From the Department of Ophthalmology, Ha’Emek Medical Center, Afula, Israel.
Presented at the VII International Symposium on Ocular Trauma, June 2006, Rome, Italy; and at the Annual Microsurgical Meeting of the Israeli Ophthalmological Society, January 2007, Eilat, Israel.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Yaron Lang, MD, Dept. of Ophthalmology, Ha’Emek Medical Center, Afula 18000, Israel.
Ocular perforating wounds may have disastrous visual consequences. The primary surgical treatment begins with closure of accessible wounds. Additional surgery may include cataract removal, corneal transplantation1 or vitrectomy for repair of a complex retinal detachment, vitreous hemorrhage2–6 and/or endophthalmitis.7
We present a case of a perforating eye injury resulting from an accidental staple gun discharge. Initial treatment included removal of the staple and closure of the scleral wounds. Despite the severity of the injury, the only secondary treatment was laser treatment to the retinal exit site. At his 12-month follow-up exam, his vision had improved to 6/9.
A 30-year-old carpenter presented to our emergency room with a 5 cm stainless steel staple imbedded in his left eye (Fig. 1) due to an inadvertent staple gun discharge.
Figure 1. Prior to the Surgical Removal of the Staple. The Upper Limb of the U-Shaped Staple Passed Through the Superior Eyelid and Perforated the Globe Superiorly 6 mm from Limbus and Exited About the Equator. The Lower Limb Was Intrascleral.
On examination, vision of the left eye was finger counting at 1.5 meters. One end of the U-shaped staple passed through the upper eyelid and penetrated the globe 6 mm posterior to the limbus at 12-o’clock position. The other end of the U tunneled deeply within the temporal part of the cornea and extended into the sclera at 3-o’clock position. The anterior chamber was deep with only mild hyphema. The pupil was round and reactive to light. The lens was completely clear. Although vitreous hemorrhage obscured a detailed view of the posterior pole, a good red reflex was seen. The vision in the fellow eye was 6/6 with a normal anterior and posterior segment. Computed Tomography (CT) examination of the left orbit validated the clinical findings (Fig. 2).
Figure 2. A Coronal CT Scan Imaging of the Eyeball Injured by the Staple. It Demonstrates the Perforating Superior Limb of the Staple Almost Tangential to the Globe. The Inferior Non-Perforating Limb, Non-Visualized, Is Hidden by the Superimposed Superior Limb.
Under general anesthesia, we observed that the upper end of the staple had exited the eye close to the 12-o’clock equator. The other lower end did not perforate the eye; rather it continued in its intrascleral course and emerged just behind the lateral rectus muscle insertion. The staple was carefully extracted in one piece. Both scleral wounds were sutured with 6/0 vicryl and mild cryo applications were applied around each wound. The skin of the upper eyelid was sutured with 8/0 nylon. At the end of the operation, vancomycin and amikacin were given subconjunctivally. The patient was treated intravenously by gentamycin 240 mg/day and cefazolin 2g/day for 1 week. In addition, topical Atropin 1% tid (Fischer, Israel), Dexamycin qid (Combined dexamethasone & neomycin drops, Teva, Israel) and Ciloxan qid (Alcon, USA) were administered.
We scheduled a vitrectomy in the next few days. However, this vitrectomy was cancelled as the vitreous hemorrhage cleared dramatically. There were no signs of endophthalmitis and the vision improved progressively to 6/9 within four days of injury. Now that the equatorial exit wound could be visualized internally, laser applications with indirect ophthalmoscope delivery system were applied in a zone extending anteriorly from this wound to the ora serrata (Fig. 3). When last seen, two years after the injury, visual acuity remained 6/9 with the retina attached, without any sign of an intraocular inflammation or vitreous hemorrhage.
Figure 3. A Peripheral Fundus Photograph of the Patients Left Eye Taken About 3 Weeks After Injury. The Exit Wound (white Arrow, an Area of Bare Sclera) Is Surrounded by Laser Applications Which Extended Anteriorly to the Entry Site. Blood Remnants Lie near the Wound.
A staple or nail propelled under high pressure by an industrial gun may cause severe, even life-threatening, damage. Instances of good results have been attributed to several factors including minimal contusive damage of a sharp, high velocity nail8 and prompt vitrectomy.9 In one similar published case, treated with scleral buckling and cryopexy but without vitrectomy, a favorable result was also achieved.10 We are not aware of any published case reporting successful treatment of this type of injury by cryo and laser alone. In our case, the staple bypassed the lens to enter the eye through the posterior pars-plana and exit via the equatorial retina.
In perforating wounds of the eye, reactive fibrovascular tissue usually connects the entry and exit sites.11 With shrinkage of this tissue, a tractional retinal detachment with proliferative vitreoretinopathy may result. Ryan et al. have demonstrated that a double perforating wound may result in a significant retinal detachment, especially if the entry site is near the ora serrata and the exit site near the posterior pole.12 Vitrectomy interrupts the process by removing the scaffold upon which proliferation may develop.13,14
Our case is unique in several aspects. This is the first description, to our knowledge, of a staple gun causing a perforating eye injury, although there are several reports relating to a nail gun.9,10,15 Such nail injuries may cause a double perforating wound with one entry and one exit site. In contrast, a U-shaped staple, could potentially perforate the eye simultaneously in two places, causing a quadruple perforating injury, with two entry and two exit sites, resulting in a significantly more severe injury. Our patient was fortunate in that only one end of the staple perforated his globe, thus this simulated the more common double perforation due to a nail gun. The favorable outcome was achieved here with minimal intervention: laser/cryo treatment applied around pars plana and retinal wounds.
Although we were aware of the importance of vitrectomy in such severe trauma, this was not performed for several reasons: First, the vitreous hemorrhage cleared spontaneously within several days, enabling us to apply laser treatment around the exit site via the pupil. Secondly, no signs of infective or toxic endophthalmitis developed. Furthermore, since the vision had improved significantly with the crystalline lens remaining clear and since both entry/exit wounds were quite peripheral, observable and close to each other, we considered it more reasonable to observe rather than intervene once again.
This unexpectedly favorable result may be attributed to the following factors: First, the contraction of the peripheral fibrovascular tissue did not threaten the posterior pole. Further, rapid clearing of the vitreous hemorrhage enabled timely access of laser treatment to the equatorial exit wound thus preventing a delayed rhegmatogenous retinal detachment (RRD) often seen with progressive liquefaction of the vitreous.
In conclusion, our unique case demonstrates that the hazard of a staple gun is similar to that of a nail gun, but potentially worse if both ends perforate the globe. In the majority of perforating wounds caused by nail guns, surgical repair usually requires either vitrectomy9,15 or scleral buckle alone.10 In selected cases of such injuries, laser and/or cryo treatment around both entry and exit sites may be sufficient when combined with close and meticulous follow-up.
- Baykara M, Dogru M, Ozçetin H, et al. Primary repair and intraocular lens implantation after perforating eye injury. J Cataract Refract Surg. 2002;28:1832–1835. doi:10.1016/S0886-3350(02)01274-9 [CrossRef]
- Rosenthal G, Bartz-Schmidt KU, Engels B, Walter P, Heimann K. Primary use of silicone oil tamponade in the management of perforating globe injury secondary to inadvertent local anaesthesia injection for ophthalmic surgery. Int Ophthalmol. 1997–1998;21:349–352.
- Bajaire B, Oudovitchenko E, Morales E. Vitreoretinal surgery of the posterior segment for explosive trauma in terrorist warfare. Graefes Arch Clin Exp Ophthalmol. 2006 ;244:991–995. doi:10.1007/s00417-005-0186-1 [CrossRef]
- Cekiç O, Batman C, Totan Y, Aslan O, Ozalp S. Management of traumatic retinal detachment with vitreon in children. Int Ophthalmol. 1999;23:145–148. doi:10.1023/A:1010637503058 [CrossRef]
- Pulido JS, Gupta S, Folk JC, Ossoiny KC. Perforating BB gun injuries of the globe. Ophthalmic Surg Lasers. 1997;28:625–632.
- Martin DF, Meredith TA, Topping TM, et al. Perforating (through and through) injuries of the globe. Surgical results with vitrectomy. Arch Ophthalmology. 1991;109:951–956.
- Verbraeken H, Rysselaere M. Post-traumatic endophthalmitis. Eur J Ophthalmol. 1994;4:1–5.
- Rofail M, Lee LR, Lee GA, Todd B. Suicide-related perforating injury of globe with nail gun. Clin Experiment Ophthalmol. 2005;33:294–295. doi:10.1111/j.1442-9071.2005.00979.x [CrossRef]
- Chen KJ, Sun MH, Hou CH, Chen TL. Retained large nail with perforating injury of the eye. Graefes Arch Clin Exp Ophthalmol. 2008;246:213–215. doi:10.1007/s00417-007-0613-6 [CrossRef]
- Newell SW. Double penetrating nail injury to the eye: a case report. J Okla State Med Assoc. 1990;83:119–121.
- Topping TM, Abrams GW, Machemer R. Experimental double-perforating injury of the posterior segment in rabbit eyes: the natural history of intraocular proliferation. Arch Ophthalmol. 1979;97:735–742.
- Hsu HT, Ryan SJ. Experimental retinal detachment in the rabbit. Penetrating ocular injury with retinal laceration. Retina1986;6:66–69. doi:10.1097/00006982-198600610-00007 [CrossRef]
- Conway BP, Michels RG. Vitrectomy techniques in the management of selected penetrating ocular injuries. Ophthalmology1978;85;560–583.
- Abrams GW, Topping TM, Machemer R. Vitrectomy for injury: the effect on intraocular proliferation following perforation of the posterior segment of the rabbit eye. Arch Ophthalmol. 1979;97:743–748.
- Lee BL, Sternberg P Jr, . Ocular nail gun injuries. Ophthalmology. 1996;103:1453–1457.