Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1999
Ocular fishhook injuries are rare, yet potentially vision threatening. Corneal scarring,1,2 retinal detachment,3,4 and endophthalmitis1 may result. Prompt surgical intervention is recommended1; however, the construction of a barbed fishhook makes removal of these objects difficult. We report what we believe is a new technique to remove a fishhook in a patient with penetration of both the eyelid and cornea. To our knowledge, this combined injury has not been reported previously.
A 24-year-old man was first seen in the emergency department after a fishing injury in which a fishhook struck his left eye. One barbed hook of a treble fishhook was embedded in the left upper lid (Figure 1) and he was unable to open the eye. The right eye was normal. Computed tomographic (CT) scanning was performed and suggested that the hook extended through the eyelid and cornea into the anterior chamber (Figure 2). The patient was started on a regimen of intravenous cefazolin sodium and gentamicin sulfate. He was taken to the operating room and general anesthesia was administered.
Barbed hook of treble fishhook embedded fully in the left upper eyelid.
Computed tomographic scan axial image showing possible fishhook penetration into the anterior chamber of the left eye.
The globe could not be visualized and the hook could not be cut since it was completely embedded and flush with the skin. There was also serious concern that trying to cut the thick metal could result in further injuries to the globe. The eyelid was infiltrated with 1% lidocaine hydrochloride with epinephrine 1:200,000. Using a No. 15 Beaver blade, a full-thickness eyelid incision was created from the margin of the upper eyelid vertically to the fishhook, followed by bipolar cautery for hemostasis. A 4-0 silk suture was placed through the apex of each of the 2 eyelid flaps that were created and reflected superiorly (Figure 3). The sutures were clamped to the drape to allow visualization of the globe.
Surgical eyelid-splitting procedure performed and the upper eyelid retracted with 2 sutures to allow visibility of the cornea.
The hook had entered vertically in the center of the cornea. The corneal wound was confined mainly to the stroma with a small region superiorly extending full thickness into the anterior chamber. A corneal incision was made anterior to the barb so that the hook could be removed gently. The anterior chamber was re-formed using balanced salt solution after the removal of the hook, and two 10-0 nylon sutures were used to close the corneal wound. No leakage was noted after this procedure.
The eyelid retraction sutures were removed. Multiple interrupted 5-0 polyglactin 910 (Vicryl; Ethicon, Inc, Somerville, NJ) sutures were placed at partial thickness through tarsus. At the apex, a buried interrupted suture re-formed the margin. No. 6-0 plain gut sutures were used to close the subcutaneous tissues and the skin.
On the first postoperative day, visual acuity was counting fingers at 3 ft. The anterior chamber was deep with marked inflammation, and there was significant corneal edema. The patient was maintained on a regimen of topical ofloxacin and intravenous antibiotics for 3 days. He was discharged on a regimen of oral ciprofloxacin hydrochloride and topical ofloxacin. Four months after surgery, visual acuity with a soft contact lens was 20/20. The corneal laceration and eyelid incision were well healed (Figure 4).
Well-healed corneal laceration and eyelid incision after 4 months.
Removal of a fishhook penetrating the globe can be very challenging. Several techniques have been described in the literature. One such technique is the "advance and cut method," in which the hook is grasped and rotated to create a new exit site for the tip. The barb is then cut off using wire cutters, and the barbless hook is backed out through the entry site.1 If the hook is located primarily within the corneal stroma, a perpendicular incision can be made in the corneal tissue anterior to the hook.2 In cases in which the fishhook penetrates the retina, the needle cover technique can be useful.3 A large-bore needle is inserted into the entry wound and the barb is engaged in the needle lumen. The needle and hook are then removed simultaneously to minimize tissue damage.
Aiello et al1 reported a series of ocular fishhook injuries. Similar to patients in that series, our patient was a young man with left eye involvement, which was seen in most cases. Like most cases, final visual acuity in our patient was good.
In our case, advancing the fishhook was not possible owing to the deep position of the hook in the eye and the unknown position in the anterior chamber. A vertical eyelid-splitting technique allowed full visibility of the cornea with minimal manipulation of the hook. Since most of the hook was intracorneal, a corneal incision over the barb allowed for easy removal. Careful repair of the surgically created marginal eyelid laceration resulted in a well-healed eyelid with minimal scarring.
To our knowledge, a fishhook injury with simultaneous penetration of the eyelid and cornea has not been previously reported. Splitting of the upper eyelid using a full-thickness vertical eyelid incision may be a useful technique when visibility of a foreign body is limited and the risk to the globe from additional manipulation is high.
Reprints: Marlon Maus, MD, Oculoplastic Department, Wills Eye Hospital, 900 Walnut St, Philadelphia, PA 19107.
Deramo VA, Maus M, Cohen E, Jeffers J. Removal of a Fishhook in the Eyelid and Cornea Using a Vertical Eyelid-Splitting Technique. Arch Ophthalmol. 1999;117(4):541-542. doi: