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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.

A computed tomography scan showed a large extraconal inferonasal metallic foreign body (FB) within the right orbit that was abutting the inferior rectus muscle without fractures or intracranial intrusion (Figure 1).

Figure 1.
Computed tomography scan of the orbit demonstrates a large extraconal metallic foreign body of the right orbit abutting the inferior rectus muscle on coronal (A) and sagittal (B) images.

Computed tomography scan of the orbit demonstrates a large extraconal metallic foreign body of the right orbit abutting the inferior rectus muscle on coronal (A) and sagittal (B) images.

Box Section Ref ID

What Would You Do Next?

  1. Observe the patient

  2. Obtain a magnetic resonance imaging study to further delineate the soft tissue injury

  3. Repair canalicular lacerations and leave the foreign body in place

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


Retained intraorbital metallic FB with canalicular lacerations

What To Do Next

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

Locating a small projectile within postseptal fat can be challenging, and associated morbidities include an orbital hemorrhage or optic neuropathy.1 The decision to perform an orbitotomy and remove an IOrbFB depends on the composition and location of the FB, as well as potential complications if left unaddressed. General recommendations are (1) remove all organic FBs that can be exposed without excessive orbital morbidity, (2) remove any inorganic FBs that are associated with complications, (3) observe inorganic, asymptomatic postseptal FBs, and (4) electively remove inorganic preseptal FBs.1-3

Despite these broad recommendations, individual cases can have unique factors. If an inorganic FB is readily exposed and surgery is required for other reasons, including orbital fractures and periocular lacerations, then removal should be considered. Magnetic resonance imaging is contraindicated in patients with retained ferromagnetic material for concern of FB displacement or heat generation.5 Although the core of a bullet is typically made of lead or a lead alloy, ferromagnetic metal can be present.5-7 Therefore, if magnetic resonance imaging is needed, the bullet should first be extracted. Although lead toxicity is possible with an FB that is located within a synovial space,8 to our knowledge, no systemic lead toxicity has been documented with an IOrbFB. In addition, many surgeons will remove iron-containing or pure copper IOrbFBs that are contacting the sclera, especially if an electroretinography shows gradual retinal deterioration.1,3,9,10

In this case, the patient had a large, accessible postseptal IOrbFB with severe pain and the need for canalicular repair, rendering repairing canalicular lacerations and performing an orbitotomy for FB removal the most appropriate choice. Repairing canalicular lacerations and leaving the FB in place is less appropriate because of the presence of significant pain with eye movements. Obtaining a magnetic resonance image study to further delineate the soft tissue injury is contraindicated because of the possibility of ferromagnetic material. Observing the patient is incorrect because of the high likelihood of posttraumatic epiphora and persistent orbital pain.

Patient Outcome

An orbitotomy with exploration was performed. A .22-caliber bullet was identified and extracted (Figure 2). The canalicular lacerations were repaired using a bicanalicular stent. There were no surgical complications. Postoperatively, the patient’s pain rapidly resolved and his visual acuity remained unchanged.

Figure 2.
An orbitotomy with a .22-caliber bullet extraction (inset) and a bicanalicular repair of lacerations were performed.

An orbitotomy with a .22-caliber bullet extraction (inset) and a bicanalicular repair of lacerations were performed.

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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.

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