[Skip to Content]
[Skip to Content Landing]

Intraorbital Bullet

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 45-year-old man presented to the emergency department after being shot with a .22-caliber pistol. The bullet passed through a wooden door before entering the patient’s right orbit. His ocular history included exotropia and amblyopia in the right eye. An examination revealed normal pupillary light reflexes, a visual acuity of 20/70 OD and 20/40 OS, and normal color vision OU.

There was 3 mm of proptosis in the right eye, as well as right-sided periocular ecchymosis. An entry wound was visible inferior to the right medial canthus, and the right upper and lower eyelids had full-thickness lacerations involving the canaliculi. The patient had a large-angle alternating exotropia, as well as mild supraduction, infraduction, and adduction deficits in the right eye. Severe pain was noted with supraduction and infraduction of the right eye. A slitlamp examination of the right eye revealed a normal anterior segment, while a mild vitreous hemorrhage, extramacular retinal whitening, and a subretinal hemorrhage in the inferonasal periphery was noted on ophthalmoscopic examination. The left globe was within normal limits and intraocular pressure was 16 mm Hg OD and 8 mm Hg OS.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Retained intraorbital metallic FB with canalicular lacerations

D. Repair canalicular lacerations and perform an orbitotomy for FB removal

Projectile injury to the orbit is a function of size, speed, and trajectory. Air and BB gun pellets are small with limited velocity and typically come to rest within the orbit, causing minimal soft tissue injury.1,2 Conversely, bullets are larger and travel at much higher speeds, often resulting in significant destruction to the orbit, adjacent sinuses, and brain.2 Although this patient was shot with a .22-caliber bullet, it passed through a barrier, reducing its velocity and limiting damage.

In contrast to metallic intraocular FBs, retained metallic intraorbital (IOrb) FBs are usually well tolerated. In one large series of metallic IOrbFBs, only 5% of patients developed long-term complications when the globe was not penetrated.3 These complications included pain with eye movement, an optic neuropathy, restrictive strabismus, fistula formation, and infection.13 Although infection is often a feared complication, fewer than 10% of inorganic IOrbFBs result in cellulitis or abscesses.1,3 By contrast, 54% to 68% of patients with organic IOrbFBs develop infections.1,4

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity
Article Information

Corresponding Author: M. Reza Vagefi, MD, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, San Francisco, CA 94143 (reza.vagefi@ucsf.edu).

Published Online: November 30, 2017. doi:10.1001/jamaophthalmol.2017.4050

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Fulcher  TP, McNab  AA, Sullivan  TJ.  Clinical features and management of intraorbital foreign bodies.  Ophthalmology. 2002;109(3):494-500.PubMedGoogle ScholarCrossref
2.
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(1):96-103.PubMedGoogle ScholarCrossref
3.
Ho  VH, Wilson  MW, Fleming  JC, Haik  BG.  Retained intraorbital metallic foreign bodies.  Ophthal Plast Reconstr Surg. 2004;20(3):232-236.PubMedGoogle ScholarCrossref
4.
Nasr  AM, Haik  BG, Fleming  JC, Al-Hussain  HM, Karcioglu  ZA.  Penetrating orbital injury with organic foreign bodies.  Ophthalmology. 1999;106(3):523-532.PubMedGoogle ScholarCrossref
5.
Dedini  RD, Karacozoff  AM, Shellock  FG, Xu  D, McClellan  RT, Pekmezci  M.  MRI issues for ballistic objects: information obtained at 1.5-, 3- and 7-Tesla.  Spine J. 2013;13(7):815-822.PubMedGoogle ScholarCrossref
6.
Eshed  I, Kushnir  T, Shabshin  N, Konen  E.  Is magnetic resonance imaging safe for patients with retained metal fragments from combat and terrorist attacks?  Acta Radiol. 2010;51(2):170-174.PubMedGoogle ScholarCrossref
7.
Karacozoff  AM, Pekmezci  M, Shellock  FG.  Armor-piercing bullet: 3-T MRI findings and identification by a ferromagnetic detection system.  Mil Med. 2013;178(3):e380-e385.PubMedGoogle ScholarCrossref
8.
Magos  L.  Lead poisoning from retained lead projectiles. A critical review of case reports.  Hum Exp Toxicol. 1994;13(11):735-742.PubMedGoogle ScholarCrossref
9.
Gerkowicz  K, Prost  M, Wawrzyniak  M.  Experimental ocular siderosis after extrabulbar administration of iron.  Br J Ophthalmol. 1985;69(2):149-153.PubMedGoogle ScholarCrossref
10.
Grant  WM,  Toxicology of the Eye. 3rd ed. Springfield, IL: Charles C. Thomas; 1986.
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Topics
State Requirements