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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 959-961

Bilateral blindness with a single bullet injury


1 Pediatric Ophthalmology and Strabismus Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiology, All India Institute of Medical Sciences, New Delhi, India

Date of Submission12-Feb-2022
Date of Acceptance12-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Prof. Rohit Saxena
Pediatric Ophthalmology and Strabismus Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_380_22

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  Abstract 


Gunshot injuries are a rising concern, which can have ocular involvement in almost 2% of cases. We present a case of a 35-year-old woman with accidental gunshot injury with no perception of light Oculus Uterque (OU). OD had disk pallor and OS, a repaired corneoscleral perforation. The bullet entered the left orbit perforating the left globe, crossed over to the opposite side, and exited through the right temple. Noncontrast computed tomography (NCCT) head revealed comminuted fractures of the roof, lateral and medial orbital walls. Multiple tiny bony fragments and foreign bodies were seen in the retrobulbar region of OD in relation to the optic nerve near the optic disk. This case highlights that gunshot injuries to the eye have high morbidity, but they are largely preventable as most injuries are unintentional, as was seen in this case. The priority should be to spread awareness and sensitize the masses regarding preventive factors.

Keywords: Bullet Injury, ocular bullet injury, orbital imaging, traumatic optic neuropathy


How to cite this article:
Warjri GB, Beniwal A, Vashistha V, Sharma S, Dhiman R, Saxena R. Bilateral blindness with a single bullet injury. Indian J Ophthalmol Case Rep 2022;2:959-61

How to cite this URL:
Warjri GB, Beniwal A, Vashistha V, Sharma S, Dhiman R, Saxena R. Bilateral blindness with a single bullet injury. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 30];2:959-61. Available from: https://www.ijoreports.in/text.asp?2022/2/4/959/358170



Gunshot injuries are a rising concern, which can have ocular involvement in almost 2% of cases.[1] In the USA, the rate of gun-related eye injury is 7.5 per 1,000,000.[2] In a retrospective study conducted in India, it was noted that 23.6% of gunshot injuries involved the eye.[1] Gunshot injuries are not only fatal, but can also cause irreversible vision loss due to direct globe involvement or visual pathway injury, especially involving the optic nerve.[2]


  Case Report Top


A 35-year-old female presented to the ophthalmology outpatient department (OPD) of a tertiary eye care center with the history of accidental gunshot injury that happened 12 days back when she was taking part in a religious festival in her village. An unknown person had fired the shot in the midst of the festivities when the bullet hit her left eye, following which the patient became unconscious for a few minutes. Upon regaining consciousness, she noticed loss of vision in both eyes. She was immediately rushed to a local hospital in the village. Her vitals were normal and Glasgow Coma Scale (GCS) score was 15. A noncontrast computed tomography (NCCT) head was advised and head injury was ruled out. She was then managed conservatively and referred to an ophthalmologist where it was noted that she was unable to perceive any light in both eyes and had a corneal perforation with uveal tissue prolapsed in the left eye. There was also a wound noted on the right temple. The left eye perforation repair was done and the right temple wound was sutured before the patient was referred to the tertiary eye care center for further management.

On examination, we noted that the patient was fully conscious and well oriented. She could not perceive light bilaterally. There was ecchymosis in both lower lids and the maxillary area [Figure 1]a. Four silk sutures were seen in the right temple, which was likely the exit wound for the bullet [Figure 1]b. The pupil of the right eye was 8 mm dilated, circular, and there was no reaction to light (direct as well as consensual) [Figure 1]c. The left eye had a hazy cornea with seven interrupted 10-0 silk sutures. The size of the wound was 11 mm × 4.5 mm, extending from 3 mm from the medial limbus and 2 mm from the lateral limbus, along the visual axis [Figure 1]d. The exit wound in the left globe could not be identified. On fundus examination, the right eye had a pale disk with distinct margins and the foveal reflex was sharp [Figure 2]. Fundus of the left eye was not visible due to the corneal haze. Based on these findings, a clinical diagnosis of right eye traumatic optic atrophy and left eye repaired corneoscleral perforation was made.
Figure 1: (a) Front profile of the face showing the ecchymosis of the maxillary region. (b) Side profile of the face showing the sutured exit wound of the bullet (arrow) at the right temple. (c) Anterior segment portraying Oculus Dexter (OD) clear cornea with 8-mm dilated circular pupil, not having direct as well as consensual light reflex. (d) OS hazy cornea with seven sutures

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Figure 2: Fundus photograph OD showing the disk with diffuse pallor

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To evaluate the cause of bilateral loss of vision, the computed tomography (CT) films of the patient were reviewed at the neuroradiology conference in our center. CT revealed comminuted fractures of the lateral wall, roof and medial wall of the orbit, greater wing of sphenoid [[Figure 3] arrows and [Figure 2]a arrowhead], medial wall of optic canal, and anterior and lateral walls of the maxillary sinus on the right side. Multiple tiny bony fragments and foreign bodies were seen in the retrobulbar region [[Figure 3] box arrow]. Continuity of right optic nerve was maintained. However, a few foreign bodies were seen in relation to the nerve near the optic disk [[Figure 3]a box arrows]. On the left side, there was comminuted fracture of the medial wall of the left orbit [[Figure 3] arrowhead]. The left globe appeared small with air foci [[Figure 3]b arrowhead]. The left optic nerve sheath complex and the orbital apex were normal. A B-scan ultrasonography was performed, which showed a foreign body impinging into the optic nerve sheath on the right eye [Figure 4]a.
Figure 3: Non-contrast CT head images showing (a) fracture of the medial wall of the right orbit (arrow), comminuted fracture of the medial wall of the left orbit (arrowhead), and multiple tiny bony fragments and foreign bodies in the retrobulbar region of the right side with fat stranding (box arrow). (b) Comminuted fracture of the right greater wing of sphenoid (arrow). The left globe appears small with air foci within (arrowhead), and few foreign bodies are seen in relation to the right optic nerve near the optic disk (box arrow). (c) Continuity of the right optic nerve is maintained, with a few foreign bodies seen in relation to the optic nerve near the optic disk (box arrow) and fracture of the roof of orbit of the right side (arrowhead). CT = computed tomography

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Figure 4: (a) B-scan ultrasonography showing a foreign body impinging into the optic nerve sheath of the right eye (arrow). (b) 3D CT head view showing the trajectory of the pellet. CT = computed tomography

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The findings were, therefore, suggestive of the following trajectory of the pellet [Figure 4]b: upon entry from the left eye and after causing a corneoscleral perforation, the bullet fractured the left medial orbital wall, crossed over to the right orbit in the retrobulbar region and in close relation to the right optic nerve, leaving multiple bony fragments on its path, thereby causing optic nerve injury in the right eye, and finally exiting through the right temple region.


  Discussion Top


In our case, vision loss in the right eye was likely due to traumatic optic neuropathy caused by the bony fragments and bullet fragments impinging onto the optic nerve as seen on NCCT and Ultrasonography (USG), and in the left eye, it was due to direct globe involvement, as evident by a massive corneoscleral perforation.

The presence of temple entry and exit wounds can be suggestive of a classical suicide attempt, which can similarly cause vision loss by blunt or penetrating globe trauma or by the involvement of the optic nerve.[3] But we ruled out a suicide attempt by taking a thorough history from the patient, whose story was corroborated by the attendant and by the medico-legal case report that was prepared after the incident.

This case highlights that gunshot injuries can not only be life-threatening, but also cause severe morbidity leaving the subjects bilaterally blind. As the patient presented late, the prognosis for both the perforated eye and the eye with optic atrophy had become worse. In this case, it was decided by the neurosurgeon not to remove the retained intraorbital foreign bodies. Retained intraorbital metallic foreign bodies usually do not affect the visual prognosis and are well tolerated. Therefore, they should be managed conservatively unless indicated otherwise.[4]

Gunshot injuries are largely preventable as most are unintentional, as was seen in this case. They have become a public health crisis,[5] and the priority should be to spread awareness and sensitize the masses regarding preventive factors. “Injuries have causes – they do not simply befall us from fate or bad luck.”[6] Passive prevention is more effective than active prevention.[7] With respect to gunshot injuries, passive prevention would mean more stringent rules for Arms Licences rather than the active prevention of instructing people not to use firearms. It has been noted that there has been a decrease in homicidal and suicidal injuries when handgun licensing is restricted.[8] There is a need for legislators to pay heed to proposals made by health-care professionals regarding preventive measures for gunshot injuries and the efficacy in terms of cost when adopting such measures, in comparison to their tertiary prevention.[7]


  Conclusion Top


Gunshot injuries are a major cause of morbidity to the eye and the prognosis worsens on late presentation. The only armament that we have presently is to strengthen awareness and to implement legislation to curb rampant use of firearms.

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.
Gupta A, Mittal S. Blindness due to firearm eye injuries in rural western Uttar Pradesh. Indian J Ophthalmol 1999;47:194-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
McGwin G, Hall TA, Xie A, Owsley C. Gun-related eye injury in the United States, 1993-2002. Ophthalmic Epidemiol 2006;13:15-21.  Back to cited text no. 2
    
3.
Matthews W, Wallis DN. Patterns of self-inflicted injury. Trauma 2002;4:17-20.  Back to cited text no. 3
    
4.
Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthalmic Plast Reconstr Surg 2004;20:232-6.  Back to cited text no. 4
    
5.
Taichman DB, Bauchner H, Drazen JM, Laine C, Peiperl L. Firearm-related injury and death: A US health care crisis in need of health care professionals. JAMA 2017;318:1875.  Back to cited text no. 5
    
6.
Preventing Injuries by dissemination information. Available from: http://www.injuryprevention.org/. [Last accessed on 2022 Jan 26].  Back to cited text no. 6
    
7.
Hazinski MF, Francescutti LH, Lapidus GD, Micik S, Rivara FP. Pediatric injury prevention. Ann Emerg Med 1993;22:456-67.  Back to cited text no. 7
    
8.
Loftin C, McDowall D, Wiersema B, Cottey TJ. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med 1991;325:1615-20.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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