Ophthalmic injuries at historic Port of Beirut blast show the need for ocular trauma protocols

Investigation of ocular and orbital injuries in survivors of the Port of Beirut explosion, the largest in a population center in recent history, revealed types of secondary blast injuries and the need for trauma preparedness.

Study design

A retrospective medical record review was conducted of all patients who presented for treatment of eye injuries to the emergency department at the American University of Beirut Medical Center or one of 13 ophthalmology outpatient clinics. Patients who presented between August 4, 2020, and November 30, 2020, were identified for inclusion in the study based on medical records and operative reports. Data collected from the medical records included patient demographics, eye examination (vision, IOP, anterior segment examination, fundus ophthalmoscopy), imaging results, treatment strategies, and patient outcomes. Ocular injuries involving the globe were classified according to the Birmingham Eye Trauma Terminology System.

Outcomes

A total of 48 eyes of 39 patients were treated secondary to the blast. Twenty-two patients presented with ocular injuries on the day of the blast, and 17 patients presented within the following 3 months to ophthalmology clinics. Thirty-five patients (89.6%) were adults, and 24 (61.5%) were female. A total of 21 patients (53.8%) required surgical intervention, 14 of whom were urgently requested on the same day of presentation. Most eye injuries were caused by debris and shrapnel from shattered glass leading to surface injury (26), eyelid lacerations (20), orbital fractures (14), brow lacerations (10), hyphema (9), open globe injuries (10), and other global injuries. Only 7 injured eyes had a final best-corrected visual acuity (BCVA) of less than 20/200, including all 4 open globe injuries with no light perception (8.3%) requiring enucleation or evisceration.

Limitations

The overall frequency and distribution of injuries have not yet been officially tallied. Low-acuity ophthalmic injuries were likely missed because those patients were referred to other nearby hospitals or clinics. Therefore, the study may have failed to capture milder ocular injuries. Additionally, on the night of the blast, clinicians had little time to await consults and make detailed patient records. More accurate examination information came from follow-ups in the days after the blast. Five patients were not followed. A more rigorous quantitative statistical analysis could not be performed due to the small sample size and the paucity of accurate official documentation on the number and distribution of injuries.

Clinical significance

A review of the injury patterns, treatment strategies, and responding physicians’ experience during the Port of Beirut explosion provides insight into the unique ocular and orbital injuries and patterns and may help guide future ophthalmic disaster response strategies. The main source of injury for most of these patients was the resulting storm of debris and shrapnel from shattered glass windows and building facades. These secondary blast injuries are the most common form of ocular injuries associated with high explosives and the most severe threat to eyes, which primarily resulted in eyelid laceration, brow laceration, and corneal injuries. Initial BCVA appears to be the single most important factor in predicting final visual acuity in patients who were affected by the blast. The other significant result is that there is a crucial need for healthcare facilities to develop comprehensive emergency ocular disaster preparations to address a mass surge in injuries, as all hospital systems were overwhelmed in this event despite existing disaster response strategies and an advanced electronic health care system.