Compressed air blast injury with palpebral, orbital, facial, cervical, and mediastinal emphysema through an eyelid laceration: a case report and review of literature

A 30-year-old male sawdust factory worker was using a compressed air jet with a 1/4 inch diameter nozzle on an air compressor hose (W-35, Fuji Compressor MFG. Co., Ltd), which expelled compressed air at approximately 170 psi. While cleaning wood particles from his clothes at the end of his working day (Figure 1a-c), he accidentally hit his right eyelid with the air hose nozzle. He noted immediate swelling of both eyelids, which was accompanied by pain, and was immediately brought to our ophthalmology service at the Tsukuba University Hospital. External examination revealed marked swelling of both the upper and lower right eyelids, along with the right half of the face. The palpebral fissure was narrowed (Figure 2a) and a slight exophthalmos (3 mm) of the right eye was observed (19 mm in the right eye, 16 mm in the left eye via Hertel exophthalmometer measurement, Figure 2b). A skin laceration near the right medial canthus (3 mm in length) was also identified on the eyelid (Figure 2c). Ocular movements in all directions were normal and decimal (Snellen in meters) best-corrected visual acuity (BCVA) was 0.6 (6/10) in the right eye and 1.5 (6/4) in the left eye. Intraocular pressure (IOP) was 15 mmHg in both eyes and slit-lamp biomicroscopy showed subconjunctival emphysema and hemorrhage (Figure 2d). The cornea was clear and had no epithelial defects. The anterior chamber was also clear and had no cells or flare. The crystalline lens was normal. Fundoscopy revealed a clear vitreous cavity a retina without abnormalities, including retinal breaks, detachment, or commotio retinae. The left eye and adnexa were completely normal.

An emergency computed tomography (CT) scan of the orbit, brain, neck, and chest showed subcutaneous eyelid emphysema, intraorbital emphysema, and right eye proptosis (Figure 3a,b). There were no apparent fractures of the orbital wall or floor, but the presence of subcutaneous air in the neck and emphysema in the mediastinum was confirmed (Figure 3c,d). It is thought that high-pressure air entered the eyelid skin and dissected subcutaneous tissues in the face and neck. It then presumably passed through the back surface of the sternum, eventually reaching the mediastinum. An internist was consulted to evaluate the neck and mediastinal emphysemas and help determine the best treatment. Because the patient had stable cardiopulmonary function, the internist recommended careful, close observation and prophylactic antibiotics. The patient was hospitalized for observation and was treated with systemic and topical antibiotics to prevent infection.

The lacerated wound of the eyelid was successfully closed with 7–0 nylon sutures (Figure 2c). Chest radiograpy 4 days after the injury showed no remaining air in the mediastinum. One week after injury, the BCVA returned to 1.0 (6/6) in the right eye, and the patient was discharged from the hospital. Although the exact cause of the decreased visual acuity at initial presentation was not determined, it is possible that the marked palpebral fissure narrowing and subconjunctival emphysema caused an unstable tear film. It may also have been that the intraorbital emphysema resulted in compression of the optic nerve. Two weeks following the injury, a CT scan was repeated and confirmed that all emphysemas had completely resolved. No ocular or systemic complications were identified at this time.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.