Grease is a thixotropic lubricant agent containing calcium, sodium, or lithium-soap jelly emulsified with mineral oil. It liquefies when agitated and solidifies when at rest. Grease guns are commonly used in factory workshop to apply grease under pressure to lubricate the parts of machines. The pressure increases up to 621–1034 kPa and ejects grease (a velocity comparable to the muzzle velocity of a rifle bullet).
Grease gun injuries can cause mechanical and chemical damage of tissue. Chemical damage is less than those of other chemical substances due to its high viscosity and low tissue toxicity. However, the high pressure of grease gun can lead to focal penetration and blunt dissection along the tissue planes. Any part of the body can be injured, but the commonest sites are the fingers and hands. Grease gun injuries of the orbit are very rare, and only seven cases have been published in the literature so far.
A 20-year- old male presented with chief complaints of dimness of vision, pain, and swelling of the left eye since morning following a trauma at his work place. He gave a history of an accidental injury in LE due to escape of grease with high velocity from a JCB machine while working on it. Immediately he consulted a local ophthalmologist; some amount of grease material was removed there and was referred to our center.
On examination, his presenting visual acuity was finger count at 1 meter in the left eye with accurate PR and 20/20 in the right eye. In the LE, there was swelling of the eye lids and the globe was tensed and chemosed. There was proptosis of 5 mm (measured with plastic scale) with restriction of movements in adduction and elevation. The conjunctiva was congested and chemosed, but no gross laceration was detected. Yellowish colored grease material was found underneath the medial and lower fornix. On mild pressure over the lower lid yellowish grease material was found to be coming out through the lower fornix [Fig. 1]. The material was cleaned thoroughly. Relative afferent pupillary defect (RAPD) was present in LE. Slit lamp examination revealed corneal abrasion at the lower part. Digital tonometry suggested high intra-ocular pressure and fundus examination was unremarkable. Orbital CT (non-contrast) revealed lateral displacement of the globe by some crescentic shaped hypodense foreign body material with proptosed left globe [Fig. 2a and b]. We provisionally diagnosed it as a traumatic optic neuropathy caused by grease gun injury and treated with methyl prednisolone injection. Intravenous ceftriaxone 1 gm BD and topical antibiotic (moxifloxacin eye drop) 8 times a day, 1% atropine sulphate drop TID, timolol maleate 0.5% drop BD, and artificial tear substitute 0.5% QID were
On next morning, same grease material was found to be exuding from the lower fornix (LE). As there was spontaneous incessant flow of the grease and there was no improvement of signs and symptoms, a surgical exploration was planned under local anesthesia on the 5th day [Fig. 3a-d]. On examination under microscope, two small conjunctival lacerations were found through which grease was coming out spontaneously, one was inferiorly and the other was medially. Both the wounds were explored by scissors and copious irrigation was done by Ringer lactate solution with the help of a 10-cc syringe. After nearly total evacuation of grease, the wounds were thoroughly cleaned with 5% povidone iodine. Post operatively, topical moxifloxacin eye drops 8 times a day and artificial tear substitute 0.5% QID was given along with oral steroid.
On the first post operative day, the visual acuity in LE improved to 20/40 with marked reduction in proptosis and chemosis, and the extraocular motility improved. Corneal abrasion healed within 2 days. No further flow of grease was detected. At 2 weeks follow up, visual acuity improved to 20/20, and the pupil was round, regular, and reacting [Fig. 4]. Intraocular pressure by Goldman applanation tonometry was 14 and 16 mm of Hg in the right and left eye respectively. Fundus examination was normal. At 1 month follow up, CT orbit was repeated, and there was no grease or any other abnormalities detected [Fig. 5a and b].
Most authors have reported that surgical removal is necessary, but Gekeler et al. suggested close observation in the absence of ocular symptoms [Table 1]. In our case, there was a 5 days delay in surgical removal of the grease, during this period the patient was on close observation with pulse steroid therapy. There was spontaneous flow of grease through conjunctival laceration, which also prompted us for initial conservative management.
The decision to operate or not should be made according to the signs and symptoms of a case, as the tissue toxicity of grease itself is limited. Timing of surgery varies from case to case, it depends upon factors like visual acuity at presentation, pupillary reaction, extent of other tissue damage, and amount of grease present in the orbital cavity. In our case, although initially we kept the patient on conservative management, finally we had to opt for the surgical removal of grease.
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