Terror strikes

“First things first,” he replied. “He’s currently undergoing external fixation of his femur, but once that’s done, it’s our turn.” Dr Derveaux showed me the orbital CT scan. There was a metallic foreign body lodged in or under the superior rectus of the right eye. The globe looked intact.

But I suspected there might be more than just the foreign body. Having spent nearly six years training in The Netherlands, I was well aware of the damage bombs can inflict on the eyes. The normally sober Dutch let loose on New Year’s Eve, igniting do-it-yourself fireworks and homemade "knallers" (“boom-booms”, which are essentially small bombs, capable of inflicting immediate death) at home, dozens of which end up exploding in hands and faces.

Those with extensive craniofacial trauma ended up at the university hospital. Those with primarily ocular injuries were sent to the Rotterdam Eye Hospital, where we treated their blast injuries: orbital fracture, globe rupture, and corneoscleral laceration.

A TERRIBLE COMBINATION

That was the “easy” part. The real challenge was identifying and treating the chemical-caustic burns of the ocular surface. The corneal erosion is so complete that it’s surprisingly easy to miss. It resembles simple fluorescein pooling, as there’s no “edge” between present and absent epithelium. And the conjunctivae look, at first glance, quite normal, reassuringly white. But this is classic fool’s gold. The eye is white because the superficial and deep vessels have been cauterised by the combination of thermal and chemical injury.

Deep in the fornix, highly alkaline bits of charred gunpowder soot continue to seep chemicals onto the eye. Limbal stem cells start to die, and the likelihood of epithelial repair diminishes by the hour. These eyes are doomed to any combination of chronic epithelial defects, corneal stromal ulceration, permanent scarring, conjunctivalisation of the cornea, multiple surgeries and often a terrible combination of pain and blindness, leading to enucleation.

Clinical examination of the patient revealed what I had expected. Yet, despite my prior experience with this type of injury, I thought it prudent to get the advice of Jan-Tjeerd de Faber, an ophthalmologist who has volunteered for each of the past 20 New Year’s Eves to be on surgical call in the Rotterdam Eye Hospital to treat the Dutch fireworks victims. He is The Netherlands’ leading campaigner against amateur fireworks. We discussed the case via WhatsApp, as he was in Taiwan, presenting blast injury cases at the Asia-Pacific Academy of Ophthalmology Congress.

With one look at a photo of the eye, Dr de Faber confirmed my suspicion: “White conjunctivae. Looks like caustic trauma. My advice: initiate fireworks treatment protocol.”

While the nurses of the burn unit were preparing the ocular irrigation system and ordering the extensive list of eye drops from the hospital pharmacy, I performed fundoscopy. The view was hazy, because of the cloudy cornea, folds in Descemet’s membrane, and the hyphema that had settled on the anterior surface of the lens.

“Can we position him upright for a little while, so the blood in the anterior chamber can settle inferiorly?” I asked the nurse.

“Not really,” she replied.

“Why not?” I asked.

“Because his hip joint was destroyed and is being held in place by pins and screws,” she said. “Strict orders from orthopaedics.”

PROCEED SLOWLY

So be it. I proceeded. Indirect ophthalmoscopy revealed a small, dense, localised vitreous haemorrhage, very peripheral at 12 o’clock. It coincided with the location of the foreign body on the CT scan. But there was no vitreous detachment, so the blood hadn’t displaced at all. Had the sclera been penetrated?! Damn!

Here I was, a vitreoretinal surgeon fresh out of residency, facing the possibility of performing an emergency vitrectomy on a 30-year-old patient in an induced coma who was unable to give consent. Hazy cornea. Hyphaema. Phakic. No PVD.

As I completed the examination, the operating room had called to say they had freed up space for us in a surgical unit. The patient could be transferred immediately. I had an hour to prepare, and I went over the steps in my mind. Careful placement of the eyelid speculum. Conjunctival peritomy. Very careful isolation and hooking of the superior rectus. Removal of the shrapnel. Localisation of potential scleral laceration or port of entry into the globe…

I was happy to hear that an experienced resident, Laura Leysen, would be assisting me. As we were scrubbing up, a senior vitreoretinal consultant, Fanny Nerinckx, called to offer some last-minute advice. She had treated several terrorist bombing victims with similar injuries earlier that day in another hospital. She had seen the CT scan and was confident that the bulb was intact.

“Proceed slowly. Avoid undue pressure on the globe. If you detach the rectus muscle, don’t let it disappear into the orbit. And if you have to convert to vitrectomy… call me!” I was thankful to have potential backup for this tricky case.

The patient arrived in the theatre. We could start immediately, as he was already anaesthetised. Here we go!

The globe was encouragingly firm. Displacement of the conjunctiva and tenon revealed an unusual fibrinous reaction around the superior rectus. As Dr Leysen deftly assisted me with peeling away the inflammatory mess, I spotted a sparkle shining through the muscle fibres. Shrapnel! But how deep did it extend? I hadn’t fully isolated the muscle, so I couldn’t simply pull it out. What if it were lodged in the sclera? I had no desire to induce suprachoroidal haemorrhage or incarcerate the retina even before I had the hooked the muscle.

But then, miraculously, as I further isolated the muscle, the metal slipped to the superior surface of the rectus. I removed it and asked the nurse to keep it for me. I held my breath as I peered under the muscle to explore the sclera. Manipulating a rectus muscle attached to a globe with a potential scleral laceration is not an enjoyable experience. Deep inside, I suspected the globe would be intact, as it was normotensive, but the presence of vitreous haemorrhage kept me doubting and vigilant. I expected the worst and hoped for the best.

The sclera looked perfect. I looked once, twice and three times just to be sure, and then asked Dr Leysen what she thought.

“I think we’re safe,” she said.

“I think so too,” I replied, happy that we were of the same opinion. “Will you close the conjunctiva?”

Dr Leysen closed the conjunctiva as I watched on the monitor. As she placed the fine sutures, I reflected on how lucky we were to be operating under such good conditions. Many acts of terror and war occur in highly disorganised locations, where delivering medical care is difficult, highly demanding and often dangerous. Here, I had everything at my disposal to do my work and deliver care.

My thoughts then shifted back to our patient, a previously healthy and presumably happy young man whose life had been made immeasurably more difficult in the blink of an eye.

Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital, Belgium