A five-year survey of ocular shotgun injuries in Ireland

Terroristic sniper shot ocular injuries: military and police casualties: case series

Introduction

Sniper shot ocular injuries (SSOI) are rare and result in poor ocular outcomes due to high energy transfer both to the eye and the adjacent brain. To our knowledge, no reports of such injuries in terms of outcomes have been previously described in the literature. The aim of this case series was to describe the treatment performed and ocular outcomes of such injuries.

Methods

Five cases of terroristic SSOIs referred to Gulhane Military Medical Academy Department of Ophthalmology between 22 July 2015 and 30 January 2017 were reviewed. Comparisons were made between the location and mechanism of injury, initial and final ocular signs, interventions and additional extraocular injuries.

Results

Two cases were of police officers and the remaining were Turkish military soldiers. All of our cases were injured in urban district by terrorist snipers hidden in apartments. Four individuals were injured in the right eye and the other was injured bilaterally. Initial visual acuities (VA) ranged from no light perception (NLP) to 0.0 with logMAR. Final VA raised to 0.0 in three patients whereas in two of NLP patients it remained the same. Mean Ocular Trauma Score was 2.2. Two eyes necessitated evisceration and the others underwent vitrectomy surgery.

Conclusions

The prognosis of SSOI is unpredictable and is highly dependent on the trajectory and energy deposition. Primary evisceration or enucleation should be reserved to severely ruptured globe cases with no chance of globe-saving procedures. If the globe remains intact, retinal and vitreal damage should be repaired. Due to risk of associated intracranial injury, all patients should be referred for neurosurgical opinion.

Unusual route of a bullet: From scapula to eye

Herein, an awkward case of globe perforation with a bullet-entering from the right posterior scapular region and leaving the body from the right orbit through the eye - is reported. Route of the bullet could be devastating - as it passed through the neck and the maxillofacial region-however by chance no vital damage occurred. Its path was assessed by plain radiography and computed tomography scans. Sometimes prediction of the trajectory is very difficult without additional radiological investigations. Especially, in the case of any high velocity projectile wounding, physician must be aware of the fact that the bullet's course will not be a linear but most probably a complicated one. Prognosis of the injury depends on the path of the bullet or shrapnel fragment, close clinical observation, an open-minded approach, and the multidisciplinary care. Moreover, even the crime investigation might be needed.

Unique neuro-ophthalmic presentation of gun pellet injury

We describe a unique case of orbital gunshot injury with isolated intraorbital pellets lodged symmetrically in the two apices, causing identical clinical presentation, and absence of any associated globe or cerebral injury. He developed bilateral complete third nerve palsy with bilateral traumatic optic neuropathy. The optic nerve strut prevented the pellets from going into the brain on both the sides.

The early management of gunshot wounds Part II: the abdomen, extremities and special situations

The management of gunshot wounds of the abdomen and extremities is evolving with centres who treat large volumes of such injuries tending to the application of a policy of selective non-operative management. This article discusses the management of gunshot wounds to the abdomen and extremities and reviews the evidence supporting these changing practices. Special situations such as wounding by shotguns or air rifles are also examined as are the special considerations needed when dealing with the gunshot injured pregnant women or in a child.

Vitreoretinal surgery for shotgun eye injuries: outcomes and complications

PURPOSE

To analyse the postoperative anatomic and functional outcomes in addition to complications after vitreoretinal surgery for patients with shotgun eye injuries related to hunting accidents.

MATERIALS

Retrospective review of the clinical records of all cases of shotgun eye injuries presented between January 2000 and January 2011 and with a minimum follow-up of 1 year. Collection of demographics, type of injury, choice of management, complications and final surgical success with final visual acuity is reported.

RESULTS

Twenty eyes of 19 patients (all male) with a mean age of 36.1 years (range 16-60 years) were included in the study. Mean postoperative follow-up was 47.5 months (range 15-118 months). Best corrected visual acuity (BCVA) at presentation ranged from perception of light to 20/200. Ten eyes had a penetrating injury and 10 others had a perforating injury. All the eyes underwent an initial vitrectomy and the intraocular pellet was removed in all the 10 penetrating injuries. Concurrent cataract surgery was performed in 12 cases, internal tamponade was used in 15 cases and a supplemental encircling scleral buckle was inserted in 12 cases. One additional vitreoretinal surgery was required in seven cases (35%) and two additional surgeries required in two other cases (10%). At last follow-up BCVA ranged from NPL to 20/20 and was 20/100 or better in 10 eyes (50%). All patients had a flat retina except for two cases (10%) that developed severe proliferative vitreoretinopathy.

CONCLUSION

These results suggest that vitreoretinal surgery can offer good visual rehabilitation in patients with shotgun eye injuries.

Retained periorbital and intracranial air-gun pellets causing sclopetaria and visual loss

Three healthy males presented on separate occasions to the emergency room at the King Khaled Eye Specialist Hospital (KKESH) after sustaining trauma by air-gun pellets. Clinical examination indicated sclopetaria in all the cases. The foreign bodies (air-gun pellets) were imbedded in different locations (subconjunctival, intraorbital, and intracranial). All cases resulted in a profound and permanent visual loss. The management of this traumatic injury is discussed and concurs with the published literature.

Gunshot wound to the eye and orbit: a descriptive case series and literature review

BACKGROUND

The objective of this study is to report ocular and orbital findings in a series of six patients (8 eyes) with gunshot wounds and to review the literature on the pathophysiology, management, and outcome of such patients.

METHODS

Retrospective case series and review of the literature. Main outcome measures were ocular and orbital injury, surgical intervention, and presenting and final visual acuity.

RESULTS

Six male patients (mean age, 32 years) were enrolled. Three patients with globe concussion and low presenting visual acuity were treated by observation. Two patients (25%) underwent primary enucleation or evisceration. Retinal detachment developed in one patient who had a globe perforation, and he underwent vitrectomy and lensectomy with silicone oil injection. Visual acuity remained unchanged in all but one patient who underwent retinal detachment surgery. Final visual acuity was poor in all patients, with five eyes ending in no perception of light. Four patients had orbital fractures, two of whom underwent orbital reconstruction. One of these patients also underwent drainage of orbital abscess, eyelid surgery, and a dacryocystorhinostomy. The mean follow-up time was 26 months.

CONCLUSIONS

Gunshot wounds to the eye and orbit cause severe open and closed ocular injuries with guarded outcome and poor visual acuity. When feasible, initial wound closure may preserve the globe and allow further surgical rehabilitation. Primary evisceration may be required in cases of a severely ruptured globe. Orbital surgery may be needed in cases of infection, orbital wall disruption with disfigurement, or late enophthalmos.

Gun-related eye injury in the United States, 1993-2002

OBJECTIVE

To present the descriptive epidemiology of gun-related eye injury in the United States from 1993 through 2002.

METHODS

Data from the National Electronic Injury Surveillance System was used to estimate the number of patients treated in the United States for gun-related eye injury (GEI) (air guns and firearms), air gun-related eye injury (AEI) (BB/pellet guns and rifles) and firearm-related eye injury (FEI) (all powder discharge guns) during the time period 1993 through 2002. Rates were calculated according to age, gender, race, weapon type and circumstances surrounding the injury event (e.g., locale and intent).

RESULTS

The rate of gun-related eye injury in the United States declined to 7.5 per 1,000,000 in 2002 from 14.8 per 1,000,000 in 1993, representing a decline of approximately 5.4% per year (p = 0.0002), due primarily to a decline in the rate of FEI (6.7% per year, p = 0.029). The rate of AEI was relatively constant. GEI rates were highest among those aged 10-19 years, males, and Blacks. The overall rate of AEI was higher than the rate of FEI (6.0 per 1,000,000 and 5.1 per 1,000,000, respectively). According to race, the rate of FEI was higher than the rate of AEI in Blacks whereas the rate of AEI was higher than the rate of FEI in Whites and Hispanics. The majority of GEIs occurred at home and were unintentional.

CONCLUSION

The rate of gun-related eye injury in the United States declined from 1993 through 2002 primarily due to a reduction in firearm-related eye injury, whereas the rate of air gun-related eye injury remained constant. Persons who were young, Black, and male were at highest risk for gun-related eye injury.

Retained intraorbital metallic foreign bodies

PURPOSE

To document the biological tolerance of retained metallic orbital foreign bodies managed with conservative treatment.

METHODS

A retrospective chart review of 43 patients treated between 1987 and 1993 with retained intraorbital metallic foreign bodies was performed. Age, sex, injury, imaging studies obtained, location of the foreign body, initial and final visual acuity, length of follow-up, treatment, and related adverse reactions and/or complications were recorded.

RESULTS

Fifty cases involving 34 male and 9 female patients ranging in age from 2 through 63 years (median, 25 years) were included. Seventeen cases were the result of gunshot wounds, 17 were from BB gun injuries, and 16 cases were from shotgun injuries. Forty-two patients had CT scans to assess the injury and one patient had plain radiographs. In 37 cases, the metallic foreign bodies were located posterior to the globe. There were 19 ocular penetrating injuries, 11 ocular contusion injuries (sclopetaria, commotio retinae, vitreous hemorrhages), and 20 injuries with no ocular involvement. Initial visual acuity ranged from 20/20 to no light perception, as did final visual acuity. The metallic foreign bodies were retained from 6 months to 68 years (median, 2 years). There were 19 ocular penetrating injuries, including 12 enucleations and 7 primary repairs. When contusion injuries were sustained, treatment consisted of vitrectomy for the removal of persistent hemorrhages (3 cases), exploration of the globe (1 case), and nonsurgical treatment (7 cases). Among the 20 cases with no ocular involvement, only 2 patients had secondary complications that required surgical intervention: One had mechanical strabismus, the other a sterile abscess. Visual acuity remained stable or improved in all cases. There were no late complications from the retained foreign bodies in 36 (95%) of 38 cases when the eye remained intact.

CONCLUSIONS

Retained intraorbital metallic foreign bodies are well-tolerated and typically have minimal adverse visual prognosis. They should be managed conservatively in the absence of specific indications for removal.

Eye injuries in twentieth century warfare: a historical perspective

With successive wars in the twentieth century, there has been a relative increase in injuries to the eye compared to injuries of other parts of the body. The main causes of eye injury have changed with advances in techniques and weaponry of warfare, with blast fragmentation injuries accounting for 50-80% of cases. Penetrating and perforating injuries are most common, and injuries associated with intraocular foreign bodies pose special diagnostic and management problems. Injuries are bilateral in 15-25% of cases. Injuries associated with chemical, nuclear, and laser weapons have distinct characteristics and epidemiology. Enucleation was commonly performed at the turn of the century, but incidence has declined with better understanding of the pathophysiology of ocular trauma, improved surgical techniques and sepsis control with antibiotics. Sympathetic ophthalmia appears to be uncommon and earlier fears of this complication seem to have been exaggerated. Timely evacuation to a surgical facility is important for a good visual prognosis and preservation of the globe. However, prevention of injuries with eye armor is ultimately the best management, and the need for a comprehensive eye protection program in the military cannot be overemphasized, especially since eye injuries pose important socioeconomic, as well as medical, problems.

Shotgun eye injuries. Ocular risk and eye protection efficacy

BACKGROUND

Little is known about the efficacy of shotgun eye protection. Shotguns can easily propel pellets with enough energy to penetrate the human eye, and a large percentage of shotgun eye injuries occur during shotgun sports such as hunting, trap, skeet, and sporting clays. Many of these injuries are preventable with proper eye protection. Although it is known that polycarbonate is the best lens material for shotgun eye protection, there has been no research that addresses the vision protective system design and its influence on eye protection.

METHODS

A field study was performed during which shotshells were fired at 1:1 scale photographs of human faces to determine the risk of ocular trauma. The protective efficacy of three types of polycarbonate protective eye wear (standard industrial safety glasses with snap-on side shields, wrap-around racket sport glasses, and three-piece glasses with integral side shields) was tested by firing shotshells at them at various distances. Both frontal and side protection was evaluated.

RESULTS

Results showed that the eye is at a high risk (55% to 100%) of being hit with shot pellets at ranges of 15 to 40 yards. It also was determined that the protective eye wear will give good frontal eye protection from shotgun pellets but integral side shields and a headband are necessary to obtain adequate side protection.

CONCLUSION

These findings, coupled with the poor visual prognosis of ocular shotgun injuries, indicate that polycarbonate protective eye wear with integral side shields and headbands should be worn by all involved with shotgun sports.

Eye injuries with metal missiles presenting to an emergency center: a three year study

The authors retrospectively evaluated 33 eye injuries due to metal missiles in 31 patients presenting to our emergency center over the last 3 years. Injuries occurred most frequently when the patients were grinding metal or working on their cars. The type of metal involved in the injury often dictates the type of ophthalmic reaction that will occur. A discussion of intraocular metallic foreign bodies with an emphasis on electroretinograms and metal analysis is presented.

Eye injury in sport

Eye injury sustained during sport is increasing in incidence worldwide, reflecting the rise in popularity of sport as recreation. It can account for up to 25% of severe eye injuries. This paper considers the historical context and demography of sports injuries, and the physical mechanisms and results of various types of ocular trauma in relation to sport. It reviews the specific problems associated with the sports considered to be most important in the epidemiology of eye injuries today. Certain sports, such as boxing, have an intrinsic risk of injury so high that some consider the sport should be banned. The risk of injury in many sports can be mitigated by changes in rules, such as the prevention of high sticking in ice hockey. Other sports with high risk of trauma could be made far safer with the widespread introduction of eye protection, and this applies especially to squash and badminton. The various types of eye protection are discussed. There is an urgent need to increase awareness of the risk of eye injury, to teach safe techniques, and to encourage the use of appropriate ocular protective wear in those at high risk of injury, especially the one-eyed.