High-pressure water jets are commonly used for cleaning the windows of buildings and automobiles, as well as during heavy demolition work (ie, the dismantling of building structures).1,2 Ocular trauma caused by the direct exposure to high-pressure water jets often exhibits the appearance of blunt ocular trauma. There are numerous reports on corneal epithelial damage, corneal laceration, corneal endothelial injury, hyphema, iridodialysis, traumatic cataract, lens dislocation, vitreous hemorrhage, traumatic retinal detachment, etc.;3–6 however, to the best of our knowledge, this is the first report of a ruptured eyeball due to close-range and direct exposure to a high-pressure water jet. The purpose of the present study was to report a case of ocular rupture and retinal detachment caused by direct exposure to high-pressure water jets that was successfully treated by vitreous surgery and full-thickness keratoplasty for subsequent bullous keratopathy.
This study involved a 49-year-old male whose right eye was severely injured due to close-range direct expose to high-pressure water jets while engaged in demolition work. Although the patient became aware of a loss of visual acuity (VA) in his right eye immediately after the injury, he did not immediately seek treatment. When he presented at a medical clinic 10 days later, examination revealed hyphema and vitreous hemorrhage in his right eye (Figure 1). Moreover, the fundus in that eye could not be observed, the corrected VA was light perception, and the intraocular pressure (IOP) was 21 mm Hg. Ultrasound echography revealed the vitreous hemorrhage; however, no obvious retinal detachment was observed (Figure 2). At 13 days post-injury, the patient underwent vitreous surgery for treatment. Briefly, after washing of the anterior chamber, subluxation of the lens, and inferior-temporal iridodialysis greater than 120° were confirmed, so ultrasonic phacoemulsification aspiration and underlying iris root suturing were performed. Next, the vitreous opacity was excised, and the fundus finding was confirmed. A large retinal break and retinal detachment were then observed on the inferior nasal quadrant (Figure 3). Since the nasal edge of the retinal break seemed to incarcerate into the choroid, we confirmed the sclera on the inferior nasal side. We observed that the Tenon's capsule at the same site was firmly adhered to the sclera, that the sclera near the lower edge of the muscle insertion was partially ruptured, and that the intraocular fluid had leaked out (Figure 4). After suturing the same site, we continued to perform vitrectomy. Vitreous gel at the periphery was sufficiently excised, and then pneumatic retinal replacement, endophotocoagulation around the retinal break, and silicone oil tamponade were performed. After surgery, the patient's corrected VA improved to 0.06. At 1 year post-injury, full-thickness corneal transplantation, vitreous surgery using an Eckard temporary keratoprosthesis, and silicone oil removal were simultaneously performed due to the progression of bullous keratopathy (Figure 5). After the surgery, visibility of the fundus improved, yet the corrected VA remained at 0.02.
Slit-lamp photograph of the patient's right eye obtained at the initial examination. A large amount of hyphema and inferior-temporal iridodialysis were observed.
Ultrasound echography photograph of the patient's right eye obtained at the initial examination. Vitreous hemorrhage was observed; however, no obvious retinal detachment was detected.
Intraoperative findings of the patient's right eye. A large retinal break and retinal detachment were observed on the inferior nasal quadrant.
Intraoperative findings of the patient's right eye. The sclera near the lower edge of the median muscle insertion was partially raptured.
Slit-lamp photograph of the patient's right eye before (right) and after (left) full-thickness keratopathy. At 1-year post-injury, full-thickness corneal transplantation, vitreous surgery using an Eckard temporary keratoprosthesis, and silicone oil removal were simultaneously performed due to the progression of bullous keratopathy. Post-surgery corneal transparency was improved.
High-pressure water jets are often used for cleaning various locations, such as structural exteriors and the windows of automobiles and buildings.1,2 Having the ability to propel an overwhelming discharge volume of water over a vast distance, they are also used for demolition work in order to protect the workers from the risk of accidents, such as the collapse of a building. High-pressure water dischargers come in a wide range of water pressure propelled through high-pressure jets. In such devices, the water pressure used for washing cars, etc., is approximately 30 liters per minute (ie, 40-times the pressure of household tap water). However, the water pressure of professional equipment used for structural demolition work, etc., is 10-times greater (ie, up to 300 liters per minute).2 Although the exact details of the high-pressure water jet equipment in the present case are unknown, the patient's eyeball was accidentally subjected to close-range and direct exposure to a high-pressure water jet used for demolition work.
It should be noted that there have been several previous reports regarding eye trauma caused by high-pressure water jets. In general, the findings in those studies showed that exposure to such jets resulted in blunt eye trauma; ie, corneal epithelial injury, corneal laceration, corneal endothelial damage, hyphema, iridodialysis, traumatic cataract, lens dislocation, vitreous hemorrhage, and retinal edema, etc.3–6 However, and to the best of our knowledge, this present study is the first report of a ruptured eyeball due to direct exposure to high-pressure water jets.
It should be noted that eye trauma caused by high-pressure jets depends on the exact situation at the time of injury. If the pressure is concentrated on one place, it is conceivable that the eyeball can excessively deform, thus leading to its rupture.1,2 Moreover, it is reported that injuries often occur under the eyeball due to the Bell phenomenon. The injury of this present case was most likely such an injury. In our patient, the rupture wound was originally found in the vicinity of the muscle insertion in the thin sclera. However, he did not undergo surgical treatment until 13 days post-injury, so the surrounding tissues, such as the Tenon's capsule, had become adhered to the surroundings of the scleral wound. Thus, low IOP was not observed. For this reason, it was difficult to know whether or not the eyeball was ruptured at the time of the patient's initial visit. However, in the findings observed during vitreous surgery, the nasal side of the retinal break was found to have been tucked into the ruptured wound, and it was thought that the retinal break was formed by this traction. In fact, when the adhesion around the lower edge of the medial rectus insertion was dissociated, intraocular fluid leaked from the ruptured wound of the sclera. Thus, it was conceivable that the ocular rupture occurred at the time of the injury. The initial vitreous surgery resulted in improved visibility of the fundus, to some extent, and improved VA. However, progression of bullous keratopathy was later observed. Although the corneal endothelial cell density following the initial surgery is unknown, it seems that considerably severe corneal endothelial damage had already occurred at the time of injury.
Duma et al. investigated the damage to pig eyes caused by high-pressure water jets used for fountains, and their findings indicated that hyphema occurred at a rate of between 4% and 27.8%, lens dislocation at a rate of between 0% and 3.0%, and retinal injury at a rate of between 0.1% and 3.3%.7 However, in that study, not one case of eyeball rupture was observed. It should be noted that the high-pressure water jets used for professional demolition work are under considerably higher pressure than those of an ordinary drinking fountain and can thus cause much greater damage to the eyeball.
In the case in this present study, only the patient's right eye was injured. However, high-pressure water jets usually have a large width, so there are many reports of bilateral injuries.
In conclusion, the findings of this study show that severe ocular trauma can occur in subjects engaged in demolition work using high-pressure water jets, so strict precautions, such as goggle eye protection, should be taken.
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