Intraconal grease-gun injury: a therapeutic dilemma

Grease-gun injury of the orbit: two cases report and literature review

BACKGROUND

The grease-guns injury is an uncommon injury to the orbit. We present the twelfth and thirteenth cases of grease-gun injury to the orbit to be reported in the English language literature since 1964. Here we discus and review the presentation, investigation, and treatment of this unusual trauma.

CASE PRESENTATION

Case 1 was a 29-year-old man who presented 1 day after a grease-gun injury of the left orbit with severe pain, marked periorbital swelling, and proptosis. Computed tomography (CT) revealed penetration of grease into his left orbit. Following surgical removal, proptosis decreased. The limitation of extraocular movement and loss of visual acuity to finger count was discovered after the initial surgery. Motility gradually returned. Visual acuity recovered after phacoemulsification, capsular tension ring and intraocular lens implantation for traumatic cataract and subluxation. Case 2 was a 6-year-old boy who was referred 2 months after a grease-gun injury for worsening swelling with sinus, necrosis and slight ptosis of the upper left eyelids. This is a case of orbital chronic inflammation from grease-gun injuries masquerading as orbital cellulitis. The imaging findings of CT and magnetic resonance imaging (MRI) are not typical. Surgical exploration and debridement was inevitable and actually relieved the symptoms.

CONCLUSIONS

Grease-gun injuries can damage the orbit in different degrees. Careful history inquiry and taking is important to establish the diagnosis. Imaging examinations using CT or MRI are helpful to determine depth of trauma and foreign bodies in the orbit at diagnosis. We suggest that surgical exploration and debridement is a key step in the management.

Severe Diesel Injection Injury to the Face, Neck and Orbit: Surgical Management and Critical Care Considerations

The purpose of this report is to discuss high-pressure injection injuries involving the face and orbit and discuss factors affecting prognosis and management as these injuries are rare and uniquely challenging to manage given the complex anatomy and extensive damage that may occur. In this case, we present severe injury to the left orbit, maxillofacial region, and neck of a 29-year-old male who suffered a high-pressure diesel injection injury requiring several surgical debridements, intensive care unit (ICU) level care, and ultimately sub-total exenteration. Initial management involved systemic antibiotics, steroids, and surgical debridement; however, our patient experienced subsequent rapid deterioration resulting in admission for more aggressive subspecialty intervention. Decision-making was guided by serial CT of the face and orbits, and C-reactive protein (CRP) levels in addition to the physical examination. His course was complicated by progressive extensive soft tissue necrosis requiring 8 surgical debridements and optic nerve tenting despite orbital decompression resulting in loss of the OS. Ultimately, definitive treatment required sub-total exenteration and negative wound pressure therapy over the orbit followed by eyelid reconstruction as an outpatient. We conclude that without prompt recognition and meticulous debridement, the resultant injury from high-pressure injection injuries can be devastating and lead to permanent vision loss, loss of an eye, loss of facial function, and airway compromise depending on the location of the injury. A multi-disciplinary team involving oculoplastics, otolaryngology, infectious disease, and ICU should be assembled based on the complexity of this injury and its sequela. CRP can be useful to monitor patient recovery and the need for further surgical intervention. When debridement results in complex wounds over the orbit and face, negative pressure wound therapy should be considered.

Diagnostic uncertainty following orbital injury from a grease gun

Orbital trauma involving high-pressure grease guns is rare and can cause significant morbidity due to retained intraorbital grease. Grease can appear similar to intraorbital air on cross-sectional imaging, and clinicians should have a high index of suspicion for retained intraorbital grease and know how to recognise this. In this case, we will share the clinical and radiological findings as well as management of retained intraorbital grease.

Grease gun injury of the orbit: A rare case report

We report a case of intraconal grease gun injury along with traumatic optic neuropathy in a 20-year-old male. He presented with dimness of vision and proptosis of the left eye (LE) following an accidental injury at work place. The computer tomography of orbit revealed hypodense grease orbit. Cream colored grease was continually exuding from the conjunctival wound. Patient improved rapidly after the surgical removal of the grease by anterior orbitotomy. Grease gun injuries to the orbit have rarely been reported. The present case is the eighth report throughout the world, and the first in India as per our knowledge.

Treatment of an Uncommon High-Pressure Orbital Injection Injury

Injection injuries occur most commonly in the hand and digits; however, there are a limited number of reports in the literature describing injection injuries involving the orbit. High-pressure orbital injection injuries pose a number of unique challenges to the treating physician, and the approach to treating these injuries remains controversial. Often times, the extent of tissue damage is not fully appreciated at presentation, which may lead to missed diagnoses or inadequate initial treatment. In this study, the authors describe a rare incidence of high-pressure orbital injection injury. A 19-year-old male presented to the emergency department after injection of his left orbit with oil-based paint. Worsening clinical symptoms and increasing intraocular pressures within the first 24 hours necessitated take back to the operating room for orbital decompression and debridement. After an initial improvement in symptoms, the patient's clinical status deteriorated again, requiring further orbital decompression and additional periorbital debridement. Two weeks after initial presentation, soft tissue reconstruction of the surgical wounds was performed with full thickness skin grafts. The patient's globe and vision were both preserved. Orbital injection injuries, though rare, are potential globe threatening injuries. Physicians should have a low threshold for intervention and patient's must be observed closely over the first 72 hours after injury. Early diagnosis, prompt debridement, and a multidisciplinary approach are keys to improving patient outcomes.

A rare case of orbital granulomatous inflammation from explosive hydraulic oil masquerading as orbital cellulitis

The differential diagnosis for acute orbital inflammation is broad. We report a case of granulomatous orbital inflammation due to high-pressure oil injury to the orbit presenting as an atypical orbital cellulitis. Here we review the presentation and treatment of orbital inflammation from oil.

Intraocular metallic foreign body: role of computed tomography

Orbital foreign bodies remain a serious diagnostic problem, despite development of diagnostic imaging techniques. Non-metallic orbital foreign body will not be detected in routine x-ray. Here we are presenting a case of 32-year-old male presented with acute pain in left eye immediately after he had been pounding a metal object with a metal chisel. Following this event patient develop blurring of vision in left eye with tearing. Patient's vision in left eye was found to be hand motion with conjunctiva mildly injected, left corneal central 1 mm Seidel-negative full-thickness laceration and dense traumatic cataract was seen on ocular examination. Dilated fundus examination of left eye was not possible due to traumatic cataract. Vitreous hemorrhage, vitreous detachment and a echogenic foreign body present in posterior segment in B-Scan sonography. Well-defied hyperdense foreign body producing streak artifacts with vitreous hemorrhage was seen in the posterior chamber of left eyeball in CT orbit. The patient was diagnosed with a corneal laceration, traumatic cataract, vitreous hemorrhage and a metallic intraocular foreign body. He was brought to the operating room urgently for corneal laceration repair, pars plana vitrectomy, lensectomy, and removal of the metallic intraocular foreign body done.

Diesel fuel injury to the orbit

A 48-year-old man was seen in the Wills Eye Institute emergency room for pain and decreased vision after having a diesel engine fuel cylinder explosion in his face. Clinical examination showed proptosis, decreased extraocular motility, and increased intraocular pressure; CT scan imaging revealed hypodense areas within the orbit. His orbital signs rapidly worsened despite aggressive antibiotics, steroids, and surgical intervention. Two orbitotomies revealed diesel fuel infiltration of the intraconal and extraconal spaces that proved impossible to evacuate completely. The patient ended up losing vision from an intense chemical cellulitis with subsequent orbital compartment syndrome and optic neuropathy. This case highlights the severity of orbital chemical injuries and their variable prognoses despite aggressive management.

Subconjunctival latex paint from occupational injury

BACKGROUND

Accidental eye trauma with spray guns are rare, but potentially very serious, injuries. Although it is agreed that these injuries require immediate and vigorous therapy, the specifics of such therapy are poorly defined. With latex paint sprayer injuries to hands and extremities, resulting chemical-induced inflammation, high-pressure necrosis, ischemic necrosis, and gangrene require surgical debridement and possibly, amputation. With eye injuries, treatment is directed at preservation of vision, as there is a potential risk of visual loss.

OBJECTIVE

There is currently no consensus on optimal treatment of ocular spray paint injuries. Here we propose a management approach to ocular spray paint injuries with a successful outcome in the case reported.

CASE REPORT

We report the first case, to our knowledge, of an industrial airless spray gun injury that resulted in subconjunctival deposition of latex paint in a soft contact lens wearer. Vision was preserved with medical management consisting of irrigation and topical corticosteroids, antibiotics and cycloplegics.

CONCLUSION

Although latex paint spray gun injuries to the eye are not encountered frequently in practice, this case shows that conservative medical management with no surgical intervention is effective for ocular injuries with preserved vision.

Traumatic optic neuropathy accompanying orbital grease gun injury

We report a case of traumatic optic neuropathy accompanying a grease gun injury to the orbit. A 48-year-old man with a grease gun injury visited our clinic with decreased visual acuity, proptosis and limited extraocular movement (EOM). Orbital CT revealed a crescent mass of fat in the medial intraconal space. The grease was exuded from a lacerated conjunctival wound. The visual evoked potential (VEP) test demonstrated a decreased response in the left eye. Proptosis and EOM were improved after surgical removal of the grease. Systemic high-dose corticosteroid therapy was administered for suspected traumatic optic neuropathy, after which VEP nearly recovered, while visual acuity was slightly improved. A second surgery for traumatic cataract did not further improve visual acuity.

Delayed presentation of grease-gun injury to the orbit

A 44-year-old man was examined for marked edema and ptosis of the right upper eyelid after grease from high-pressure hydraulic machinery penetrated his right orbit 20 days earlier. The diagnosis of residual grease in the injured orbit was confirmed by CT and MRI, and the clinical presentation. During orbital exploration, the grease was removed completely. Among the wide variety of orbital foreign bodies, grease is rarely reported. We present the sixth case of grease-gun injury to the orbit to be reported in the English language literature since 1964.