Some residents were blinded by eye injuries after a devastating explosion in the Lebanese capital of Beirut last summer, research has revealed.
Shortly after 6pm on 4 August 2020, white smoke and fire poured out of the Port of Beirut. Minutes later, "a devastating massive explosion ensued, creating a mushroom-like cloud and a supersonic blast wave".
At least 200 people died, more than 6,000 were injured and 300,000 citizens were displaced from their homes. The cause was later determined to be the detonation of 2,700 tons of ammonium nitrate stored in the city's harbour, making it one of the largest non-nuclear explosions in history.
To better understand the extent of eye injuries among the survivors, medics from the American University of Beirut Medical Center analysed the health records of all the patients who presented to their emergency department or 13 ophthalmology outpatient clinics between 4 August and the end of November.
Of the 39 patients, 22 presented with eye injuries on the day of the blast. With the centre's emergency department "filled beyond capacity", the remaining 17 patients sought medical attention up to three months later.
The patients endured shattered glass in their eyes, eyelid cuts and fractures in the bones around their eyeball. Four of the injured eyes lost all vision, while seven were judged to be "legally blind", resulting in very poor eyesight.
The Beirut blast's "sheer magnitude was so strong" it "generated seismic waves that were felt around 200km (124 miles) away in the neighbouring Mediterranean island of Cyprus", the medics wrote in the journal JAMA Ophthalmology.
Hospitals and medical centres in the city were "severely damaged" by the explosion, which also left first aid services "paralysed".
A "disaster code was activated" at the American University.
"The ED [emergency department] was filled beyond capacity with moderate to severe casualties and mild injuries were immediately turned away at the door", wrote the medics.
The team has therefore turned its attention to the number of patients who sought treatment up to three months later.
In total, 48 eyes in 39 patients were treated as a result of the blast. Of the patients, nearly nine in 10 (89%) were adults.
More than half (53%) required surgery, most of which was "urgently requested on the same day of presentation".
Eye injuries caused by debris or shrapnel from shattered glass were the most common injury, making up more than half (54%) of the presentations.
This was followed by eyelid cuts (41%), fractures to the bone around the eyeball (29%), brow gashes (20%) and pooling of blood in the eye (18%).
Open globe injuries, a penetrating injury by a sharp object, affected one in five (20%) of the patients.
Despite being treated, seven of the eyes went on to have less than 20/200 vision, defined as being legally blind. This means if an object is 200ft (60m) away, you have to stand 20ft (6m) away to see it perfectly.
Four of the open globe injuries caused total blindness, with the eyes having to be surgically removed.
Watch: Lebanese citizens protest one year on from Beirut blast
The blaze that preceded the explosion is thought to have worsened the eye injuries, "as people watched the fire through their glass windows before the detonation".
The injuries that occurred were comparable to the "substantially less powerful" ammonium nitrate blasts in west Texas in 2013, and Tianjin, China, in 2015.
"At our institution, despite having robust disaster contingency plans and an advanced electronic patient record system, the magnitude of casualties overwhelmed all hospital systems," wrote the medics.
"More than 500 patients were received at the emergency services at our institution within the first few hours of the explosion, which greatly surpassed the hospital's maximum emergency plan capacity of 300 patients."
Among those who were treated immediately, "clinical documentation reverted back to pen and paper" due to power outages and a "spotty" Wi-Fi connection.
"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," wrote the medics.
"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 such scenarios should be included in disaster emergency preparation plans despite the low rate of such severe and unfortunate events."
Watch: 'There are no jobs' – Beirut blast one year on