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This article describes an unusual case of enucleation from a high-pressure water jet. Treatment is described and an etiologic hypothesis is presented.
Report of a Case.
A 37-year-old man was seen in the emergency department with a traumatic injury to his right orbit. The patient, not wearing protective eyewear, was tightening a high-pressure industrial pipe that began to leak. Owing to a sudden malfunction, a high-pressure water jet was directed into his right orbit. The right globe was found approximately 45 m (50 yd) from the scene of the injury by emergency personnel. Ophthalmic examination of the right orbit showed relatively clean, soft tissue with conjunctival chemosis and an anophthalmic socket. Gross and histopathologic examination findings of the eye revealed an intact globe with no readily identifiable sites of scleral rupture and 15 mm of optic nerve present (Figure 1). The extraocular muscles were avulsed through their insertions on the globe. A computed tomographic scan of the orbits confirmed the anophthalmic socket. The extraocular muscles were in their normal anatomical positions and intact (Figure 2). Ophthalmic examination of the left eye, including confrontation visual fields, showed no abnormalities.
A gross specimen of the right globe. Note some debris on sclera. The optic nerve remnant is seen with an intact sclera and cornea and extraocular muscle stumps present at insertion.
Coronal and axial computed tomographic sections done the day of the initial trauma, showing the anophthalmic right socket with an intact orbital rim. The optic nerve stump and extraocular muscle bellies show some intraorbital air.
The patient underwent right socket and orbital debridement and a moderate amount of ecchymotic nonviable tissue was removed. The orbit was explored extensively and the recti muscles were isolated. The muscle ends were pulled anteriorly and sutured to a 20-mm, scleral-wrapped, hydroxyapatite implant through scleral fenestrations.
Six months after the initial injury and surgery, the patient showed excellent cosmetic results, with a well-healed right orbit and excellent socket motility. Nuclear medicine imaging revealed a well-vascularized, hydroxyapatite implant.
Systemic high-pressure injection injuries have been documented in the literature since the 1930s.1 Most of these have occurred in industrial settings and have involved a variety of high-pressure grease, air, and water machines that cause systemic trauma.2 These pipes contain water at pressures of between 6000 and 8000 psi, whereas pressures of only 100 psi are necessary to penetrate skin. A break in the closed system can propel water at speeds of up to 600 ft/s—close to the muzzle velocities of some rifles. Similar injuries to the eyes and adnexa are much less common. Holds et al3 described 8 patients with hydraulic orbital injection injuries. No patient lost vision permanently as a sequelae of the initial trauma.
To our knowledge, this is the first reported case of a hydraulic orbital injection injury resulting in enucleation. The proposed mechanism of injury in this patient involved a high-pressure jet of water transecting the conjunctiva, travelling to the retrobulbar space, and then building up enough posterior pressure to rupture all of the connective tissue support, the 4 recti near their insertions, and the optic nerve. Orbital trauma associated with anterior pressure alone usually results in globe rupture. The pathologic condition in our patient is similar to that reported in psychiatric patients, where a finger or instrument is placed behind the globe and force is applied outward, resulting in enucleation.4 This is not a common pathophysiological mechanism of injury, but considering the velocities attainable with pressurized fluids, one that should not be surprising.
Reprints: James H. Oestreicher, MD, FRCSC, 309-1033 Bay St, Toronto, Ontario, Canada, M5S 3A5.
DeAngelis DD, Oestreicher JH. Traumatic Enucleation From a High-Pressure Water Jet. Arch Ophthalmol. 1999;117(1):123–124. doi:
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