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JAMA Ophthalmology Clinical Challenge
March 2018

Intraorbital Bullet

Author Affiliations
  • 1Department of Ophthalmology, University of California, San Francisco, San Francisco
JAMA Ophthalmol. 2018;136(3):295-296. doi:10.1001/jamaophthalmol.2017.4050

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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