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Arch Ophthalmol. 1999;117:1090-1091.

Air compressor injuries have been implicated in numerous reported cases of facial and eye trauma. Severe facial trauma may result in fracture of the orbits or sinuses, leading to the accumulation of air within the orbit or even within the brain.¹ We report a case in which trauma to the conjunctiva (without compromise of the skull, bony orbits, or sinuses) led to accumulation of air within the brain.

Report of a Case.
A healthy 47-year-old white man was disconnecting an air compressor hose (120 psi) when the free end suddenly popped off and struck him in the right eye. The patient complained of severe pain and experienced swelling of the eyelids and bleeding from the eye socket. He was evaluated in the emergency department.

Uncorrected visual acuity was 20/100 OD and 20/20 OS. External examination revealed extensive edema and echymoses of the right eyelids. The right palpebral fissure opened only 3 mm with voluntary effort. Motility examination was normal. The nasal conjunctiva had a large (10-mm) jagged laceration with intermixed mucoid debris and Tenon fascia. The sclera was completely intact. The cornea was clear with no epithelial defect or laceration. The anterior chamber showed cell (1+) and flare. The lens and vitreous cavity were normal. The optic disc was also normal. The retina showed evidence of peripheral and macular commotio. There were no retinal breaks or detachment noted. The left eye and adnexa were completely normal.

A computed tomographic scan of the head and orbits was obtained (Figure 1). There were no bony fractures in the face, orbits, sinuses, or skull. There was extensive soft tissue swelling of the face, particularly in the region of the right orbit. In addition to swelling, there was an accumulation of air within the soft tissues of the eyelid, face, and right orbit. Interestingly, air was also noted within the optic canal, within the subarachnoid space, and within the third and fourth ventricles of the brain (Figure 2). Air was also present near the base of the skull in the region of the circle of Willis.

View larger version (50K): [in this window] [in a new window] Figure 1. Axial computed tomographic scan showing extensive soft tissue swelling. There is air within the soft tissues and orbit and shrouding the optic nerve. Air is also present within the suprasellar cistern.

View larger version (58K): [in this window] [in a new window] Figure 2. Axial computed tomographic scan demonstrating air within the frontal horn of the lateral ventricle.

The patient underwent irrigation and debridement of his conjunctival wound under topical anesthesia. No sutures were placed. The patient was prescribed oral cephalexin as well as a topical combination product of dexamethasone, neomycin sulfate, and polymyxin B sulfate drops and ointment. A tetanus toxoid injection was also given. During the next several weeks, the patient's eyelid and soft tissue swelling resolved, as did his mild iritis and commotio retinae. Visual acuity returned to an uncorrected 20/25 OD. The conjunctival wound has healed with minimal visible scarring.

Comment.
Air within the cranial cavity (pneumocephalus) has been described in several clinical situations including facial trauma.^2-3 Given the lack of bony fractures in this patient, it is presumed that the air within the brain arrived there by an unusual route; dissection beneath the Tenon fascia, around the optic nerve, and through the optic canal into the subarachnoid space and ventricles. This pathway is possible because the cerebrospinal fluid surrounding the optic nerve is in continuity with the intracranial subarachnoid space. Intracerebral air is generally well tolerated, although its presence in the setting of bony fracture can signify increased risk of intracranial pressure or meningitis.⁴ A similar case was reported in 1977, in which a 12-year-old boy had air demonstrated on x-ray films in the region of the sella turcica after lacerating his conjunctiva with an air-compressor tip.⁵ To our knowledge, our case is the first to confirm this unusual mechanism of traumatic pneumocephalus using the more sophisticated technique of computed tomographic imaging.

AUTHOR INFORMATION

T. Reginald Williams, MD; Nicholas Frankel, MD
Hickory, NC

Reprints: T. Reginald Williams, MD, Graystone Ophthalmology Associates, PO Box 2588, Hickory, NC 28603 (e-mail: retina{at}twave.net).

REFERENCES
1. Waring GO, Flanagan JC. Pneumocephalus: a sign of intracranial involvement in orbital fracture. Arch Ophthalmol. 1975;93:847-850. FREE FULL TEXT 2. Orebaugh SL, Margolis JH. Post-traumatic intracerebral pneumatocele: case report. J Trauma. 1990;30:1577-1580. PUBMED 3. Dandy WE. Pneumocephalus (intracranial pneumatocele or aerocele). Arch Surg. 1926;12:949-982. FREE FULL TEXT 4. Keskil S, Baykaner K, Ceviker N, et al. Clinical significance of acute traumatic intracranial pneumocephalus. Neurosurg Rev. 1998;21:10-13. FULL TEXT | PUBMED 5. Koenig RP. Traumatic eye and intracranial air-movement from a subconjunctival to an intracranial position. Am J Ophthalmol. 1977;83:915-917. PUBMED

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