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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 554-556

Intraoperative use of C-arm fluoroscope for removal of gun pellet in the orbit


Axis Eye Clinic and Department of Ophthalmology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

Date of Submission17-Sep-2021
Date of Acceptance07-Jan-2022
Date of Web Publication13-Apr-2022

Correspondence Address:
Ramesh Murthy
Axis Eye Clinic, Kumar Millenium, Paud Road, Pune, Maharashtra - 411 038
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2390_21

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  Abstract 


Gun pellet injury is rare but devastating to the eye. Airgun pellets made of lead can ricochet between the orbital bony walls and can damage the intraocular structures, even causing loss of vision. These pellets can get displaced in the orbital fat during surgical manipulation. Intraoperative CT scan is not readily available in hospitals; however, C-arm fluoroscopy is readily available in most setups. We used a C-arm fluoroscope and three instruments (i.e., two malleable retractors and a periosteal elevator) for locating and removing the pellet successfully in two cases, which to the best of our knowledge has not been reported before.

Keywords: C-arm fluoroscopy, gun, intra-orbital, lead, pellets


How to cite this article:
Murthy R. Intraoperative use of C-arm fluoroscope for removal of gun pellet in the orbit. Indian J Ophthalmol Case Rep 2022;2:554-6

How to cite this URL:
Murthy R. Intraoperative use of C-arm fluoroscope for removal of gun pellet in the orbit. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 24];2:554-6. Available from: https://www.ijoreports.in/text.asp?2022/2/2/554/342953



Gun-shot wounds though rare are associated with severe organ damage.[1] Bullets fired at the face usually lodge in the maxillary, frontal, ethmoid, and sphenoid sinuses.[2] Orbit involvement is generally coincidental. Airguns frequently use lead pellets and are used for recreational purposes. The position of the pellet may shift after the CT scan has been done and may be difficult to locate intraoperatively in the orbital fat. A C-arm fluoroscope gives a real-time view of the location of the pellet. We describe two cases where we successfully removed gun pellets from within the orbit by using a C-arm fluoroscope.


  Case Reports Top


Case 1

A 5-year-old boy presented with black eye and lid swelling of the right eye [Figure 1]a. While he denied any history of injury, his parents noted that a pellet loaded in an airgun was missing. On examination, he was noted to have no light perception in the right eye, the lid showed ecchymosis, ocular movements were full, conjunctiva showed subconjunctival hemorrhages, pupil showed afferent pupillary defect, and ocular movements were full [Figure 1]a. The disc was faintly seen with the presence of hemorrhage over the disc and vitreous hemorrhage. CT scan was performed which showed a radio-opaque foreign body approximately 1 cm long and approximately 6 mm wide, with high echogenicity in the intraconal space between the eyeball and the orbital walls, suggestive of an air gun lead pellet [Figure 1]b and [Figure 1]c with disruption of optic nerve contour. The option of leaving the foreign body alone was given to the parents, especially with no hope of vision salvage. However, the parents were doctors and were keen on the removal of the foreign body. Under general anesthesia, a medial transconjunctival approach was planned. Six-0 sutures were passed through the medial rectus, and the medial rectus was disinserted [Figure 1]d. The eyeball was rotated laterally by traction with Moody fixation forceps at the medial rectus insertion stump. Using a periosteal elevator, artery forceps, and the malleable retractor as three instruments, the C-arm was used to take images to locate the gun pellet in three dimensions [Figure 1]e, [Figure 1]g, and [Figure 1]h. The gun pellet could be located and was held with the artery forceps and removed [Figure 1]f. The medial rectus was reinserted at its original location, and the conjunctiva was closed with 8-0 vicryl interrupted sutures. The patient recovered well but vision remained no perception of light.
Figure 1: (a): A 5-year-old boy presented with right eyelid ecchymosis, lid edema, and subconjunctival hemorrhage. CT scan orbits - axial scan (b) and coronal scan (c) showed the hyperdense foreign body in the intraconal space between the medial rectus and optic nerve. (d) The medial rectus was disinserted, and by using three instruments, the gun pellet was removed (e) and (f). A C-arm fluoroscope was used to identify the gun pellet (black arrow) by using a malleable retractor (1), artery forceps (2), and a periosteal elevator (3) (g and h)

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Case 2

A 25-year-old male patient presented with an injury to the right eye by accidental firing from an air gun. He had no perception of light in the right eye. The right eye showed superior scleral tear approximately 5 mm from the limbus extending from 2-o'clock to 10-o'clock position with uveal tissue prolapse, and there was subconjunctival hemorrhage and total hyphema [Figure 2]a and [Figure 2]b. CT scan showed a radio-opaque foreign body embedded in the zygomatic bone in the superotemporal orbit [Figure 2]c and [Figure 2]d. The eyeball was distorted with vitreous hemorrhage inside the eyeball. As the patient and relatives were keen on the removal of the lead pellet, surgery was undertaken under general anesthesia. The scleral tear was sutured. The lateral rectus was tagged with 6-0 vicryl sutures and was disinserted. The superior orbit was explored and using a C-arm fluoroscope and three instruments, namely two malleable retractors and a periosteal elevator, the pellet was localized [Figure 2]e, [Figure 2]f, and [Figure 2]h. Using an artery forceps, the bullet was held and was removed [Figure 2]g. The lateral rectus muscle was reinserted and the conjunctiva was closed with 8-0 vicryl sutures. Postoperatively, the patient recovered well but vision remained no light perception.
Figure 2: A 25-year-old male presented with accident injury to right eye with gun pellet. (a) The right eye showed subconjunctival hemorrhage, lid ecchymosis, and (b) lid entry wound. CT scan orbits axial (c) and coronal (d) showed a gun pellet embedded in the zygomatic bone temporally. The lateral rectus was disinserted (e), and by using three instruments, the pellet was removed (f and g). A C-arm fluoroscope was used to identify the gun pellet (dotted arrow), and three instruments, namely malleable retractors (two thin arrows) and a periosteal elevator (thick arrow) (h) were used

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  Discussion Top


The extent of injury caused by a gun pellet depends on the type of pellet, shooting distance, initial velocity, and the effect of the ricochet of the bullet in the orbit.[3] Gun pellets fired from airguns usually lodge between the eyeball and orbit, but if shot from a close distance can lodge in the bone. The force of a high-velocity object close to the globe can cause rupture of the choroid and retina, leaving the sclera intact, with vitreous hemorrhage and fibroglial proliferation. In 1901, Goldzieher described the fundus after a periorbital bullet wound as “chorioretinitis plastica sclopetaria,” which is now called “chorioretinitis sclopetaria.” Metallic foreign bodies are generally inert, while organic foreign bodies can incite an immune reaction.[4] Surgical intervention may not be needed if there is a single metallic pellet; however, our patients were keen on removal. Moazeni et al.[5] reported that only cases of multiple pellets increase the risk of lead poisoning and may need surgery. Immediate surgical intervention includes foreign body removal, globe exploration, pars plana vitrectomy, scleral buckle, enucleation, etc.; this may be detrimental and resulted in final best-corrected visual acuity (BCVA) worse than 20/20 more significantly than in patients with no intervention (91.7% vs. 78.4%).[6]

The primary aim is to highlight the use of the C-arm fluoroscope as a useful and accessible option for locating foreign bodies in the orbit. The portable radiography unit may not be immediately available, additional time will be spent in processing the film or scanning in the radiological suite, or it may fail to localize the object. This time lag can mean displacement of the foreign body downwards. The fluoroscope allows for real-time visualization and localization of the object. Moreover, the orientation of the beam can be changed to get a more detailed position of the object. However, one must remember that there is additional radiation exposure both to the patient and the operating team due to the C-arm. To reduce radiation exposure, we used pulsed exposure setting and used lead aprons for all present, thus reducing the radiation exposure. However, the removal of such pellets in a seeing eye needs to be performed with caution. Use of a C-arm has been described in maxillofacial surgery for the removal of foreign bodies.[7]


  Conclusion Top


Orbit is difficult to negotiate due to prolapsing orbital fat and easy displacement of the foreign body. Using a C-arm is a viable and cost-effective option for cases of orbital metallic foreign bodies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Claros P, Fokouo JVF, Claros A. Intraorbital foreign body: A rifle bullet removed 20 years after the accident. Eur Ann Otorhinolaryngol Head Neck Dis 2017;134:63-5.  Back to cited text no. 1
    
2.
Khyani IAM, Hafeez A, Farooq MU, Alam J. Endoscopic removal of bullet from orbital apex. J Coll Physicians Surg Pak 2008;18:646-8.  Back to cited text no. 2
    
3.
Gönül E, Akbörü M, Izci Y, Timurkaynak E. Orbital foreign bodies after penetrating gun shot wounds: Retrospective analysis of 22 cases and clinical review. Minim Invasive Neurosurg 1999;42:207-11.  Back to cited text no. 3
    
4.
Charteris DG. Posterior penetrating injury of the orbit with retained foreign body. Br J Ophthalmol 1988;72:432.  Back to cited text no. 4
    
5.
Moazeni M, Alibeigi FM, Sayadi M, Mofrad EP, Kheiri S, Darvishi M. The serum lead levels in patients with retained lead pellets. Arch Trauma Res 2014;3:e18950.  Back to cited text no. 5
    
6.
Ludwig CA, Shields RA, Do DV, Moshfeghi DM, Mahajan VB. Traumatic chorioretinitis sclopetaria: Risk factors, management, and prognosis. Am J Ophthalmol Case Rep 2019;39:39-46.  Back to cited text no. 6
    
7.
Bhaskaran MV, Lijo J, Shenoy A, Rao CV. Intraoperative use of C arm fluoroscope for location of foreign body in maxillofacial surgery: Series of cases. Craniomaxillofac Trauma Reconstr Open 2019;3:e6-8.  Back to cited text no. 7
    


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