foreign bodies were of related blast injury. The foreign bodies were of various compositions. The patient achieved various compositions. The patient achieved excellent visual recovery after removal of the excellent visual recovery after removal of the superficially embedded foreign particles, superficially embedded foreign particles, conservative management of the deeply conservative management of the deeply embedded materials and aggressive lubrication embedded materials and aggressive lubrication of the ocular surface. of the ocular surface.

INTRODUCTIONINTRODUCTION

Thermal blast injuries can cause damage to the Thermal blast injuries can cause damage to the ocular and facial structures through several ocular and facial structures through several mechanisms. mechanisms. Potential damage from heat which can lead to 2Potential damage from heat which can lead to 2ndnd and and

33rdrd degree burns of the facial and eyelid structures. degree burns of the facial and eyelid structures. Damage to the globe from flames is usually limited by Damage to the globe from flames is usually limited by Bell’s phenomenon and rapid-reflex eyelid closureBell’s phenomenon and rapid-reflex eyelid closure11 . .

The other significant source of damage is from foreign The other significant source of damage is from foreign particles, propelled at a high velocity from the blast. particles, propelled at a high velocity from the blast.

INTRODUCTIONINTRODUCTION

Some of these structures may remain Some of these structures may remain embedded in the cornea and result in a focal embedded in the cornea and result in a focal inflammatory response known as ophthalmia inflammatory response known as ophthalmia nodosumnodosum1. 1. They may also remain inert or They may also remain inert or migrate.migrate.

Embedded particles also pose an infection Embedded particles also pose an infection risk.risk.

CASE REPORTCASE REPORT

A 43 year old male patient presented for a A 43 year old male patient presented for a cornea evaluation by a referring cornea evaluation by a referring ophthalmologist. ophthalmologist.

The patient stated that he attempted to light a The patient stated that he attempted to light a propane fired torch when uncontrolled propane fired torch when uncontrolled combustion occurred, most likely due to a leak combustion occurred, most likely due to a leak from the pressure regulator. The patient was from the pressure regulator. The patient was standing on a gravel roadway at the time of the standing on a gravel roadway at the time of the accident and his face was close to the torch at accident and his face was close to the torch at the time of the injury. the time of the injury.

CASE REPORTCASE REPORT

He was evaluated and treated at the localHe was evaluated and treated at the local

Emergency Room for his facial burns and Emergency Room for his facial burns and was seen by an ophthalmologist 24 hours was seen by an ophthalmologist 24 hours later.later.

The patient presented to me for a cornea The patient presented to me for a cornea evaluation 72 hours after his injury.evaluation 72 hours after his injury.

On presentation he was complaining of On presentation he was complaining of pain and severe foreign body sensation.pain and severe foreign body sensation.

CASE REPORTCASE REPORTThe exam revealed areas of erythema and blistering of his face, The exam revealed areas of erythema and blistering of his face, upper and lower eyelids, singed eyebrows and eyelashes. upper and lower eyelids, singed eyebrows and eyelashes. BCVA was 20/150 OD and 20/200 OSBCVA was 20/150 OD and 20/200 OSPupils and IOPs were normal.Pupils and IOPs were normal.There was severe bilateral injection and chemosis, 360 degrees There was severe bilateral injection and chemosis, 360 degrees with multiple embedded foreign bodies in the interpalpebral with multiple embedded foreign bodies in the interpalpebral fissure nasally and temporally. Foreign particles were also fissure nasally and temporally. Foreign particles were also present in the corneal epithelium, sub-epithelium and stroma. present in the corneal epithelium, sub-epithelium and stroma. The foreign bodies were a mixture of metal, gravel and some The foreign bodies were a mixture of metal, gravel and some unidentified refractile-appearing substance. They were too unidentified refractile-appearing substance. They were too numerous to countnumerous to countThere were large epithelial defects bilaterally. There were large epithelial defects bilaterally. No foreign bodies were identified in the anterior chamber, angle, No foreign bodies were identified in the anterior chamber, angle, lens or iris. lens or iris. The posterior segment was unremarkable. The posterior segment was unremarkable.

72hrs after injury

72 hrs after injury

RESULTSRESULTS

Saline lavage of the cornea and the cul-de-sac Saline lavage of the cornea and the cul-de-sac was performed. This removed some of the was performed. This removed some of the debris that was not embedded in the ocular debris that was not embedded in the ocular surface. surface.

After topical anesthesia was applied, using a After topical anesthesia was applied, using a bent 25 gauge needle, the superficial particles bent 25 gauge needle, the superficial particles were extracted without any difficulties.were extracted without any difficulties.

The patient was put on frequent preservative-The patient was put on frequent preservative-free artificial tears, a cycloplegic and an free artificial tears, a cycloplegic and an antibiotic/steroid ointmentantibiotic/steroid ointment

RESULTSRESULTS

4 weeks after the injury the patient’s VA without 4 weeks after the injury the patient’s VA without correction was OD 20/20 , and OS 20/25correction was OD 20/20 , and OS 20/25+2. +2.

The epithelial surface of both corneas was fairly The epithelial surface of both corneas was fairly smooth. There were residual foreign particles in smooth. There were residual foreign particles in the stroma without significant inflammation.the stroma without significant inflammation.

7 months after the injury, the patient’s VA 7 months after the injury, the patient’s VA remains stable and the foreign materials in the remains stable and the foreign materials in the cornea appear inert and have not shown any cornea appear inert and have not shown any migration. migration.

28 days after injury

28 days after injury

4 months after injury

DISCUSSIONDISCUSSIONPatients with severe blast injuries involving the facial Patients with severe blast injuries involving the facial structures and ocular structures sometimes have a structures and ocular structures sometimes have a delay in being referred to an ophthalmologist due to the delay in being referred to an ophthalmologist due to the severity of the injury to other parts of their body. severity of the injury to other parts of their body. Spencer et al report that prompt ophthalmologic Spencer et al report that prompt ophthalmologic examination and the early use of prophylactic ocular examination and the early use of prophylactic ocular surface lubrication protect the cornea and decrease the surface lubrication protect the cornea and decrease the need for surgical intervention need for surgical intervention 22. In a review of blast . In a review of blast injuries to the eye by Zerihun, iris, conjunctival, corneal injuries to the eye by Zerihun, iris, conjunctival, corneal foreign-bodies, and corneal/ scleral lacerations were the foreign-bodies, and corneal/ scleral lacerations were the most frequent types of injury seen most frequent types of injury seen 33 It is advisable to remove metallic foreign particles as It is advisable to remove metallic foreign particles as materials left in the cornea may lead to persistent materials left in the cornea may lead to persistent epithelial defects and inflammationepithelial defects and inflammation11. .

DISCUSSIONDISCUSSION

There are several tools that can be applied in There are several tools that can be applied in evaluating and treating these patients. Anterior evaluating and treating these patients. Anterior Segment Optical Coherence Tomography can Segment Optical Coherence Tomography can be useful in establishing the location and size of be useful in establishing the location and size of these particles which in turn aids in these particles which in turn aids in management and follow-up management and follow-up 44..

Patients with an irregular surface from corneal Patients with an irregular surface from corneal foreign bodies can also be treated with foreign bodies can also be treated with Phototherapeutic keratectomy Phototherapeutic keratectomy 55

CONCLUSIONCONCLUSION

Thermal blast accidents can cause significant injuries Thermal blast accidents can cause significant injuries to the face and ocular structures. These injuries can to the face and ocular structures. These injuries can also lead to the deposition of foreign objects in also lead to the deposition of foreign objects in superficial and deep layers of the cornea. While it is superficial and deep layers of the cornea. While it is important to remove the superficial foreign bodies, important to remove the superficial foreign bodies, overly aggressive attempts at the removal of deep overly aggressive attempts at the removal of deep foreign particles could lead to corneal perforations or foreign particles could lead to corneal perforations or disruption of the corneal stroma. If there is no disruption of the corneal stroma. If there is no resultant inflammation or infection, these deeply resultant inflammation or infection, these deeply embedded foreign bodies can be managed by close embedded foreign bodies can be managed by close observation as it is possible to obtain good visual observation as it is possible to obtain good visual results without surgical intervention results without surgical intervention 11. .

REFERENCESREFERENCES

1 External Disease and Cornea. Basic and Clinical 1 External Disease and Cornea. Basic and Clinical Science Course 2007-2008; 404-406Science Course 2007-2008; 404-4062 Ophthalmic plastic reconstructive surgery 2002 2 Ophthalmic plastic reconstructive surgery 2002 May;18(3):196-201. May;18(3):196-201. 3 Blast injuries of the eye. Zerihun N. Trop Doct. 3 Blast injuries of the eye. Zerihun N. Trop Doct. 1993 Apr;23(2):76-8.1993 Apr;23(2):76-8.4 Anterior segment optical coherence tomography in 4 Anterior segment optical coherence tomography in eye injuries. Graefes Arch Clin Exp Ophthalmol. 2008 eye injuries. Graefes Arch Clin Exp Ophthalmol. 2008 Sep 3. Sep 3. 5 Phototherapeutic keratectomy of diffuse corneal 5 Phototherapeutic keratectomy of diffuse corneal foreign bodies caused by gunpowder explosion. Yan foreign bodies caused by gunpowder explosion. Yan Ke Xue Bao. 2005 Jun;21(2):70- 73Ke Xue Bao. 2005 Jun;21(2):70- 73

ACKNOWLEDGEMENTACKNOWLEDGEMENT

I would like to thank Dr Kindy for my I would like to thank Dr Kindy for my participation in the care of this patientparticipation in the care of this patient