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Penetrating injuries to the orbit despite safety equipment
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British Journal of Oral and Maxillofacial Surgery 47 (2009) 71–72
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Penetrating injuries to the orbit despite safety equipment Ahmed Al Hashmi, Andrew Cheng, Dimitrios Nikolarakos, Alastair Goss ∗ Oral and Maxillofacial Surgery Unit, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia Accepted 5 May 2008 Available online 20 June 2008
Abstract Penetrating injuries to the orbit are uncommon but may have catastrophic consequences ranging from blindness, cerebral damage to death. Apparently similar injuries but with a slight difference in the anatomic pathway may have minimal morbidity. Prevention by the use of full safety equipment is recommended. This case report shows that full safety equipment may not prevent injury. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Orbital injury; Penetrating injury; Safety equipment; DIY
Introduction Penetrating injuries of the orbit are uncommon but may have catastrophic consequences ranging from blindness,1,2 and cerebral damage,3,4 to death.5 Apparently similar injuries (but with a slight difference in the anatomical pathway) may have minimal morbidity.6,7 Prevention by the use of full safety equipment is recommended.8 This case report shows that full safety equipment may not prevent injury.
posterior orbit (Fig. 2). On computed tomography (CT) the inferior rectus muscle was displaced medially and the tip of the blade lay 2 mm below the optic nerve (Fig. 3). The patient was prepared for removal of the foreign body under general anaesthesia. After initial resistance, the strip was mobilised freely with minimal bleeding. Intraoperative eye examination showed no evidence of retrobulbar haemorrhage. The forced duction test was normal. He recovered well and was discharged within 24 hours. There were no residual eye problems and minimal facial scarring.
Case report: Discussion A 43-year-old man who was fit and well and a qualified tradesman was using a diamond grinding machine. He was wearing full safety equipment: ear protectors, strengthened safety goggles, and gloves, and the grinder was new and well-maintained.8 Unfortunately the strengthened diamond cutting edge separated from the wheel and struck his face at high velocity beneath the edge of the safety goggles. On examination the only finding was a curved, diamondcoated metal strip protruding from his right cheek Fig. 1). Plain radiographs showed a 19 cm curved metallic object that had passed through the right maxillary sinus and entered the ∗
Corresponding author. Tel.: +61 8 83035103; fax: +61 8 83034402. E-mail address: [email protected] (A. Goss).
This case report shows that, even with full protective equipment, penetrating injuries from equipment failure may still occur. The CT images showed that the object came within millimetres of causing immediate blindness or penetrating the brain. Despite efforts to prevent penetrating eye injuries, it has been reported that up to half of such injuries occur despite the use of protective eye wear, and 40% occur outside the workplace during DIY activities. Overall, eye injuries comprise 30% of all DIY-related injuries, most being associated with the use of grinders.9 A recent report published by the Australian National Injury Surveillance Unit recognised the risk of objects flicking underneath safety glasses and recommended changes in the standards of eye-protectors in the
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.05.001
72
A.A. Hashmi et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 71–72
Fig. 1. Presentation showing metal cylinder strip in the right side of the face causing right periorbital ecchymosis.
Fig. 3. Computed tomogram showing the metal strip within the orbit inferolaterally and displacing the inferior rectus muscle medially.
ment of individual cases, with careful clinical and imaging assessment of the regional anatomical structures close to the penetrating object being key to the planning of treatment planning (Figs. 1–3).2 Adjunctive measures should include giving steroids and antibiotics to minimise swelling and infection. Once the precise relations of the penetrating object to the relevant anatomy are known, then removal under controlled circumstances can proceed. Although the surgical team was fully prepared to remove the object by an open approach, and to control haemorrhage or repair damage, this was not required. A potentially catastrophic injury ended up as a short stay procedure.
References
Fig. 2. Lateral radiograph showing the cylindrical object penetrating the orbit.
workplace to include full face visors.10 This has been highlighted by our case in which an experienced tradesman was injured, despite the use of all the Australian standards for personal eye protection. We support the introduction of full face visors in an effort to prevent such injuries.8 The injured man also knew enough not to attempt to pull out the protruding metal spike but to get promptly to the major regional trauma centre. Intraorbital foreign bodies can be a challenge to treat. Published classifications are of limited benefit in the treat-
1. Chen E, Stewart MG, Raup G. Penetrating injuries of the face. Otolaryngol Head Neck Surg 1996;115:464–70. 2. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494–500. 3. Alexandrakis G, Davis JL. Intracranial penetrating orbital injury. Ophthalmic Surg Lasers 2000;31:61–3. 4. Bard LA, Jarrett WH. Intracranial complications of penetrating orbital injuries. Arch Ophthalmol 1964;71:332–43. 5. Sarvesvaran ER. Fatal penetrating orbital injuries. Med Sc Law 1991;31:261–3. 6. Bourguignon Filho AM, Puppin AA, Pimentel DP, et al. Unusual penetrating orbit injury. Int J Oral Maxillofac Surg 2006;35:92–3. 7. Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20:232–6. 8. Australian Standards: Recommended practices for eye protection in the industrial environments. Vol. 1336; 1997. 9. Imberger A, Altmann A, Watson W. Unintentional adult eye injuries inVictoria. Monash University Accident Research Centre, report no 137; 1998. 10. Moller JBS. Eye injuries in the workplace occurring while wearing recommended and approved eye protection. In.: Research Centre for Injury Studies, National Injury Surveillance Unit, Flinders University, South Australia.; 1997.
British Journal of Oral and Maxillofacial Surgery 47 (2009) 71–72
Short communication
Penetrating injuries to the orbit despite safety equipment Ahmed Al Hashmi, Andrew Cheng, Dimitrios Nikolarakos, Alastair Goss ∗ Oral and Maxillofacial Surgery Unit, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia Accepted 5 May 2008 Available online 20 June 2008
Abstract Penetrating injuries to the orbit are uncommon but may have catastrophic consequences ranging from blindness, cerebral damage to death. Apparently similar injuries but with a slight difference in the anatomic pathway may have minimal morbidity. Prevention by the use of full safety equipment is recommended. This case report shows that full safety equipment may not prevent injury. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Orbital injury; Penetrating injury; Safety equipment; DIY
Introduction Penetrating injuries of the orbit are uncommon but may have catastrophic consequences ranging from blindness,1,2 and cerebral damage,3,4 to death.5 Apparently similar injuries (but with a slight difference in the anatomical pathway) may have minimal morbidity.6,7 Prevention by the use of full safety equipment is recommended.8 This case report shows that full safety equipment may not prevent injury.
posterior orbit (Fig. 2). On computed tomography (CT) the inferior rectus muscle was displaced medially and the tip of the blade lay 2 mm below the optic nerve (Fig. 3). The patient was prepared for removal of the foreign body under general anaesthesia. After initial resistance, the strip was mobilised freely with minimal bleeding. Intraoperative eye examination showed no evidence of retrobulbar haemorrhage. The forced duction test was normal. He recovered well and was discharged within 24 hours. There were no residual eye problems and minimal facial scarring.
Case report: Discussion A 43-year-old man who was fit and well and a qualified tradesman was using a diamond grinding machine. He was wearing full safety equipment: ear protectors, strengthened safety goggles, and gloves, and the grinder was new and well-maintained.8 Unfortunately the strengthened diamond cutting edge separated from the wheel and struck his face at high velocity beneath the edge of the safety goggles. On examination the only finding was a curved, diamondcoated metal strip protruding from his right cheek Fig. 1). Plain radiographs showed a 19 cm curved metallic object that had passed through the right maxillary sinus and entered the ∗
Corresponding author. Tel.: +61 8 83035103; fax: +61 8 83034402. E-mail address: [email protected] (A. Goss).
This case report shows that, even with full protective equipment, penetrating injuries from equipment failure may still occur. The CT images showed that the object came within millimetres of causing immediate blindness or penetrating the brain. Despite efforts to prevent penetrating eye injuries, it has been reported that up to half of such injuries occur despite the use of protective eye wear, and 40% occur outside the workplace during DIY activities. Overall, eye injuries comprise 30% of all DIY-related injuries, most being associated with the use of grinders.9 A recent report published by the Australian National Injury Surveillance Unit recognised the risk of objects flicking underneath safety glasses and recommended changes in the standards of eye-protectors in the
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.05.001
72
A.A. Hashmi et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 71–72
Fig. 1. Presentation showing metal cylinder strip in the right side of the face causing right periorbital ecchymosis.
Fig. 3. Computed tomogram showing the metal strip within the orbit inferolaterally and displacing the inferior rectus muscle medially.
ment of individual cases, with careful clinical and imaging assessment of the regional anatomical structures close to the penetrating object being key to the planning of treatment planning (Figs. 1–3).2 Adjunctive measures should include giving steroids and antibiotics to minimise swelling and infection. Once the precise relations of the penetrating object to the relevant anatomy are known, then removal under controlled circumstances can proceed. Although the surgical team was fully prepared to remove the object by an open approach, and to control haemorrhage or repair damage, this was not required. A potentially catastrophic injury ended up as a short stay procedure.
References
Fig. 2. Lateral radiograph showing the cylindrical object penetrating the orbit.
workplace to include full face visors.10 This has been highlighted by our case in which an experienced tradesman was injured, despite the use of all the Australian standards for personal eye protection. We support the introduction of full face visors in an effort to prevent such injuries.8 The injured man also knew enough not to attempt to pull out the protruding metal spike but to get promptly to the major regional trauma centre. Intraorbital foreign bodies can be a challenge to treat. Published classifications are of limited benefit in the treat-
1. Chen E, Stewart MG, Raup G. Penetrating injuries of the face. Otolaryngol Head Neck Surg 1996;115:464–70. 2. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494–500. 3. Alexandrakis G, Davis JL. Intracranial penetrating orbital injury. Ophthalmic Surg Lasers 2000;31:61–3. 4. Bard LA, Jarrett WH. Intracranial complications of penetrating orbital injuries. Arch Ophthalmol 1964;71:332–43. 5. Sarvesvaran ER. Fatal penetrating orbital injuries. Med Sc Law 1991;31:261–3. 6. Bourguignon Filho AM, Puppin AA, Pimentel DP, et al. Unusual penetrating orbit injury. Int J Oral Maxillofac Surg 2006;35:92–3. 7. Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20:232–6. 8. Australian Standards: Recommended practices for eye protection in the industrial environments. Vol. 1336; 1997. 9. Imberger A, Altmann A, Watson W. Unintentional adult eye injuries inVictoria. Monash University Accident Research Centre, report no 137; 1998. 10. Moller JBS. Eye injuries in the workplace occurring while wearing recommended and approved eye protection. In.: Research Centre for Injury Studies, National Injury Surveillance Unit, Flinders University, South Australia.; 1997.