Good Visual Acuity Outcome from an Ocular Blast Injury with Proper Management in Dr. Soetomo General Hospital Surabaya, Indonesia

Introduction: Ocular blast injury related to fireworks most often causing corneal erosion (29%), conjunctival erosion (11%), and conjunctival foreign body (10%) with children are more often than adults (65.9%:34.1%), and males far more often than female (71.9%:28.1%). Knowing proper management is very important to achieve the best result. Case presentation: We describe an ocular blast injury that experienced broad erosion and multiple foreign bodies on the corneal and pericorneal surface in the left eye and visual acuity decreased. The foreign body was scattered, and the fluorescein test was positive. We did proper foreign body extraction, irrigation, and ocular bandage. It was treated with chloramphenicol 0.5% eye ointment and homatropine eye drop. In two months, the patient’s left eye had clear cornea with a small scar formation near the visual axis. The visual acuity was 6/7 and BCVA was 6/6 with S-0.5 C-0.5 A 50° correction. Conclusions: Patients with ocular blast injury limited to superficial cornea erosion and and conjunctival erosion have a reasonable probability of achieving the best visual acuity. Foreign body extraction, proper irrigation, and topical medication show promising results. Scar formation near the visual axis can disrupt visual acuity however can be corrected in this case it can be corrected with glasses. Furthermore, public promotion and regulation to control firework using are very important.


Introduction
Fireworks have been commonly used worldwide as part of public festivals or entertainment for hundreds or thousands of years. Fireworks related to ocular blast injury cases increase in holidays like the new year or religious special day celebrations. [1] In the United States, from 2000 to 2010, 97.562 blast injury cases related to fireworks have been reported in the emergency room, with head and neck injuries covered 42% of all cases. In his new report, [2] the United States Consumer Product Safety Commission estimated that in 2017 there was 12.900 cases, 1.538 cases (12%) were categorized as an ocular blast injury.Thirty patients with 34 eyes affected were found during Eid Al-Fitr in the East Coast Peninsula of Malaysia from 10 th September to 17 th October 2008; 38.24% had visual acuity outcomes worse than 6/9. [3] Ocular blast injury related to fireworks most often causes corneal erosion (29%), corneal punctate staining (13%), conjunctival erosion (11%), and conjuncitval foreign body (10%). [1] The child is more often than adults (65.9%:34.1%) and males are more often than females (71.9%:28.1%). [2] Knowing proper examination and therapies is very important, especially in emergency settings, to achieve the best outcome of patient's management. It is the first case report of ocular blast injury in children in Soetomo General Hospital Surabaya in 2021 that shows clinical condition, initial management, follow-up management, and good outcome shown in the end. https://e-journal.unair.ac.id/VSEHJ

Case presentation
The patient was a nine-year-old boy from Lamongan District, and the first examination was on 14 th April 2021 in the Emergency Room (ER). Chief complaints were redness, pain, watery, blurry, and burnt sensation in the left eyelid. The patient had a history of exposure to firework blast 20 hours before he came to the hospital.
After the injury, the patient rubbed his eye and irrigated with 1.5 L tap water. The patient went to Dr. Soegiri General Hospital Lamongan then he was referred to Dr.
Objective examination showed Glasgow Coma Score Fluorescein test showed epithelial corneal erosion of 8 x 11 mm. Seidel test was negative while anterior chamber, iris, pupil, and lens were within the normal limit ( Figure   1). Retinal reflex in both eyes was positive, the right eye was within normal limit while the left eye was difficult to be evaluated. Visual acuity was 6/7.5 with correction S-0.50 C-0.50 axis 50° became 6/6. The clinical presentation is shown in Figure 6, and the patient was prescribed glasses.

Discussion and conclusions
Blast injury is a complex event and has a direct and indirect pathway to cause damage. It can be from industrial components, recreational like fireworks, or warfare tools.
In the past, blast injury was dominated by war causes, but today domestic cause is the primary cause. [4] History taking is essential to understand the mechanism of injury.  Shape, size, the proximity of the point of impact to the globe, energy, and angle of incidence are essential factors in the mechanism of injury. [5] Young and middle-aged males (22 ± 13 years) most widely affected compared to females even experienced more devastating damage. The dominant male role in using or manufacturing fireworks and other prone to explode components is the leading cause of this condition. [1] This case report also happened in the male patient.
Blast injury has four categories of trauma mechanism, primary, secondary, tertiary, and quarter. Primary is the blast's direct force that hits the body. Secondary is fragment things thrown by blast that hit the body. Tertiary is blast force with body damaged. The quarter is every damage uncategorized to primary, secondary, or tertiary. [4] From the clinical examination, we categorized this patient's injury as primary and secondary mechanisms.
We present a case report about multiple foreign bodies with corneal erosion, pericorneal hyperemia, and excoriation in the eyelid caused by firework blast. Corneal foreign bodies are usually associated with immediate pain, foreign-body sensation, tearing, and discomfort. The presence, extent, and depth of the corneal defect can be determined using slit-lamp examination. The fluorescein test is beneficial in diagnosing foreign body and epithelial defects of the cornea. Conjunctival foreign bodies are best recognized by the slit-lamp examination with eyelid eversion. [8] In this case, a foreign body in conjunctiva and cornea were found on slit-lamp examination and fluorescein test examination.
In spasm associated with corneal abrasion. [8] Non-Steroid Anti Inflammatory Drugs (NSAIDs) [6] should be given in cases of pain. There is no evidence that topical NSAIDs are better than oral NSAIDs. Topical anesthetic drops can safely be used at low concentrations for short periods.
Overuse and unsupervised topical anesthetic exert toxic effects that delay corneal healing. Ice or cold pack can be the alternative option for analgesia. [9] Eye patching for corneal abrasion can alleviate some degree of pain, even though some studies show no significant difference between patching and non-patching groups. [10] A B C A B   cell with tight junction to prevent exogenous infiltration. [12] Epithelial cells have an age duration of 7-10 days, fastest among corneal layers. [13] Some scar formation always occurs in foreign bodies that entering the corneal stroma deeply to the Bowman layer. Stromal injury may induce secretion of proinflammatory and profibrotic cytokines such as IL-1, TNF-, and MCP-1 that contribute to extracellular matrix remodeling and scar formation. [14] Scar formation in the visual axis may result in glare and vision decreased with irregular astigmatism. [8] In this case, corneal erosion in the left eye has disappeared three weeks after the initial accident. Scar formation was found in inferior cornea near the visual axis causing visual acuity disturbance.The patient can get normal vision using glasses. Firework bans have been recommended worldwide by The World Health Organization (WHO) [2] since 1984 and the effectivity of this ban is well presented in the USA. States without restricting fireworks regulation have an incidence of blast injury ten times bigger than those with regulation. Fireworks ban in Norway in 2008 significantly reduced firework-related eye injuries by half compared with the mean incidence in 2005-2007 when the firework is allowed. [15] The lifting of restrictive fireworks law in North Ireland is followed by the threefold increase of firework-related ocular injury. [16] Patients with ocular blast injury limited to superficial erosion of cornea and conjunctiva have a reasonable probability of achieving the best visual acuity. Foreign body extraction, proper irrigation, and topical medication have shown promising results. Scar formation near the visual axis can disrupt visual acuity but can be corrected with glasses. Furthermore, the public promotion that fireworks can cause blast injury to the cornea and regulation to control firework using is essential.