The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.04.030
Clinical Communications: Adults ORBITAL COMPRESSED AIR AND PETROLEUM INJURY MIMICKING NECROTIZING FASCIITIS Faye E. Mellington, FRCOPHTH,* Annette S. Bacon, FRCOPHTH,† Mohammed A. J. Abu-Bakra, FRCOPHTH,† Pablo Martinez-Devesa, FRCS(ED), FRCS(ORL-HNS),‡ and Jonathan H. Norris, FRCOPHTH* *Oxford Eye Hospital, Headington, Oxford, United Kingdom, †Royal Berkshire NHS Foundation Trust, Reading, United Kingdom, and ‡Ear, Nose and Throat Department, John Radcliffe Hospital, Headington, Oxford, United Kingdom Reprint Address: Faye E. Mellington, FRCOPHTH, Oxford Eye Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
, Abstract—Background: Orbital injury secondary to petroleum-based products is rare. We report the first case, to our knowledge, of a combined compressed air and chemical orbital injury, which mimicked necrotizing fasciitis. Case Report: A 58-year-old man was repairing his motorcycle engine when a piston inadvertently fired, discharging compressed air and petroleum-based carburetor cleaner into his left eye. He developed surgical emphysema, skin necrosis, and a chemical cellulitis, causing an orbital compartment syndrome. He was treated initially with antibiotics and subsequently with intravenous steroid and orbital decompression surgery. There was almost complete recovery by 4 weeks postsurgery. Why should an emergency physician be aware of this?: Petroleum-based products can cause severe skin irritation and necrosis. Compressed air injury can cause surgical emphysema. When these two mechanisms of injury are combined, the resulting orbitopathy and skin necrosis can mimic necrotizing fasciitis and cause diagnostic confusion. A favorable outcome is achievable with aggressive timely management. Ó 2014 Elsevier Inc.
orbital injury mimicking necrotising fasciitis. It is the first case, to our knowledge, documenting this combined etiology. CASE REPORT A 58-year-old man was repairing his motorcycle engine when a piston fired, shooting compressed air and petroleum-based carburetor cleaner (Forte Lubricants Ltd, Coventry, UK) into his left eye. After immediate self-irrigation with water from the garden hose, he presented 5 h later to his local Emergency Department, unable to open his left eye. He had no past ocular, medical, or drug history and no known allergies. On examination, he was apyrexial, nontachycardic (heart rate 80 beats/min, blood pressure 146/82 mm Hg), and had marked left periorbital edema and erythema, preventing ocular examination (Figure 1A). Left conjunctival pH was 7. Conjunctival swabs were taken (which later showed no growth). An internal medicine physician reviewed the patient and, in the absence of any symptoms or signs of respiratory distress (oxygen saturation of 97% on air, respiratory rate 16 breaths/min, and clear lungs on auscultation), excluded petrol inhalation injury. Computed tomography (CT) of the orbits revealed approximately 6 mm of left proptosis with surgical emphysema, indicating possible orbital cellulitis (Figure 1B).
, Keywords—compressed; air; petroleum; injury; orbit; chemical; cellulitis; necrotizing; fasciitis
INTRODUCTION There are few reports in the literature of orbital injury secondary to petroleum-based products. We report our recent experience of a combined compressed air and chemical
RECEIVED: 20 July 2013; FINAL SUBMISSION RECEIVED: 8 February 2014; ACCEPTED: 28 April 2014 1
2
F. E. Mellington et al.
Figure 1. (A) Photograph showing marked left periorbital edema (arrow) on presentation. (B) Axial computed tomography (CT) scan (soft tissue window) showing thickened periorbital tissues, left proptosis (dotted arrow), and hypodense subcutaneous and intraorbital spaces consistent with surgical emphysema (arrow). (C) Photograph taken on day 2, to show dusky ulcerated patch of skin on left upper lid measuring 1 cm by 1 cm (arrow). (D) Axial CT scan (bony window) showing increased left proptosis of approximately 9 mm (dotted arrow) and reduced surgical emphysema (arrow). (E) Sagittal CT scan (bony window) showing intraorbital inflammation extending to orbital apex (arrow). (F) Perioperative photograph to show extent of periorbital edema and conjunctival inflammation (arrow). Note lateral cantholysis (dotted arrow).
Due to previous self-irrigation, the risk of a contaminated conjunctival wound, and the surgical emphysema, a diagnosis of suspected necrotizing fasciitis was made. Intravenous meropenem, clindamycin, and flucloxacillin were started. A few hours later, he developed a small dusky ulcerated patch of skin on his left upper lid (Figure 1C). By day 5, the patient remained systemically well, but the skin lesion had enlarged and he could hardly open his left eye. Left unaided visual acuity (VA) was measured as hand movements only. He was transferred to our institution (a UK tertiary referral center for Ophthalmology and Plastic Surgery) for ongoing observation and consideration of surgical debridement. Repeat CT of the orbits showed increased proptosis of almost 10 mm, intraorbital inflammation extending to the orbital apex, but reduced surgical emphysema. Notably, there was no fluid collection or bony fracture (Figure 1D, E). In view of the time course of events, systemic stability, and lack of significant progression and pain, necrotizing fasciitis was excluded. A diagnosis of acute orbital inflammation secondary to chemical injury and compressed air was made. A 3-day course of intravenous methylprednisolone 1 g was commenced (in addition to: omeprazole 20 mg once a day [o.d.], calcium carbonate [AdCal, ProStrakan, Galashiels, UK] 1.5 g orally o.d., and ascorbic acid 1 g 4 times a day [q.i.d.], topical g. dexamethasone 0.1% 6 times a day to the left eye, and chloramphenicol 0.5 % preservative-free q.i.d. to the left eye). In addition, due to our concerns regarding
his continued inability to open the eye, marked proptosis, and in particular, the viability of his left optic nerve, which was on constant stretch; an examination under anesthesia, left endonasal medial orbital wall decompression, and lateral canthotomy and cantholysis were performed that day (day 5 postinjury; Figure 1F). Immediately postoperatively, unaided left VA remained hand movements only. On day 1 postoperation, unaided Snellen VAwas 20/20 and 20/80 in the right and left eye, respectively. Left intraocular pressure was 18 mm Hg. By day 3 postoperatively, left VA remained 20/80 (unaided) and the left palpebral aperture was 4 mm, with marked restriction of left up gaze and abduction. A corneal abrasion and small area of stromal corneal haze was seen (Figure 2A). A tapering course of oral prednisolone 50 mg daily was started and the left lateral canthus was reconstructed. By day 8 postoperatively, the left VA had improved to 20/30–2 (unaided). The patient could fully open the eye and a small-area corneal stromal haze remained (Figure 2B). At 4 weeks postsurgery, the left VA was 20/20 unaided. Optic nerve function was normal with full range of eye movement. In addition, the corneal opacity had significantly improved (Figure 2C, D). DISCUSSION Orbital emphysema after injury with compressed air is extremely rare (1–5). High-pressure airflow can breech
Orbital Compressed Air and Petroleum Injury Mimicking Necrotizing Fasciitis
3
Figure 2. (A) Three days postorbital decompression. Photographs to show restriction of left adduction and elevation. (B) Eight days postop. Photograph to show left inferior corneal opacity (arrow) and necrotic skin on left upper lid (dashed arrow). Four weeks post orbital decompression: (C) A photograph to show resolution of both necrotic patch of skin left upper lid (dashed arrow) and corneal opacity (arrow). (D) Photographs to show improved range of left eye movement, particularly elevation.
the conjunctiva and orbital septum, allowing air (and subsequently chemicals) to track into the subconjunctival, subcutaneous, and retro bulbar spaces (5). The specialist engine cleaner (Forte Lubricants Ltd) used by this patient consisted of several petroleum-based products, specifically benzene, phenol, and naphtha, which further compounded the orbital injury. Each of these products can penetrate the skin, and naphtha, in particular, is highly corrosive (causing severe burns) and toxic, which would account for the skin necrosis seen (Forte Material Safety Data Sheet for product: Specialist Injector Cleaner 42217; Forte Lubricants Ltd) (6,7). It is our belief that the combination of high-pressure air and petroleum-based chemicals produced such a severe orbital injury, with one potentiating the penetration of the other. The result in this case was an acute orbital compartment syndrome secondary to surgical emphysema and severe orbital edema from an inflammatory cascade. These orbital signs in association with skin necrosis highlight the difficulty for the clinician in differentiating between necrotizing fasciitis and acute (noninfective) orbital chemical/compression injury with entirely distinct management strategies for each. Key presenting features of periocular necrotizing fasciitis include pale-red tense swollen skin, pyrexia, severe pain, and rapid deterioration over 24 to 48 h (8). In contrast, our patient remained afebrile throughout, never had severe pain, and did not rapidly deterio-
rate. As such, the diagnosis of necrotizing fasciitis was brought into question, and although intravenous antibiotics were started and the patient was kept under close observation for signs of rapid deterioration, he did not undergo early surgical debridement. Notably, LRINEC (laboratory risk indicator for diagnosis of necrotizing fasciitis), which involves scoring blood investigations such as total white blood cell count, C-reactive protein, hemoglobin, serum sodium, serum creatinine, and blood glucose, has been shown not to be a sensitive indicator for the early detection of periocular necrotizing fasciitis (8). Important presenting features of periocular, ocular, and orbital chemical injuries include first/second/third degree burns of the skin, conjunctival chemosis, and hyperemia (mild to moderate cases), or blanching of the conjunctival and episcleral vessels (due to ischemia in severe cases). Corneal epithelial defects (which stain with topical fluorescein), edema, and opacification, as well as anterior chamber inflammation and raised intraocular pressure, may also occur. Orbital injuries with compressed air would be expected to cause surgical emphysema of the periorbita, conjunctival chemosis and hyperemia, and corneal abrasions, as seen in our case. Chemical injuries have the potential to cause profound ocular and orbital injury. Immediate irrigation is probably the most important determinant of outcome. We recommend testing the conjunctival pH, then instilling topical
4
anesthetic (e.g., proxymetacaine) and neutralizing the pH by irrigation with water or normal saline prior to a full history and examination. Tetanus status should be checked and updated where needed. Examination should include VA, assessment of the ocular surface (including instilling topical fluorescein), and, where possible, intraocular pressure, extraocular movements, color vision, and relative afferent pupillary defect. An urgent ophthalmology consultation and a CT scan of the orbits should be requested. The presence of tight eyelids and proptosis with resistance to retropulsion, along with vision loss, an afferent pupillary defect and reduced color vision, should raise concerns about possible orbital compartment syndrome. In this event, an emergency lateral canthotomy and cantholysis should be performed; ideally, after prompt discussion with an ophthalmologist, providing this does not incur undue delay. If there is any suspicion from the history or examination of mouth or airways involvement, the airway should be assessed and stabilized as needed. The Emergency Department physician may then start topical antibiotics such as preservative-free chloramphenicol 0.5% q.i.d., topical lubricants, for example, preservative-free carmellose (Celluvisc) q.i.d. and liquid paraffin nocte, as well as appropriate systemic analgesia. Final visual outcome in these cases is variable: Rabinowitz and Goldstein report visual loss secondary to optic neuropathy, whereas our patient and that described by Dallas had favorable final visual acuities (20/20 and 20/40, respectively) (1,2). Furthermore, in contrast to both Rabinowitz and Goldstein and Dallas, we did not detect any drainable fluid or collection during surgery (1,2).
F. E. Mellington et al.
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? This case is the first, to our knowledge, to report combined pathology of compressed air and chemical orbital injury. The resulting skin necrosis and surgical emphysema can mimic necrotizing fasciitis, however, in this case the clinical signs were not related to a superimposed infection. As such, in similar cases where the mechanism of injury includes compressed air and petroleum, we would advocate early suspicion of chemical cellulitis, urgent ophthalmology consultation, and prompt aggressive management to prevent or treat the orbital compartment syndrome using a combination of high-dose steroid and surgery (including lateral canthotomy and cantholysis or orbital decompression) where necessary. REFERENCES 1. Dallas NL. Chronic granuloma of the orbit caused by grease-gun injury. Br J Ophthalmol 1964;48:158–9. 2. Rabinowitz MP, Goldstein SM. Diesel fuel injury to the orbit. Ophthal Plast Reconstr Surg 2013;29:e31–3. 3. Li T, Mafee MF, Edward DP. Bilateral orbital emphysema from compressed air injury. Am J Ophthalmol 1999;128:103–4. 4. Caesar R, Gajus M, Davies R. Compressed air injury of the orbit in the absence of external trauma. Eye 2003;17:661–2. 5. Mathew S, Vasu U, Francis F, Nazareth C. Transconjunctival orbital emphysema caused by compressed air injury: a case report. Indian J Ophthalmol 2008;56:247–9. 6. Blank IH, McAuliffe DJ. Penetration of benzene through human skin. J Invest Dermatol 1985;85:522–6. 7. Ingram AJ, King DJ, Grasso P, Sharratt M. The early changes in mouse skin following topical application of a range of middle distillate oil products. J Appl Toxicol 1993;13:247–57. 8. Tambe K, Tripathi A, Burns J, Sampath R. Multidisciplinary management of periocular necrotising fasciitis: a series of 11 patients. Eye 2012;26:463–7.
http://dx.doi.org/10.1016/j.jemermed.2014.04.030
Clinical Communications: Adults ORBITAL COMPRESSED AIR AND PETROLEUM INJURY MIMICKING NECROTIZING FASCIITIS Faye E. Mellington, FRCOPHTH,* Annette S. Bacon, FRCOPHTH,† Mohammed A. J. Abu-Bakra, FRCOPHTH,† Pablo Martinez-Devesa, FRCS(ED), FRCS(ORL-HNS),‡ and Jonathan H. Norris, FRCOPHTH* *Oxford Eye Hospital, Headington, Oxford, United Kingdom, †Royal Berkshire NHS Foundation Trust, Reading, United Kingdom, and ‡Ear, Nose and Throat Department, John Radcliffe Hospital, Headington, Oxford, United Kingdom Reprint Address: Faye E. Mellington, FRCOPHTH, Oxford Eye Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
, Abstract—Background: Orbital injury secondary to petroleum-based products is rare. We report the first case, to our knowledge, of a combined compressed air and chemical orbital injury, which mimicked necrotizing fasciitis. Case Report: A 58-year-old man was repairing his motorcycle engine when a piston inadvertently fired, discharging compressed air and petroleum-based carburetor cleaner into his left eye. He developed surgical emphysema, skin necrosis, and a chemical cellulitis, causing an orbital compartment syndrome. He was treated initially with antibiotics and subsequently with intravenous steroid and orbital decompression surgery. There was almost complete recovery by 4 weeks postsurgery. Why should an emergency physician be aware of this?: Petroleum-based products can cause severe skin irritation and necrosis. Compressed air injury can cause surgical emphysema. When these two mechanisms of injury are combined, the resulting orbitopathy and skin necrosis can mimic necrotizing fasciitis and cause diagnostic confusion. A favorable outcome is achievable with aggressive timely management. Ó 2014 Elsevier Inc.
orbital injury mimicking necrotising fasciitis. It is the first case, to our knowledge, documenting this combined etiology. CASE REPORT A 58-year-old man was repairing his motorcycle engine when a piston fired, shooting compressed air and petroleum-based carburetor cleaner (Forte Lubricants Ltd, Coventry, UK) into his left eye. After immediate self-irrigation with water from the garden hose, he presented 5 h later to his local Emergency Department, unable to open his left eye. He had no past ocular, medical, or drug history and no known allergies. On examination, he was apyrexial, nontachycardic (heart rate 80 beats/min, blood pressure 146/82 mm Hg), and had marked left periorbital edema and erythema, preventing ocular examination (Figure 1A). Left conjunctival pH was 7. Conjunctival swabs were taken (which later showed no growth). An internal medicine physician reviewed the patient and, in the absence of any symptoms or signs of respiratory distress (oxygen saturation of 97% on air, respiratory rate 16 breaths/min, and clear lungs on auscultation), excluded petrol inhalation injury. Computed tomography (CT) of the orbits revealed approximately 6 mm of left proptosis with surgical emphysema, indicating possible orbital cellulitis (Figure 1B).
, Keywords—compressed; air; petroleum; injury; orbit; chemical; cellulitis; necrotizing; fasciitis
INTRODUCTION There are few reports in the literature of orbital injury secondary to petroleum-based products. We report our recent experience of a combined compressed air and chemical
RECEIVED: 20 July 2013; FINAL SUBMISSION RECEIVED: 8 February 2014; ACCEPTED: 28 April 2014 1
2
F. E. Mellington et al.
Figure 1. (A) Photograph showing marked left periorbital edema (arrow) on presentation. (B) Axial computed tomography (CT) scan (soft tissue window) showing thickened periorbital tissues, left proptosis (dotted arrow), and hypodense subcutaneous and intraorbital spaces consistent with surgical emphysema (arrow). (C) Photograph taken on day 2, to show dusky ulcerated patch of skin on left upper lid measuring 1 cm by 1 cm (arrow). (D) Axial CT scan (bony window) showing increased left proptosis of approximately 9 mm (dotted arrow) and reduced surgical emphysema (arrow). (E) Sagittal CT scan (bony window) showing intraorbital inflammation extending to orbital apex (arrow). (F) Perioperative photograph to show extent of periorbital edema and conjunctival inflammation (arrow). Note lateral cantholysis (dotted arrow).
Due to previous self-irrigation, the risk of a contaminated conjunctival wound, and the surgical emphysema, a diagnosis of suspected necrotizing fasciitis was made. Intravenous meropenem, clindamycin, and flucloxacillin were started. A few hours later, he developed a small dusky ulcerated patch of skin on his left upper lid (Figure 1C). By day 5, the patient remained systemically well, but the skin lesion had enlarged and he could hardly open his left eye. Left unaided visual acuity (VA) was measured as hand movements only. He was transferred to our institution (a UK tertiary referral center for Ophthalmology and Plastic Surgery) for ongoing observation and consideration of surgical debridement. Repeat CT of the orbits showed increased proptosis of almost 10 mm, intraorbital inflammation extending to the orbital apex, but reduced surgical emphysema. Notably, there was no fluid collection or bony fracture (Figure 1D, E). In view of the time course of events, systemic stability, and lack of significant progression and pain, necrotizing fasciitis was excluded. A diagnosis of acute orbital inflammation secondary to chemical injury and compressed air was made. A 3-day course of intravenous methylprednisolone 1 g was commenced (in addition to: omeprazole 20 mg once a day [o.d.], calcium carbonate [AdCal, ProStrakan, Galashiels, UK] 1.5 g orally o.d., and ascorbic acid 1 g 4 times a day [q.i.d.], topical g. dexamethasone 0.1% 6 times a day to the left eye, and chloramphenicol 0.5 % preservative-free q.i.d. to the left eye). In addition, due to our concerns regarding
his continued inability to open the eye, marked proptosis, and in particular, the viability of his left optic nerve, which was on constant stretch; an examination under anesthesia, left endonasal medial orbital wall decompression, and lateral canthotomy and cantholysis were performed that day (day 5 postinjury; Figure 1F). Immediately postoperatively, unaided left VA remained hand movements only. On day 1 postoperation, unaided Snellen VAwas 20/20 and 20/80 in the right and left eye, respectively. Left intraocular pressure was 18 mm Hg. By day 3 postoperatively, left VA remained 20/80 (unaided) and the left palpebral aperture was 4 mm, with marked restriction of left up gaze and abduction. A corneal abrasion and small area of stromal corneal haze was seen (Figure 2A). A tapering course of oral prednisolone 50 mg daily was started and the left lateral canthus was reconstructed. By day 8 postoperatively, the left VA had improved to 20/30–2 (unaided). The patient could fully open the eye and a small-area corneal stromal haze remained (Figure 2B). At 4 weeks postsurgery, the left VA was 20/20 unaided. Optic nerve function was normal with full range of eye movement. In addition, the corneal opacity had significantly improved (Figure 2C, D). DISCUSSION Orbital emphysema after injury with compressed air is extremely rare (1–5). High-pressure airflow can breech
Orbital Compressed Air and Petroleum Injury Mimicking Necrotizing Fasciitis
3
Figure 2. (A) Three days postorbital decompression. Photographs to show restriction of left adduction and elevation. (B) Eight days postop. Photograph to show left inferior corneal opacity (arrow) and necrotic skin on left upper lid (dashed arrow). Four weeks post orbital decompression: (C) A photograph to show resolution of both necrotic patch of skin left upper lid (dashed arrow) and corneal opacity (arrow). (D) Photographs to show improved range of left eye movement, particularly elevation.
the conjunctiva and orbital septum, allowing air (and subsequently chemicals) to track into the subconjunctival, subcutaneous, and retro bulbar spaces (5). The specialist engine cleaner (Forte Lubricants Ltd) used by this patient consisted of several petroleum-based products, specifically benzene, phenol, and naphtha, which further compounded the orbital injury. Each of these products can penetrate the skin, and naphtha, in particular, is highly corrosive (causing severe burns) and toxic, which would account for the skin necrosis seen (Forte Material Safety Data Sheet for product: Specialist Injector Cleaner 42217; Forte Lubricants Ltd) (6,7). It is our belief that the combination of high-pressure air and petroleum-based chemicals produced such a severe orbital injury, with one potentiating the penetration of the other. The result in this case was an acute orbital compartment syndrome secondary to surgical emphysema and severe orbital edema from an inflammatory cascade. These orbital signs in association with skin necrosis highlight the difficulty for the clinician in differentiating between necrotizing fasciitis and acute (noninfective) orbital chemical/compression injury with entirely distinct management strategies for each. Key presenting features of periocular necrotizing fasciitis include pale-red tense swollen skin, pyrexia, severe pain, and rapid deterioration over 24 to 48 h (8). In contrast, our patient remained afebrile throughout, never had severe pain, and did not rapidly deterio-
rate. As such, the diagnosis of necrotizing fasciitis was brought into question, and although intravenous antibiotics were started and the patient was kept under close observation for signs of rapid deterioration, he did not undergo early surgical debridement. Notably, LRINEC (laboratory risk indicator for diagnosis of necrotizing fasciitis), which involves scoring blood investigations such as total white blood cell count, C-reactive protein, hemoglobin, serum sodium, serum creatinine, and blood glucose, has been shown not to be a sensitive indicator for the early detection of periocular necrotizing fasciitis (8). Important presenting features of periocular, ocular, and orbital chemical injuries include first/second/third degree burns of the skin, conjunctival chemosis, and hyperemia (mild to moderate cases), or blanching of the conjunctival and episcleral vessels (due to ischemia in severe cases). Corneal epithelial defects (which stain with topical fluorescein), edema, and opacification, as well as anterior chamber inflammation and raised intraocular pressure, may also occur. Orbital injuries with compressed air would be expected to cause surgical emphysema of the periorbita, conjunctival chemosis and hyperemia, and corneal abrasions, as seen in our case. Chemical injuries have the potential to cause profound ocular and orbital injury. Immediate irrigation is probably the most important determinant of outcome. We recommend testing the conjunctival pH, then instilling topical
4
anesthetic (e.g., proxymetacaine) and neutralizing the pH by irrigation with water or normal saline prior to a full history and examination. Tetanus status should be checked and updated where needed. Examination should include VA, assessment of the ocular surface (including instilling topical fluorescein), and, where possible, intraocular pressure, extraocular movements, color vision, and relative afferent pupillary defect. An urgent ophthalmology consultation and a CT scan of the orbits should be requested. The presence of tight eyelids and proptosis with resistance to retropulsion, along with vision loss, an afferent pupillary defect and reduced color vision, should raise concerns about possible orbital compartment syndrome. In this event, an emergency lateral canthotomy and cantholysis should be performed; ideally, after prompt discussion with an ophthalmologist, providing this does not incur undue delay. If there is any suspicion from the history or examination of mouth or airways involvement, the airway should be assessed and stabilized as needed. The Emergency Department physician may then start topical antibiotics such as preservative-free chloramphenicol 0.5% q.i.d., topical lubricants, for example, preservative-free carmellose (Celluvisc) q.i.d. and liquid paraffin nocte, as well as appropriate systemic analgesia. Final visual outcome in these cases is variable: Rabinowitz and Goldstein report visual loss secondary to optic neuropathy, whereas our patient and that described by Dallas had favorable final visual acuities (20/20 and 20/40, respectively) (1,2). Furthermore, in contrast to both Rabinowitz and Goldstein and Dallas, we did not detect any drainable fluid or collection during surgery (1,2).
F. E. Mellington et al.
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? This case is the first, to our knowledge, to report combined pathology of compressed air and chemical orbital injury. The resulting skin necrosis and surgical emphysema can mimic necrotizing fasciitis, however, in this case the clinical signs were not related to a superimposed infection. As such, in similar cases where the mechanism of injury includes compressed air and petroleum, we would advocate early suspicion of chemical cellulitis, urgent ophthalmology consultation, and prompt aggressive management to prevent or treat the orbital compartment syndrome using a combination of high-dose steroid and surgery (including lateral canthotomy and cantholysis or orbital decompression) where necessary. REFERENCES 1. Dallas NL. Chronic granuloma of the orbit caused by grease-gun injury. Br J Ophthalmol 1964;48:158–9. 2. Rabinowitz MP, Goldstein SM. Diesel fuel injury to the orbit. Ophthal Plast Reconstr Surg 2013;29:e31–3. 3. Li T, Mafee MF, Edward DP. Bilateral orbital emphysema from compressed air injury. Am J Ophthalmol 1999;128:103–4. 4. Caesar R, Gajus M, Davies R. Compressed air injury of the orbit in the absence of external trauma. Eye 2003;17:661–2. 5. Mathew S, Vasu U, Francis F, Nazareth C. Transconjunctival orbital emphysema caused by compressed air injury: a case report. Indian J Ophthalmol 2008;56:247–9. 6. Blank IH, McAuliffe DJ. Penetration of benzene through human skin. J Invest Dermatol 1985;85:522–6. 7. Ingram AJ, King DJ, Grasso P, Sharratt M. The early changes in mouse skin following topical application of a range of middle distillate oil products. J Appl Toxicol 1993;13:247–57. 8. Tambe K, Tripathi A, Burns J, Sampath R. Multidisciplinary management of periocular necrotising fasciitis: a series of 11 patients. Eye 2012;26:463–7.
