Debris and Shrapnel Eye Injuries After Massive Beirut Explosion

After last August’s blast at the Port of Beirut, a nearby medical center was flooded with injured people, including those with ocular injuries, Lebanese researchers said.

About half of eye injuries were caused by debris and shrapnel, and many presented to the hospital in the days after the explosion because of a strained healthcare system, reported Wajiha Jurdi Kheir, MD, of the American University of Beirut Medical Center, and colleagues in JAMA Ophthalmology.

“At our institution, despite having robust disaster contingency plans and an advanced electronic patient record system, the magnitude of casualties overwhelmed all hospital systems,” the authors wrote. “For most patients, immediate clinical documentation reverted back to pen and paper because of power outages, insufficient electronic stations, a spotty institutional Wi-Fi connection, and incomplete patient registrations at triage. Initial ophthalmologic examination was limited and, in some cases, delayed depending on the patients’ condition, associated systemic injuries, and need for life-saving care.”

About 2,700 tons of ammonium nitrate exploded on Aug. 4, 2020, which Kheir noted was in the middle of a lockdown due to the COVID-19 pandemic. It was one of the largest non-nuclear blasts in history, the authors said.

Within a few hours, more than 500 patients flooded into American University of Beirut Medical Center, which had an emergency plan capacity set for 300.

The blast destroyed many hospital structures, Kheir told MedPage Today, and knocked out its power grid; the emergency department (ED) was briefly running only on emergency lighting. “It was complete chaos,” she said.

At least 500 patients in the ED were screened for ophthalmic complaints such as decreased visual acuity, redness, pain, and clear eye injuries. Critically ill patients were rushed to urgent surgeries, and assessed for eye injuries later.

The authors conducted this single-center retrospective medical record review of patients who presented to the ED or ophthalmology outpatient clinics with ocular or orbital injuries from August to November 2020. Patients were identified from outpatient and emergency records, as well as operative reports.

Ophthalmic complaints were assessed using the Birmingham Eye Trauma Terminology system.

Over the 3 months following the blast, the team treated 48 eyes in total from 39 patients with ocular injuries (22 patients were treated right after the blast for ocular or orbital injuries, with 14 patients requiring surgery). They followed up with patients twice and after 2 months on average. In all, 21 patients ultimately required surgery (53.8%).

Surface injury was the most common presentation (54.2%), followed by lacerations to the eyelid (41.6%), orbital fractures (29.2%), brow lacerations (20.8%), hyphema (18.8%), and open globe injuries (20.8%). Initially, 27.1% of the injured eyes had a best-corrected visual acuity of less than 20/200, which decreased to 14.5%, which included four open globe injuries that required enucleation or evisceration.

“The overall frequency and distribution of injuries has not yet been officially tallied. The number of injuries given is the most accurate estimate provided by the hospital at the time of manuscript submission [in May],” the authors wrote.

“The report … highlights the need for and utility of organized ocular trauma systems, with layers or echelons of capabilities that are integrated with the larger trauma system,” wrote Richard Blanch, MBChB, PhD, of the Royal Centre for Defence Medicine in Birmingham, England, and colleagues in an accompanying commentary.

“Centralized and subspecialized ophthalmic trauma management should be balanced by measures to maintain ophthalmic trauma knowledge and skills in smaller units peripheral to major trauma centers so that they remain able to contribute effectively to major incident management,” they suggested. “It may be less expensive, easier, and safer to move appropriate ophthalmic casualties to other facilities distant from the incident, easing pressure on local resources.”

Kheir called the hospital’s overall response effective. “Once things get really messy, we go back to the basics,” she said.

The authors acknowledged that the study may have failed to capture mild ocular injuries. “Some patients did not return for follow-up; therefore, a more comprehensive assessment was not possible for all patients. A more rigorous quantitative statistical analysis could not be performed because of the small sample size and the paucity of accurate official documentation on the number and distribution of injuries,” they noted.