Mechanism and Emergency Management of Blast Eye/Orbital Injuries

Sabri T Shuker

Disclosures

Expert Rev Ophthalmol. 2008;3(2):229-246. 

In This Article

Clinical Blast Eye/Orbital Injuries

A 28-year-old patient sustained severe blast facial injury. Fortunately, the eyes were intact and other associated injuries were not serious. Chest radiography revealed nopulmonary blast injury. True lateral and occiptomental view radiographs revealed crushed eggshell injuries to the NOE region, as demonstrated in a true lateral radiograph, which revealed the amount of tissue destruction in which no fracture lines were seen as in civilian trauma cases.

Under general anesthesia via oral intubations the wound debridement was carried out using normal saline to the pulverized bones and shredding soft tissue layer by layer, and detached or not vascularized tissue was removed. Small finger palpation of the deep anatomical nasal cavity through the laceration was used. When it is not feasible to see the naso–pharynx devastation tissue, finger-touch feeling is used to detect lacerated surface and mucosal surface, and restore the mucosa to its proper position – medial and lateral to the finger. Then, two Haworth periosteal elevators (Figures 3 & 4) were inserted along the side of the finger in position to maintain mucosa in position and prevent it from collapsing until the modified portex tracheotomy tube number 8 (Figure 3A) was inserted in position in between the two elevators, then the elevators were removed. This technique was invented by Shuker (1988) for use in severe NOE blast injuries.[36] Hard and soft tissue builds can be performed on the tubes, which act as a parabolic arc scaffold. The canthal ligament is explored using fine wires by guiding a 30-gauge steel wire through a thick portion and looping it through the hole placed in the posterior lacrimal crest on small piece of bone that ligament is attached to and approximate the two ligaments to an acceptable position. In case no bone segment is left attached to the ligament, then pass the silk needle through the medial canthal tendon.[37–40] Care should be used not to pass the silk needle with wire through the portex tube as the wire will be left in position permanently while the tube will be removed.

Nasal–orbital–ethmoidal blast injuries immediate management. (A) Portex trachesotomy tubes showing convex curvature of its arch are heated in a flame, the upper curvature squeezed with straight artery forceps. Used as scaffold and physiological air path. (B) Number (7 & 8) tracheostomy tubes used in the treatment of NOE crushed blast injuries. (C) Severe NOE blast injury, very wide intercanthal region showing pulverized, tethered and shredded region. (D) Demonstrating the extent of NOE tissue damaged radiographically. (E) Portex tracheostomy tubes in position, showing by arrow after which tissue build on them. (F) Skull lateral view radiograph showing total destruction to the nasal orbital and ethmoidal region also showing metallic small foreign bodies (G) Occipitomental skull view demonstrating the portex tube in postion. (H) Lateral photograph showing uneventful recovery in NOE region. (I) Photograph showing excellent result of the NOE region, no collapsed nasal saddle compared with the severity of the injury as well as eye movement. NOE: Nasal–orbital–ethmoidal.

Dark uveal demonstrating ruptured left eye ball. (A) Patient ruptured left eye by shell fragment showing the dark uveal tissue filling the eye cavity and the destruction to intercanthal space. (B) Left eye enucleate, two portex tubes used for intranasal stabilization, intercanathal space reduction tracheostomy tubes wings used instead of lead plates for the region.

Tubes secured on the ala of the nose, and left in position for 1 month, resulted in the patient having cosmetically acceptable NOE region, normal phonation, inspiration and expiration and no diplopia or any other complications, leading to an uneventful recovery (Figure 3H & 3I).

In the author's experience, mini-plates, which are used successfully in severe road traffic maxillofacial injuries and allow fixation of larger fragments, were not practical in the immediate management of severe blast injuries because of small bone fragments, soft tissue mutilation, decreased blood supply and because they are time consuming at a critical stage.[41]

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