Orbital compressed air and petroleum injury mimicking necrotizing fasciitis.

BACKGROUND: Orbital injury secondary to petroleum-based products is rare. We report the first case, to our knowledge, of a combined compressed air and chemical orbital injury, which mimicked necrotizing fasciitis. CASE REPORT: A 58-year-old man was repairing his motorcycle engine when a piston inadvertently fired, discharging compressed air and petroleum-based carburetor cleaner into his left eye. He developed surgical emphysema, skin necrosis, and a chemical cellulitis, causing an orbital compartment syndrome. He was treated initially with antibiotics and subsequently with intravenous steroid and orbital decompression surgery. There was almost complete recovery by 4 weeks postsurgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Petroleum-based products can cause severe skin irritation and necrosis. Compressed air injury can cause surgical emphysema. When these two mechanisms of injury are combined, the resulting orbitopathy and skin necrosis can mimic necrotizing fasciitis and cause diagnostic confusion. A favorable outcome is achievable with aggressive timely management.

Suicide-related perforating injury of globe with nail gun.

A case is reported of nail gun injury due to suicide attempt involving both orbits, frontal lobe and abdomen, which resulted in an unusual posterior perforation of the left globe. Injury was inflicted with a total of eight nails. Three nails entered the left orbit, one of which perforated the posterior aspect of the left globe. One nail entered the right orbit involving the optic nerve and crossed the midline to finish in the left sphenoid sinus. Three nails entered the frontal lobe near the midline and the final nail pierced the left lobe of the liver. The left eye underwent primary repair, lensectomy and vitrectomy with silicone oil and achieved a visual acuity of 6/60, 3 months post removal of oil with sutured posterior chamber intraocular lens. The right eye suffered traumatic optic neuropathy and currently has a visual acuity of 6/36 due to senile cataract formation. No other serious sequelae resulted from the other injuries and the patient has recovered from his episode of depression.

Artistic assault: an unusual penetrating head injury reported as a trivial facial trauma.

The authors report a case of penetrating head injury that presented with a deceptively mild complaint. To our knowledge, it is the first report of a paint brush penetrating the brain. The patient reported being punched in the left eye and presented with a minor headache, swelling around the left orbit, a small cut on the cheek and slightly reduced left eye abduction. After radiological evaluation, a penetrating head injury was diagnosed. Under general anesthesia, through a lateral eyelid incision a 10.5 cm long paint brush, which had penetrated from the left orbit to the right thalamus, was removed. No post-operative infection was seen at six months follow-up. This brief report serves to highlight that penetrating brain injury can occur without neurological deficit and that a minimally invasive surgical approach was successful in avoiding any complications.

Death associated with an indwelling orbital catheter.

We report a case of a 38-year-old woman who underwent revision of an orbital implant. A flexible indwelling orbital catheter was placed for postoperative anesthesia. Marcaine, administered to the patient through the 5.25-inch catheter while the patient was at home, led to respiratory arrest. After unsuccessful resuscitation, the patient died. At autopsy, it was noted that the catheter passed through the superior orbital fissure, with evidence of injection of marcaine in the subarachnoid space. This patient had signs and symptoms of Stickler syndrome. This leads us to believe that deficiencies in collagen II led to a weakness of the connective tissue surrounding the superior orbital fissure, leading to facilitated passage of the catheter into the subarachnoid space. This may be the first report of this type of outcome when using indwelling catheters for ophthalmic surgery. We recommend that placement of orbital indwelling catheters be performed in a controlled hospital setting.

Ocular complications of needle perforations during retrobulbar and peribulbar injections.

As a whole, the complication rate of retrobulbar and peribulbar injections is low, especially if done correctly (see appendix I). Side effects, however, can be extremely serious, and alternative methods such as topical or sub-Tenon's anesthesia should be considered (see appendix II), particularly when evaluating monocular patients with high-risk characteristics.

Combined cataract extraction and submacular blood clot evacuation for globe perforation caused by retrobulbar injection.

A 45-year-old woman, originally scheduled for cataract surgery in the left eye, was referred for management of a globe perforation noticed after the retrobulbar injection of an anesthetic solution. There was a moderate degree of vitreous hemorrhage, and initial visual acuity was hand movement. A submacular blood clot of about 4-disc diameter was detected when the vitreous hemorrhage gradually cleared. One week after the incident, combined phacoemulsification, intraocular lens implantation, pars plana vitrectomy, and submacular clot removal using tissue plasminogen activator (tPA) as an adjunct were performed. Recovery was uneventful. At the last follow-up 6 months after surgery, best corrected visual acuity was 20/30.

Delayed-onset expulsive choroidal hemorrhage following traumatic globe rupture.

The authors describe a 59-year-old woman who had a traumatic wound rupture 6 months following penetrating keratoplasty. While she was in the pre-operative holding area awaiting surgical repair, hemorrhagic choroidal detachments developed. Digital pressure was initiated on diagnosis of imminent expulsion of intraocular contents and maintained until repair of the wound rupture could be performed. Four months postoperatively, the patient's vision was 20/80 and her central pachymetry was 585 microns. This case demonstrates that a delayed-onset expulsive choroidal hemorrhage may be successfully managed with simple and rapid intervention based on knowledge of the disease process.

Vitreoretinal surgery after inadvertent globe penetration during local ocular anesthesia.

OBJECTIVE: This study aimed to review visual morbidity resulting from inadvertent globe penetration during administration of local anesthetic and to identify the most appropriate management. DESIGN: The records of 20 consecutive patients referred to a specialist vitreoretinal unit over a 2-year period were reviewed. PARTICIPANTS: Twenty eyes of 20 consecutive patients were included. INTERVENTION: Observations included type of local anesthetic administered (e.g., retrobulbar or peribulbar), level of training of person administering the block, type of needle used for the block, and findings at presentation to the vitreoretinal unit. The authors also observed results of B-scan ultrasound evaluation of the retina, interval between the recognition of the complication and referral, as well as nature and timing of subsequent surgical intervention. MAIN OUTCOME MEASURES: Final visual acuity and retinal status (attached versus detached) were measured. RESULTS: The most common presentation was vitreous hemorrhage observed from the first postoperative day. Ten eyes were found to have an associated retinal detachment on initial assessment in the vitreoretinal unit. These eyes generally had a poor visual outcome despite vitrectomy with long-acting gas or silicone oil tamponade. Seven (70%) of the remaining eyes with attached retina at the time of presentation achieved good visual recovery after vitrectomy. CONCLUSIONS: The authors recommend prompt referral for consideration of early vitrectomy in eyes with dense vitreous hemorrhage after inadvertent globe penetration. This management may improve the overall visual prognosis by preventing subsequent retinal detachment.