Team of eye physicians report on ophthalmic injuries following Port of Beirut blast
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A review of the type of injuries, treatment strategies, difficulties encountered and actions undertaken in response to the 2020 Port of Beirut blast was published in JAMA Ophthalmology, providing insights into the ocular consequences.
The authors, a team of eye physicians and ophthalmology residents at the American University of Beirut Medical Center (AUBMC), expressed the hope that documenting their experience may guide future ophthalmic disaster response plans.
Just after 6 p.m. on Aug. 4, 2020, one of the largest nonnuclear explosions in history created a supersonic blast wave that rippled through the densely populated capital city of Beirut, Lebanon, killing more than 200, injuring more than 6,000 and displacing 300,000 citizens from their homes.
With several nearby hospitals and medical centers damaged by the explosion, a few emergency departments and tertiary care institutions were overflown by injuries. At the AUBMC, a disaster code was activated, and the emergency department rapidly filled with severe injuries, while mild injuries were turned away at the door.
A team of four attending physicians and seven residents/fellows (including one who arrived after 1 hour on foot, after his house and car had been damaged) found themselves dealing with at least 500 patients who presented that night with ocular injuries. All of the patients were screened, 22 were treated, and 14 had surgery on that same night. In the following weeks, 17 other patients presented and were treated, for a total of 48 eyes of 39 patients. Twenty-one patients (53.8%) underwent surgery. Four injured eyes required enucleation. Final best corrected visual acuity was less than 20/200 in only seven eyes (14.5%).
All ocular injuries were classified according to the Birmingham Eye Trauma Terminology system. Most eye injuries were caused by debris and shrapnel from shattered glass, resulting in surface injuries (54.2%), eyelid lacerations (41.6%), orbital fractures (29.2%), brow lacerations (20.8%), hyphema (18.8%), open globe injuries (20.8%) and other global injuries.
“A fire preceded the Port of Beirut explosion and contributed to the large number of ocular injuries, as people watched the fire through their glass windows before the detonation. The resulting storm of debris and shrapnel from shattered glass windows and building facades was the main source of injury to most patients,” the authors wrote.
The high-velocity shrapnel was responsible for the extensive damage caused to the ocular structures and the high number of open globe injuries, they said.
Chemical injuries were caused by plumes of nitrous dioxide, as well as byproducts of toxic materials stored in the port.
“In our opinion, this disaster showed how physicians can be resilient and have strong intuitions to manage tragic situations sometimes by resorting to basic approaches. The Port of Beirut explosion overwhelmed all hospital systems despite all existing disaster response strategies and an advanced electronic health care system, with an almost complete breakdown of the latter. The authors believe that such scenarios should be included in disaster emergency preparation plans despite the low rate of such severe and unfortunate events,” the authors wrote.
Perspective
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This study clearly tells us that at any trauma center serving a large area, a system must be in place to deal with mass casualties, from triaging to actual treatment. This system must be able to respond to emergency situations as fast and efficiently as possible.
Relative to the size of the Port of Beirut blast and the number of deaths that it caused, the number of people with eye injuries reported in this study was relatively small. This may be because data were collected at a single hospital or because, as the authors themselves specified, people with less severe injuries received no medical care. Whatever the reason, a regional or national surveillance system would be desirable, as it would give us a clearer and more realistic picture of the ocular consequences of such a major disaster.
As the experience showed in this case, electronic medical records are great when the system works; when it breaks down, however, they can be a huge disadvantage. It should be evaluated whether an old-fashioned paper-based backup system should always be kept. As a trauma specialist, I cannot help wondering whether some of the eyes that had no light perception vision really necessitated enucleation. There is insufficient information about this in the paper, and my advice in such cases would be to delay the enucleations until after all the other emergency surgeries have been performed and reconsider the single cases at that stage.
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