Penetrating ocular trauma is one of the most frequent causes of monocular vision loss in children younger than 18 years of age.1 This mechanism of damage may result from firearm use or misuse, most often involving compressed air guns.1 We report an unusual mechanism of preventable penetrating ocular trauma and recommend suggestions regarding firearm and ammunition safety and an ophthalmologist's role in educating parents and patients.
A 2-year-old previously well girl presented to the emergency department following a .22 caliber cartridge casing injury to her left eye. The patient was playing in a car when she found a .22 caliber cartridge (comprising bullet, gunpowder, primer, and metallic casing) and placed it in the car cigarette lighter. The cartridge subsequently discharged and a foreign body perforated her left cornea, lodging within the globe. The bullet was not seen within the car.
On initial examination, her visual acuity was no light perception in the left eye. The left globe was mangled and depressed. External examination revealed only left upper and lower eyelid edema. No evidence of brain trauma was noted. Computed tomography (CT) of the orbits revealed left globe rupture and presence of a metallic foreign body without orbital fracture or intracranial damage (Figure 1). She was taken to the operating room for examination under anesthesia with further exploration and open globe repair.
Axial computed tomography scan of the orbits reveals left globe rupture with metallic foreign body.
In the operating room, she was noted to have an 18-mm corneoscleral laceration oriented horizontally, from the nasal limbus to the temporal limbus extending posteriorly between the lateral and inferior recti muscles. Protruding uveal contents were excised and globe exploration was performed. Severe hemorrhage and disorganized intraocular contents blocked the view of the posterior pole and identification of the foreign body. Given the artifact created by the metallic foreign body on CT, it was unclear whether the foreign body was within the globe or just outside the sclera behind the globe. Thus, the decision was made to close the eye anteriorly in an attempt to salvage the globe if possible and discuss the limited prognosis with the family again.
The next day, given the overall discomfort of the patient, potential for development of sympathetic ophthalmia in the fellow eye, and the unlikely chance of visual recovery, the decision was made to enucleate the left eye. Thorough exploration of the orbit, including the use of a surgical magnet, did not attract any fragments or foreign bodies within the orbital fat. After enucleation, the globe was found to contain the entire brass casing with a portion emerging through the unrepaired, posterior aspect of the scleral rupture (Figure 2). Histological examination of the left globe revealed diffuse suprachoroidal hemorrhage, traumatic aphakia, iridodialysis, cyclodialysis, retinal detachment, and a penetrating corneal and scleral injury (Figure 3).
Enucleated left eye with horizontal corneoscleral laceration status after anterior repair. The cartridge casing is seen protruding from the posterior scleral opening.
Histological examination of enucleated left globe highlights disorganized intraocular architecture including diffuse vitreous hemorrhage (asterisk), traumatic iridodialysis and cyclodialysis (arrowhead indicates absence from expected location), and full-thickness laceration of the globe (arrow) (hematoxylin–eosin, original magnification ×0.6).
Severe ocular trauma is one of the most common causes of monocular blindness in pediatric populations.1 Injuries resulting in ocular damage are often preventable.1 Thus, effective interventions aimed at minimizing activities associated with ocular trauma are essential to decreasing the associated morbidity. Projectile-related traumas comprise approximately 20% of all eye injuries, although this is typically secondary to fireworks, paintballs, and airsoft guns.2 In this case, we present a highly irregular mechanism of penetrating ocular trauma. The damage resulting from the shell is comparable to injuries from compressed air guns, in which up to 59% result in either enucleation or evisceration.1
Identifying the precise location of the initially unknown foreign body represented a significant challenge in the surgical management of this patient. Typical cartridge casings are brass, which is an alloy of copper and zinc. Therefore, surgical magnets are not useful in locating these foreign objects. Less commonly, casings may be nickel plated or composed of steel, which could be attracted by a surgical magnet.3 Because of the imaging artifact created by the metallic casing on CT imaging, it was also difficult to be certain whether the object was within or adjacent to the globe. Because brass casings are soft and unlikely to fragment into smaller pieces, an injury with such a large object will likely cause significant ocular injury.
This case highlights the importance of proper storage of firearms and ammunition. Safe storage practices, including keeping firearms locked and unloaded and storing ammunition in a locked location separate from the firearm, have been shown to be protective for unintentional firearm shootings among children.4 Although physicians do not often discuss this issue with patients,5 brief preventive discussions have been shown to result in increased safe firearm storage.6 Talking to parents about home firearm safety is typically seen as the responsibility of pediatricians, but ophthalmologists (especially pediatric ophthalmologists) can be highly beneficial in educating both parents and patients about the potential dangers associated with unprotected, unattended, or unconstructive gun and ammunition use.
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- Gonullu M, Filinte G, Cardak N, Kucuk S, Akoz T. The surgical strategy for the intraorbital foreign bodies. J Craniofac Surg. 2016;27:1785–1788. doi:10.1097/SCS.0000000000002950 [CrossRef]
- Grossman D, Mueller B, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA. 2005;293:707–714. doi:10.1001/jama.293.6.707 [CrossRef]
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- Barkin S, Finch S, Ip E, et al. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics. 2008;122:e15–e25. doi:10.1542/peds.2007-2611 [CrossRef]