Letters 487

Bilateral corneal contusion and angle and corneal oedema have also been parking a 1992 Toyota Camry when she hit a recession caused by an airbag reported, and were attributed to the fine alkali pole head on. She was travelling forward, at aerosol released from the bag.' about 16 km/h (10 mph) in a parking lot. The Br J Ophthalmol: first published as 10.1136/bjo.80.5.487-a on 1 May 1996. Downloaded from EDrrOR,-Airbags have been installed as stan- Our patient's injuries were most probably passenger in the car, who was reading, dard equipment on most new cars in order to inflicted by the airbag hitting the face, and the thought the driver stopped abruptly, and was enhance automobile safety. Several reports of corneal oedema requiring irrigation with surprised to see that the car had hit a light airbag associated injuries have recently water was almost certainly caused by the pole and the driver's airbag had deployed. appeared. 1-7 aerosol released from the airbag. There was no passenger-side airbag, and the We describe herein a case of severe ocular Airbag injuries to a front seat passenger are passenger was not injured. trauma caused by an airbag to a front seat rare7 because airbags were initially installed The driver of the car was treated for head passenger. on the driver's side, causing only the driver to and brow lacerations. On ophthalmic exami- suffer these kinds of injuries. nation, her visual acuity was 20/25 right eye The medical community should be alert to and 20/400 left eye. The left cornea had a CASE REPORT the potential ocular injuries induced when- large, interpalpebral epithelial defect, with A 20-year-old woman was the belted front ever an airbag is activated: immediate irriga- prominent Descemet's folds centrally. The seat passenger involved in a car accident in a tion of the eyes with water is recommended tear pH was 7 0 in both eyes. Eversion of the 1994 model car. The driver was killed in the followed by a prompt referral to an ophthal- left eyelid and sweeping of the conjunctival accident. Our patient suffered mild contusion mologist. fornices yielded several pieces of glass from of the chest, Colles' fracture of the right arm, ADI MICHAELI-COHEN the patient's shattered sunglasses, which were and multiple abrasions and blunt contusion MEIR NEUFELD found broken on the car floor. Each eye was marks on the face. An ophthalmic examina- MOSHE LAZAR with balanced ORNA GEYER irrigated salt solution, followed tion revealed visual acuity limited to hand Department of , by normal saline. Fundus examination movement in the right eye, and to only light Sourasky Medical Center, showed a vitreous haemorrhage, without perception in the left eye. The eyelids were Tel-Aviv, Israel view of the . Contact ultrasonography swollen, with marked chemosis and subcon- RIAD HADDAD revealed that the retina was attached. She also junctival haemorrhages. Opaque corneas and HANOCH KASHTAN had a radial and ulnar fracture that Department ofSurgery A, required hyphaema were noted in each eye. No details Sourasky Medical Center, orthopaedic surgery. Three days after the of the fundus could be detected in either eye. Tel-Aviv, Israel accident, the patient's vision improved to A diagnosis ofairbag injury was made and her 20/70, with resolution ofthe vitreous haemor- were with Correspondence to: Dr Adi Michaeli-Cohen, eyes irrigated water. Department of Ophthalmology, Sourasky Medical rhage. Fundus examination showed an On examination 2 days later, visual acuity Center, 6 Weizman Street, Tel-Aviv 64239, Israel. attached retina without retinal tears. was 20/50 in the right eye and remained unchanged in the left eye. The cornea was Accepted for publication 11 December 1995 thick with Descemet's folds and haemor- 1 Smally AJ, Binzer A, Dolin S, Viano D. Alkaline COMMENT rhages were present over the irides. chemical keratitis: eye injury from airbags. Ann The airbag in the car that this patient was Sphincterotomy in the left eye gave the left Emerg Med 1992; 21: 1400-2. driving is designed to deploy in response to a pupil an oval shape. The fundus was indis- 2 Rimmer S, Shuler JD. Severe ocular trauma from collision force greater than that created by a a driver's-side air bag. Arch Ophthalmol 1991; cernible, and the ultrasound examination 109: 774. crash into a fixed, non-deforming barrier at demonstrated attached retina and clear vitre- 3 Scott IU, John GR, Stark WJ. Airbag-associated approximately 19-25 km/h (12-16 mph). ous. ocular injury and periorbital fractures. Arch However, a sharp impact like a rock striking Two weeks after the accident, visual acuity Ophthalmol 1993; 111: 25. the undercarriage of the vehicle may 4 Whitacre MM, Pilchard WA. Air bag injury pro- trigger improved to 20/50 in both eyes. Intraocular ducing retinal dialysis and detachment. Arch airbag deployment. Whether the airbag mal- pressure was 12 mm Hg in both eyes. Ophthalmol 1993; 111: 1320. functioned and activated without sufficient Gonioscopy showed an angle recession of one 5 Driver PJ, Cashweil LF, Patrick Yeatts R. Airbag- forward deceleration force, or something http://bjo.bmj.com/ nasal quadrant in the right eye, and an angle associated bilateral hyphemas and angle reces- sion. Amy Ophthalmol 1994; 118: 250-1. under the vehicle triggered the airbag, is not recession of the whole circumference in the 6 Larkin GL. Airbag-mediated corneal injury. Am J known. It may also be that the airbag sensor left eye. The rest of the anterior segment Emerg Med 1991; 9: 444-6. was accurate and fully operational, since our examination was unremarkable in both eyes. 7 Braude L. Passenger side airbag ocular injury patient was travelling at about 16 while wearing sunglasses. Br Jf Ophthalmol km/h. The right fundus was normal; however, 1995; 79: 391. There is abundant evidence that airbags retinal haemorrhages and oedema were reduce fatalities when deployed for high speed present in the left fundus. frontal crashes.' The airbag is actuated in One month later, the uncorrected visual response to sudden longitudinal decelerations on September 29, 2021 by guest. Protected copyright. acuity was 20/20 and intraocular pressure was Airbag injury during low impact collision which, in turn, activate the ignition of a 16 mm Hg, again in both eyes. The slit-lamp sodium azide propellant cartridge. The libera- and fundus examinations were within normal EDITOR,-The fact that motor vehicle trauma tion of nitrogen gas from the combustion of limits in both eyes. continues to be a leading cause of morbidity sodium azide results in instant inflation of the and mortality in America, and the over- airbag.2 During inflation, the airbag is pro- whelming evidence that airbags reduce fatali- pelled out of its storage compartment at COMMENT ties in frontal crashes has led to airbags being speeds typically more than 160 km/h (100 Airbags are designed primarily to protect the standard equipment on many new and mph).6 Airbag associated ocular injuries driver and passengers from smashing against domestic cars.' However, reports of airbag occur from the blunt trauma or the liberation the steering wheel, dashboard, or windshield associated ocular injuries are increasing with ofgas when the airbag inflates. Ocular injuries during frontal collisions. They inflate in about the more widespread use of these devices.2-9 from airbag associated injuries include 10 ms in response to sudden longitudinal Because of the nature of the motor vehicle hyphaemas, alkali keratitis, and vitreous and deceleration of approximately 20 kph and accident in the previously reported cases of retinal haemorrhage.2-9 It has been suggested deflate within seconds. Gaseous and particu- airbag associated injuries the amount of that eyeglass wear presents an additional risk late components (sodium hydroxide, carbon trauma the patients may have sustained, with- factor for ocular injury during airbag infla- monoxide) are emitted in the vehicle interior out the airbag, may have been significant. tion.9 Polycarbonate lenses have an increased at airbag deployment.' We report a case of a driver who had resistance to impact shatter over glass or other Although airbags are designed to be a significant ocular and upper extremity types of plastic. However, shattering of the safety device, they have recently been trauma, due to airbag deployment while frames appears to be a greater problem. reported to be associated with facial and parking her car. The passenger, who was not Further study in this area is warranted. ocular injuries.1-7 Skin abrasions and eyelid subjected to an airbag, was uninjured. No one knows for sure what injuries the ecchymoses, the most common facial injuries, Because of the nature of the accident, and the driver avoided by the airbag inflation. But, are usually short lived. Ocular injuries include uninjured passenger, we speculate that our considering the impact ofthe collision and the orbital fractures, corneal oedema, abrasions, patient may have sustained minimal injury if extent of this patient's injuries, it seems hyphaema, angle recession, lens subluxation, her airbag had not deployed. reasonable to assume the injuries the driver commotio retinae, choroidal rupture, retinal sustained because of the airbag are more and vitreous haemorrhage, and retinal tears significant than she would have sustained and detachment.26 The airbag striking the CASE REPORT without it. face at high velocity and with great force is A 49-year-old woman, wearing sunglasses, Our case is interesting because of the probably responsible for such injuries. with a three point lap-shoulder seatbelt was extensive injuries, from a low impact 488 Letters collision, sustained by the driver while the passenger, without an airbag, had no injuries. While there is ample literature to show that Br J Ophthalmol: first published as 10.1136/bjo.80.5.487-a on 1 May 1996. Downloaded from the use of airbags decreases driver fatalities,' there are no data showing the optimum threshold impact for their deployment. Optimum threshold deployment pressure should be studied in order to maximise the benefits offatality reduction and minimise the risks of airbag induced morbidity. Also, in light of recent literature concern- ing airbag associated injuries, it would seem reasonable that airbag impact sensors should be checked regularly. Figure 1 Pigmnented scaling lesion ofupper LEANNE M MOLIA eyelid (case 1). EDWARD STROH Figure 3 Brown pigmented lesion of upper 300 Community Drive, eyelid (case 2), with seborrhoeic scales on eyelid Manhasset, NY 11030, USA margin and mucopurulent discharge. Accepted for publication 22 February 1996

1 Lund AK, Ferguson SA. Driver fatalities in pityriasis versicolor, the yeast form causes 1985-1993 cars with airbags. J Trauma 1995; 38: 469-75. seborrhoeic dermatitis. In pityriasis versicolor 2 Larkin GL. Airbag-mediated corneal injury. Am J the skin becomes scaly and skin pigmenta- Emerg Med 1991; 9: 444-6. tion is altered, while seborrhoeic dermatitis 3 Ingraham HJ, Perry HD, Donnenfeld ED. Air- gives excessive scaling and chronic inflamma- bag keratitis. N Engl Y Med 1991; 324: 1599-600. tion. 4 Sastry SM, Copeland RA Jr, Mezghebe H, Siram Clinically, case 1 better fits the pityriasis SM. Retinal hemorrhage secondary airbag- versicolor category; however, the organism related ocular trauma. J Trauma 1995; 38: 582. 5 Mishler KE. caused by air bag. Arch was a round yeast and mycelial elements were Ophthalmol 1991; 109: 1635. not seen. Case 2 exhibited features of pityri- 6 Han DP. caused by air bag asis versicolor and seborrhoeic injury. Arch Ophthalmol 1993; 111: 1317-8. simultaneously, with microscopic picture 7 Scott IU, John GR, Stark WJ. Airbag-associated ocular injury. Arch Ophthalmol 1993; 111: 25. similar to case 1. 8 Kuhn F, Morris R, Witherspoon CD. Air bag: Information about factors predisposing to X .- friehd or foe? Arch Ophthalmol 1993; 111: :.- A., diseases caused by Mfiurfur is limited. Being 1333-4. " I S a defect in the 9 Braude IS. Passenger side airbag ocular injury -*'. 4-- i %3 $ an opportunistic pathogen, while wearing sunglasses. Br Y Ophthalmol s. t host defence mechanism is presumed. The 1995; 79: 391. 1:. tij strikingly similar clinical presentation and a history of our patients may have a common pathogenesis. Neither patient had evidence of atopic disease, which might link Unilateral Malasseziafurfur blepharitis to fungal susceptibility. The lesion being uni- after perforating keratoplasty lateral, without other skin lesions, argues for a http://bjo.bmj.com/ local disorder. Possibly prolonged cortico- EDITOR,-Malassezia furfur (Pityrosporum steroid use had modulated local lymphocyte genus), a yeast considered part of the normal transformation depressing cellular immune skin microflora, is also known to cause pityri- ;------response. Other factors, however, cannot be asis versicolor, folliculitis, and seborrhoeic Figure 2 Potassium hydroxide staining of excluded - for example, both patients eyelid scraping showing sphericalyeas; ~tM dermatitis. We report two cases of unilateral furfur. reported that they had not washed the peri- blepharitis where Malassezia was retrieved orbicular region since the operation. Possibly from eyelid scrapings. These occurred after the patients' age could be significant; we have on September 29, 2021 by guest. Protected copyright. an uncomplicated perforating keratoplasty for never seen this condition in older patients keratoconus in two young (central European) Case 2 after perforating keratoplasty. patients, and resolved rapidly after local anti- A 19-year-old man presented at follow up It is important to consider the possibility of fungal therapy. with a brownish scaling lesion of the upper fungal infection in longstanding blepharitis. eyelid on the side of surgery, 1 mLonth after Eyelid scrapings are easy to perform and are the operation. Postoperative treattment was valuable in establishing therapeutic guide- CASE REPORTS identical to case 1. The eyelid mLargin was lines. Case I seborrhoeic with slightly mucopu rulent dis- We thank Dr G Simon, Department of A woman aged 22 underwent perforating charge (Fig 3). The corneal transsplant was Dermatology, Semmelweis University, for help in keratoplasty. The postoperative period was clear, but there was mild conjuncitival injec- identifying the fungus. uneventful. Prednisolone acetate eyedrops tion, , and tearing. The latter JEANNTE T6TH were applied postoperatively five times daily, were probably related to the surgeery, not to MARIA BAUSZ and later at reduced frequency, without other the eyelid lesion. A dermatologist prescribed LASZL() IMRE University School, therapy. At follow up 6 months later, she an antibiotic-fluocinolone ointment. How- SemmelweisDepartment of OphthalmologyMedical No 1, exhibited a slightly pigmented scaling lesion ever, 9 months later the cond[ition was H-1083 Budapest, of the upper eyelid on the side of surgery, unchanged. Tomo U 25-29, Hungary without itching or discharge. The eyelid mar- This case was strikingly similar to case 1; gin was unaffected, the skin was not inflamed the same organism was found. L anti- 1 V, I, or ulcerated (Fig 1). There was no evidence of fungal treatment was followed by ocoalcomplete Huber-SpitzySommeregger K, GrabnerBaumgartnerG. BlepharitisB6hler-- a conjunctival infection, and the transplanted resolution within 2 weeks. diagnostic and therapeutic challenge. Graefes cornea was clear. No skin lesions were seen Arch Clin Exp Ophthalmol 1991; 229: 224-7. 2 Dougherty JM, McCulley JP. Comparative bac- elsewhere. teriology ofchronic blepharitis. BrJ Ophthalmol Fungal infection was suspected and an ink- COMMENT 1984; 68: 524-8. potassium hydroxide preparation of an eyelid Blepharitis is a common ophthalnlic disease, 3 Huber-Spitzy V, B6hler-Sommeregger K, scraping disclosed a spherical yeast (Fig 2) involving various infection agents.'- 3MfurfUr, Arocker-Mettinger E, Grabner G. Ulcerative characteristic of M fur.fur. No culture was a dimorphic lipophilic yeast, is part of the blepharitisspecies the incausativeatopic agent?patientsBr-YisOphthalmolCandida performed. Local antifungal ointment (clotri- normal cutaneous microflora. It has been 1992; 76: 272-4. mazole) was prescribed. She missed the linked to seborrhoeic blepharitis, biut without 4 Ingham E, Cunningham AC. Malassezia furfur. JMed Vet Mycol 1993; 31: 265-88. follow up visit, but 3 weeks later reported that convincing proof.4 The dimorphic iforms have 5 Parunovic A, Halde C. Pityrosporum orbiculare. she was asymptomatic. When seen 6 months long been considered different otrgarsms.5gais5 Its possible role in seborrheic blepharitis. Am later the condition had resolved. While the mycelial form is assoc,iated with Y Ophthalmol 1967; 63: 815-20.