Eyeworld

EW RESIDENTS 96 February 2015 by Lena Dixit, MD, and Walter Parker, MD to approximately 50% depth and spared the central cornea. Epithelial defects overlying the particles were also noted, however the entry tracks of stromal penetration could not be visualized for most particles. Bio- microscopy of the left eye showed similar findings except the cornea had more numerous black particles with multiple overlying epithelial defects involving the entire cornea. There was also mild stromal edema with central Descemet's membrane folds. Seidel testing was negative for both corneas. Gonioscopy and dilat- ed fundus examination revealed no intraocular foreign bodies or other abnormalities in either eye. Intraoc- ular pressures were normal. The construction company was contacted and the sandblasting abrasive material was identified as Black Beauty. The material contained 48.78% silicon dioxide, 20.97% alu- minum oxide, 19.08% ferric oxide, 6.02% calcium oxide, 1.67% potassi- um oxide, 0.94% titanium dioxide, 0.90% magnesium oxide, and 0.62% sodium oxide. Discussion The case was presented at our bi- weekly Grand Rounds where several of our cornea specialists offered their opinions. We asked what would be the first step in management. Dr. Hamill commented, "Many different materials are used in sandblasting, such as aluminum oxide, crushed glass grit, glass beads, silicon car- bide, plastic abrasive, pumice, steel shot, steel grit, corn cob, and walnut shell, to name just a few. Therefore, it is very important to first find out what sandblasting agent caused the injury because the effects on the eye can be different with each material. You can contact the company that makes the product or call poison control." Dr. Khandelwal noted that when the eye encounters material of un- known composition, it should raise a red flag. "I would be wary of all un- known foreign material in the eye, as it could contain alkali or acid compo- nents that could cause rapid damage. In the acute setting, you may not be able to reach the manufacturer or determine the exact material. Check the pH and copiously irrigate, but avoid using a Morgan contact lens, which could push superficial material deeper into the cornea." Introduction from Mitchell Weikert, MD, residency program director This month, we present an interest- ing case seen by the cornea special- ists at Baylor College of Medicine, Houston. This gentleman presented emergently to the Ben Taub Hospital eye clinic where he was evaluated by 2 of our residents: Lena Dixit, MD, a third-year resident who will enter a cornea fellowship at the Bascom Palmer Eye Institute in July, and Walter Parker, MD, a first-year resi- dent rotating on our public hospital service. Drs. Dixit and Parker chose this case for the high educational value and variability in management options. Our discussion panel includes M. Bowes Hamill, MD, and Sumitra Khandelwal, MD, both from the cornea division at Baylor College of Medicine. I was also consulted on this case and was asked to share my opinion. Case presentation A 52-year-old Hispanic male pre- sented to the eye clinic after being injured in a sandblasting accident. The patient was working on a con- struction site when the hose from a nearby sandblasting unit became disconnected, which resulted in dis- charge from the unit being directed into the patient's face. The force dislodged his safety goggles, and he was sprayed in both eyes with the abrasive material. He reported sudden pain, redness, tearing, and blurry vision. The patient noted no past medical or ocular history, no family history of medical or ocular prob- lems, and no significant social history. Upon presentation, his uncorrected distance visual acuities (UDVA) were 20/25 OD and 20/50 OS with no improvement with pinhole testing in either eye. Slit lamp biomicroscopy of the right eye showed mild ptosis with superficial debris in the skin of the upper and lower eyelids, 2+ hyperemia of the conjunctiva, multiple small black particles embedded in the nasal and temporal bulbar conjunctiva, and an inferior subconjunctival hem- orrhage. Multiple black particles of varying size were embedded in his right cornea and were most numer- ous superonasally and inferiorly. They ranged from very superficial Sandblasted cornea We asked the panel what type of sequelae to expect from sandblast- ing material in the eye. Dr. Hamill commented, "Ocular toxicology studies with silicon dioxide (48.78% of Black Beauty abrasives) have revealed reactions that produce fibrotic nodules in the eye similar to pulmonary silicosis. These studies showed minimal reaction in the cornea but caused inflammation in the anterior chamber and fibrotic Figure 1: External photograph of the right eye showing multiple black particles embedded in the skin, bulbar conjunctiva, and cornea. Figure 2: High magnification slit lamp photograph of the left eye showing multiple black particles of varying size embedded in the cornea. Figure 3: Thin slit beam illumination of the left eye showing particles that are deeply within the cornea. Source (all): Mitchell Weikert, MD Academic grand rounds: Baylor College of Medicine, Cullen Eye Institute

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