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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.
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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.1- 3 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
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Corresponding Author: M. Reza Vagefi, MD, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, San Francisco, CA 94143 (firstname.lastname@example.org).
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.
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