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ARTICLES
Year : 1985  |  Volume : 33  |  Issue : 2  |  Page : 99-103

Bilateral orbital perforation - (a single bullet injury)


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
S K Angra
Associate Prof. Ophthalmology, Dr- Rajendra Prasad Centre For Ophthalmic Sciences, A.I.I.M.S, New Delhi- 110029
India
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Source of Support: None, Conflict of Interest: None


PMID: 3833744

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How to cite this article:
Angra S K, Padhy S C, Venkateswarlu K, Kalra V K. Bilateral orbital perforation - (a single bullet injury). Indian J Ophthalmol 1985;33:99-103

How to cite this URL:
Angra S K, Padhy S C, Venkateswarlu K, Kalra V K. Bilateral orbital perforation - (a single bullet injury). Indian J Ophthalmol [serial online] 1985 [cited 2019 Nov 12];33:99-103. Available from: http://www.ijo.in/text.asp?1985/33/2/99/30830

Gun shot injuries are often associated with both extraocular and intraocular damage. More commonly these are encountered in war and commonly in civil life as accidental, homicidal or suicidal attempts. In such in­juries a great amount of ocular damage is caused because the bullet has both the for­ward as well as rotatory movements and therefore possesses much higher amounts of kinetic energy. Bony fragments also act as missiles and add to the damage. The nature of damage varies with the direction of impact and the part of globe involved[1],[2].

The present cases are interesting, because a single bullet has caused damage to both the orbits, ocular structures and adnexa lead­ing to total blindness.


  Case reports Top


Case I

A 34 year old Hindu male came to the casualty with the history of homicidal bullet injury. The firing was done at a close range. Out of the bullets fired, the first one did not hurt him, the second hit his temple and the third one hit his left groin. The patient lost consciousness for five minutes and thereafter complained of blindness in both eyes and had bleeding from both the nostrils.

On examination the patient was fully conscious, well oriented and responded well to stimuli. There was bleeding from both the nostrils. The wound of entry was seen about 2 cms. horizontally away from the outer canthus of the right eye [Figure l]a. The wound of exit could not be seen. Another wound of entry was seen in the left inguinal region and the femoral pulsations were pre­sent. There was no perception of light in either of the eyes and there was gross restric­tion in ocular movements. The right eye showed chemosed conjunctiva protruding from the temporal side of palpebral aperture and was associated with gross conjunctival congestion. Eye ball was collapsed with gross corneal folds. Rest of the ocular details could not be discerned due to gross retro­corneal haemorrhage.

In the left eye there was gross conjunctival chemosis. Cornea was clear, the pupil was dilated (6 mm), circular and there was no reaction to light (direct as well as consensual) [Figure - 1]b. Fundus details could not be seen due to vitreous haemorrhage, though in the lower temporal region, retinal vessels and a few haemorrhagic patches could be seen.

X-ray skull revealed a large radio opaque foreign body in the postero-superior part of the left orbit. Both the orbital roofs showed fracture and associated fracture of ethmoid bones of both sides [Figure - 1]c,d.

Topical antibiotics were instilled in both the eyes, systemic steroids and broad spectrum antibiotics were started and a close watch was maintained for the vital signs, bleeding from the nostrils and the wound site. The right eye was enucleated as it was grossly damaged. A circular aper­ture with irregular margins about 1.5 cm. in diameter was seen in the medial wall of the orbit. Bony fragments were seen near the defect. The bullet in the left orbit. The bullet, in the left orbit was removed by an anterior orbitotomy under general anaes­thesia. There was no perforation of left globe. The proptosis in left eye gradually reduced with time but however, there was no visual gain.

Case II

Twenty nine year old Hindu male was admitted with close range homicidal gun­shot injury on the right temple. Soon after injury, he lost consciousness from which he regained after 2-3 hours.

On examination a wound of entry [Figure - 2] of the size of I cm. X I cm. was seen I cm posterior to the right lateral orbital margin. A similar wound was seen on the left temple about 5 cm. from the left lateral orbital margin. There was no perception of light in both eyes. Axial proptosis with gross restriction of movements was observed in both eyes. Eyelids were edematous with conjunctiva grossly chemosed. Left eye showed signs of black eye. The right cornea showed multiple superficial foreign bodies while left cornea was normal. Anterior chamber was present and showed grade I flare in both eyes. Pupils were dilated and fixed. Lens was normal in both eyes. Vitreous haemorrhage was seen in both eyes. Fundus could be hazily seen.

X-ray skull (AP) was Normal. X-ray skull lat. view revealed a long fracture line [Figure - 2]c in the temporal bone. X-ray PNS showed left frontal sinus hazy both maxilly sinuses hazy. ERG was flat both eye [Figure - 3]a. VER-No pattern was recorded [Figure - 3]b in both eyes.

Ultrasonography- Immersion B scan, right eye revealed widening of retrobulbar fat complex, and enlargement of extraocular muscles. The anterior acute angle of the optic nerve could not be seen.

Contact A scan revealed vitreous haemor­rhage in right eye and vitreous haemorrhage with retinal detachment with harmorrhagic SRF in left eye cr scan showed evidence of contusion in left basifrontal lobe. Rest of the brain parenchyma and ventricular system were normal.


  Discussion Top


In homicidal attempts, bullets come from front and/or obliquely. But in our cases though homicidal ones, wound of entry of bullets were in the right temple region which gives a suspicion of suicide. Important ocular and orbital structures are often injured in bullet injury. Although the optic nerve damage and chorioretinal laceration is common, in case I. the bullet caused perfora­ting injury of the globe near the point of entry. But in the contralateral eye of this case and in both eyes of case II, the globes remained intact but there was total blindness. We feel this depends upon the size of the bullet and the direction of entry in the orbit. Usually the bullets get lodged in the second orbit (case I) and rarely the bullet came out of the second orbit (case II).

The proptosis and the chemosis produced in our cases might be due to retrobulbar haemorrhage as well as edema of the retro­ocular and periocular structures. The trauma may be due to the bullet or due to the bony fragments which might have acted as second­ary missiles. In our cases the wounds were not infected. Such wounds are usually not infected because of the high temperature of the bullet and excessively good vascular supply of the face which provides an excellent defense to infection and necrosis.[2]

The projectile may reach the other orbit through various routes. Vogt[3] reported a case in which bullet, traversing one orbit and naso­pharynx, eventually entered the other orbit. This is route of bullets in our cases. An inte­resting case was described by Shimkin[4], where the whole orbit suffered auto- exenteration. A rare instance where the missile entered both the orbits without causing permanent damage to vision, has been described by Weeks[5]. If the bullet traverses the head be­hind the orbit, the wound is usually fatal, but a case has been reported by Roy' where­in missile became impacted in the chiasma, causing complete blindness in one eye and partial blindness in the other.

In case I, because of large size of the bullet and the damage produced by it in left eye, we attempted to remove it. The bullet of such nature may be extracted safely without damaging the eyeball through an anterior route. However, under certain circumstances lateral orbitotomy or transfrontal approach may be resorted to[2]. Though the bullet has not damaged orbital roof on the left side the left frontal lobe on CT scan showed evidence of contusion. This might be an indirect evi­dence of bullet impact on the frontal bone.

Freeman[7] described that in cases of trau­matic injuries resulting in optic nerve sheath haemorrhage, the visual acuity is normal initially. But the vision drops down after one or two days rapidly. At this stage optic nerve decompression is advised. He has also mentioned that subnormal ERG is a good prognostic indicator. But in our cases the perception of light and ERG response were negative. Though we attempted anti-infla­mmatory and corticosteroid therapy, the visual outcome was nil in our patients.


  Summary Top


2 unusual cases of bullet injury are des­cribed in which a single bullet has enered bdth the orbits and caused bilateral blindness.

 
  References Top

1.
Chundawat H S , Vyas V.K., Agarwal R L., Nepaliya L.K. Shashi, 1976, East. Arch, Ophthal­mol, 4 : 95.  Back to cited text no. 1
    
2.
Duke Elder S. 1972, System of Ophthalmology, Vol. XLV, 676, Henry Kimpton, London.  Back to cited text no. 2
    
3.
Vogt, 1952 : Klin mob! Augenkeik, 120 : 539  Back to cited text no. 3
    
4.
Shimkin. 1940, Brit. journ. Ophthalmol. 24: 265.  Back to cited text no. 4
    
5.
Weeks, 1903, Trans. Ophth. Amer. Med. Asso­ciation. 217.  Back to cited text no. 5
    
6.
Roy, 1912, Ophthalmology, 9 : 63.  Back to cited text no. 6
    
7.
Freeman. H. M. 1976, Ocular Trauma, p 335, Appleton Century Crofts, New York.  Back to cited text no. 7
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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