BB guns are non-powdered air guns that fire spherical projectiles typically made of steel and coated with either zinc or copper. Although BB guns are often easily accessible to the pediatric population and perceived as safe by parents, they may cause serious accidental injury.1,2 In the United States, up to 12% of these injuries involve the eye.3 Complications of ophthalmologic involvement include globe penetration or perforation, retinal detachment, vitreous hemorrhage, endophthalmitis, and choroidal rupture with generally poor visual outcomes.4–8
We present three cases of pediatric orbital BB injury highlighting the variability in injury severity and visual outcome, as well as the need for improved public safety education and regulations.
A 15-week-old male infant was being nursed by his mother at the dining table when his father placed a BB gun on the table without securing the safety. The gun fired, striking the infant through the left upper eyelid. On examination, the patient was found to have marked left upper eyelid swelling and ecchymosis with a small horizontal eyelid laceration and a grossly intact globe (Figure 1A). Computerized tomography (CT) scan revealed a spherical metallic foreign body lateral to the intact globe (Figure 1B). The patient was taken to the operating room for examination under anesthesia and exploration. Dilated examination revealed an intact globe with a superotemporal area of vitreous hemorrhage overlying a choroidal rupture. On exploration of the lateral orbit, a BB pellet was discovered and removed (Figure 1C). On follow-up examination, the patient’s external wound healed well with scarring in the area of choroidal rupture (Figure 1D). On the 5-month follow-up visit, visual acuity was 4.8 cycles/cm at 38 cm by Teller Acuity Cards in each eye, which was within normal range for the patient’s age.
Case 1. (A) External photograph showing the left eyelid entry site, ecchymosis, and swelling. (B) Axial non-contrast computed tomography of orbits demonstrating intact left globe with intraorbital metallic foreign body (arrow). (C) Exploration of the left orbit reveals the BB pellet (arrow). (D) Fundus photograph of the left eye demonstrating normal-appearing macula with superotemporal chorioretinal scarring.
A healthy 18-year-old man was playing with friends when a BB gun discharged and struck him in the right eye. On examination, visual acuity was hand motions in the right eye and 20/20 in the left eye with normal intraocular pressures bilaterally. On slit-lamp examination of the right eye, it was noted that the patient had temporal subconjunctival hemorrhage and chemosis. Dilated fundoscopic examination of the right eye revealed diffuse commotio retinae with an inferior choroidal rupture and large amounts of preretinal, retinal, and subretinal hemorrhage in the macula (Figure 2A). CT scan revealed a spherical metallic foreign body lateral to the intact right globe (Figure 2B). The patient was taken to the operating room for exploration under anesthesia. The globe was found to be intact and a BB pellet was identified and removed from the lateral sub-Tenon’s space (Figure 2C). At the 1-month follow-up visit, the patient’s visual acuity had improved to 20/100 with resolving hemorrhage and chorioretinal scarring (Figure 2D).
Case 2. (A) Fundus photograph of the right eye demonstrating preretinal, intraretinal, and subretinal hemorrhage with commotio retinae. (B) Axial non-contrast computed tomography of orbits demonstrating intact right globe with intraorbital metallic foreign body (arrow). (C) Exploration of right temporal subconjuctival space reveals the BB pellet. (D) Fundus photograph of the right eye 1 month after surgery, demonstrating resolving hemorrhage with temporal area of chorioretinal scarring.
A healthy 13-year-old boy was cleaning his BB gun with his older brother when the gun fired and a BB pellet struck the patient’s right eye with immediate loss of vision. On presentation, visual acuity was no light perception in the right eye and 20/25 in the left eye. On examination of the right eye, there was conjunctival chemosis temporally and a total hyphema. CT scan revealed an anteriorly and posteriorly ruptured right globe with a retained spherical metallic foreign body (Figure 3A). The patient was emergently taken to the operating room for exploration under anesthesia. The anterior wound was exposed and closed with interrupted 9-0 nylon sutures. After isolating the lateral rectus muscle, the sub-Tenon’s space was examined and a BB pellet external to the sclera was removed (Figure 3B). On follow-up examination, the patient remained at no light perception. Follow-up B-scan ultrasonography revealed vitreous hemorrhage, disorganized globe, and a posterior rupture (Figure 3C). The patient subsequently underwent enucleation for a blind, painful eye.
Case 3. (A) Axial non-contrast computer tomography of orbits demonstrating ruptured right globe with intraorbital metallic foreign body (arrow). (B) Exploration of right temporal subconjunctival space reveals the BB pellet. (C) B-scan ultrasonography of the right eye showing dense vitreous opacities.
Although the rate of BB gun–related injuries has declined in recent years due to improving public safety education, these injuries still represent an important disease burden in the pediatric population.9 Surveys of parents whose children own BB guns demonstrate that the majority still do not perceive these air-powered guns as dangerous.2 As was the case for all three of our patients, BB gun injuries are usually either self-inflicted or caused by a known family member or friend.
Approximately 12% of BB gun injuries involve the eye, and they represent a significant fraction of eye injuries.3 In a large series of projectile metallic foreign bodies, the majority of the cases were due to BB gun injury.10 LaRoche et al. found that 7% of pediatric ocular eye injuries were secondary to BB gun pellets, and 42% of the eyes involved had no light perception final visual acuity.6
Sternberg et al. reported 22 patients with globe perforation secondary to a BB pellet with 19 of those patients undergoing enucleation, similar to case 3.4 In that same study, the majority of patients with non-penetrating injury from a BB pellet had 20/40 visual acuity or better. The poor visual outcome with globe involvement is attributed to higher rates of endophthalmitis, retinal detachment, and vitreous hemorrhage.7 Ahmadabadi et al. reported 13 patients with globe perforation, all of whom presented with retinal detachment, and none of whom improved past counting fingers.8 On the other hand, Pulido et al. reported final visual acuity of 5/200 or better in five of seven eyes with globe perforation.11 When compared to other retained metallic intraocular foreign bodies, BB pellets are associated with worse visual outcomes and globe loss, perhaps secondary to the high-velocity mechanism of injury.12
Although in all three of our cases the BB pellet was removed, removal of a metallic orbital foreign body located external to the globe, especially when posteriorly located, is not essential in improving visual outcome.10 Ho et al. conducted a series of retained intraorbital metallic foreign bodies, 34% of which were BB pellets, and described no complications associated with long-term follow-up of retained foreign bodies.13
In 1993, McNeill et al. reported an annual incidence of over 30,000 BB and pellet gun injuries in the United States.14 More than two decades later, these injuries remain a major cause of morbidity and mortality.15 This suggests a need for heightened public education in schools and through the media. Although certain states have outlawed the sale of BB guns to minors, the majority still do not and stricter control of access of these guns to minors may be necessary to address this safety issue.15,16
Recently, there has been a rise in the use of airsoft guns, which are a type of replica non-powdered firearm that typically deploy plastic pellets at lower power and velocity than the metallic projectiles from BB guns. Although airsoft guns are often regarded by the public as safer than BB guns, the potential for eye injury remains significant. This explains why overall air gun ophthalmologic trauma is on the rise even though BB gun–related eye injury rates have dropped. Recently, Lee and Fredrick reported an increase of more than 600% in rates of admission for air gun eye injuries.17 Airsoft gun pellets can cause the full spectrum of ocular trauma, including a unique form of corneal erosion first described by Kratz et al.18
Our three cases illustrate the broad spectrum of pediatric BB orbital injury. Given the potential severity of the ocular injuries, efforts must continue to educate children and parents about the danger of accidental eye injury related to BB guns in the pediatric population.
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- Sternberg P Jr, de Juan E Jr, Green WR, Hirst LW, Sommer A. Ocular BB injuries. Ophthalmology. 1984;91:1269–1277. doi:10.1016/S0161-6420(84)34159-8 [CrossRef]
- Brown GC, Tasman WS, Benson WE. BB-gun injuries to the eye. Ophthalmic Surg. 1985;16:505–508.
- LaRoche GR, McIntyre L, Schertzer RM. Epidemiology of severe eye injuries in childhood. Ophthalmology. 1988;95:1603–1607. doi:10.1016/S0161-6420(88)32952-0 [CrossRef]
- Newman TL, Russo PA. Ocular sequelae of BB injuries to the eye and surrounding adnexa. J Am Optom Assoc. 1998;69:583–590.
- Ahmadabadi MN, Karkhaneh R, Valeshabad AK, Tabatabai A, Jager MJ, Ahbadabadi EN. Clinical presentation and outcome of perforating ocular injuries due to BB guns: a case series. Injury. 2011;42:492–495. doi:10.1016/j.injury.2010.11.006 [CrossRef]
- Nguyen MH, Annest JL, Mercy JA, Ryan GW, Fingerhut LA. Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985–99. Inj Prev. 2002;8:185–191. doi:10.1136/ip.8.3.185 [CrossRef]
- Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology. 1997;104:96–103. doi:10.1016/S0161-6420(97)30355-8 [CrossRef]
- Pulido JS, Gupta S, Folk JC, Ossoiny KC. Perforating BB gun injuries of the globe. Ophthalmic Surg Lasers. 1997;28:625–632.
- Ehlers JP, Kunimoto DY, Ittoop S, Maguire JI, Ho AC, Regillo CD. Metallic intraocular foreign bodies: characteristics, interventions, and prognostic factors for visual outcome and globe survival. Am J Ophthalmol. 2008;146:427–433. doi:10.1016/j.ajo.2008.05.021 [CrossRef]
- Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg. 2004;20:232–236. doi:10.1097/01.IOP.0000129014.94384.e6 [CrossRef]
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- United States Department of Health and Human ServicesCenters for Disease Control and PreventionNational Center for Injury Prevention and Control. Firearm Injury Surveillance Study, 1993–2008 [Computer file]. ICPSR30543-v1. Vol. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2011-08-09. Accessed: January 4, 2015.
- Dayton Daily News. No laws regular air rifles, BB guns. Available at: http://www.daytondailynews.com/news/news/no-laws-regulate-air-rifles-bb-guns/nhdbj/#__federated=1. Accessed November 30, 2014.
- Lee R, Fredrick D. Pediatric eye injuries due to nonpowder guns in the United States, 2002–2012. J AAPOS. 2015;19:163–168. doi:10.1016/j.jaapos.2015.01.010 [CrossRef]
- Kratz A, Levy J, Cheles D, Ashkenazy Z, Tsumi E, Lifshitz T. Airsoft gun-related ocular injuries: novel findings, ballistics investigation, and histopathologic study. Am J Ophthalmol. 2010;149:37–44. doi:10.1016/j.ajo.2009.08.013 [CrossRef]