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PHOTO ESSAY
Year : 2016  |  Volume : 64  |  Issue : 10  |  Page : 770-771

Bilateral complete blindness following globe-sparing single-bullet orbital injury


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

Date of Submission02-Feb-2016
Date of Acceptance12-Aug-2016
Date of Web Publication1-Dec-2016

Correspondence Address:
Brijesh Takkar
Room No. 487, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.195001

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Keywords: Bullet injury, foreign body, orbital perforation, traumatic optic neuropathy


How to cite this article:
Gaur N, Takkar B, Sharma P. Bilateral complete blindness following globe-sparing single-bullet orbital injury. Indian J Ophthalmol 2016;64:770-1

How to cite this URL:
Gaur N, Takkar B, Sharma P. Bilateral complete blindness following globe-sparing single-bullet orbital injury. Indian J Ophthalmol [serial online] 2016 [cited 2020 May 30];64:770-1. Available from: http://www.ijo.in/text.asp?2016/64/10/770/195001

Traumatic optic neuropathy due to missile injury typically results in unilateral visual loss.[1] We discuss an uncommon case, in which injury from retroocular passage of a single bullet resulted in bilateral orbital perforations, frozen globes, and complete blindness.

A 20-year-old female presented with bilateral absent light perception detected immediately, following alleged accidental bullet injury. There were no cranial manifestations and sutured skin wounds were visible on the temporal aspects of both the orbits. Bilateral ocular coats were intact with normal intraocular pressure and anterior segments. However, there was bilateral complete afferent pupillary defect and vitreous hemorrhage. Noncontrast computerized tomography (NCCT) imaging revealed multiple orbital and nasal fractures, a bony fragment abutting the right globe [Figure 1]a, and bilateral temporal orbital perforations on reconstructed images [Figure 1]b and [Figure 1]c. The entry wound was left-sided and slightly lower than the right-sided exit wound [Figure 1]b and [Figure 1]c. Sonography revealed attached bilateral retinas. The combination of complete afferent and efferent neural dysfunction was attributed to injury of bilateral posterior orbits near the apical region. No ocular intervention was planned due to poor prognoses and absence of any foreign body.
Figure 1: (a) Transverse computerized tomography scan depicting bilateral multiple orbital and nasal fractures along with a bony fragment abutting the right posterior globe. (b) Three-dimensionally reconstructed computerized tomography image of the right side of the face showing the exit wound of the bullet (black arrow). (c) Three-dimensionally reconstructed computerized tomography image of the left side of the face showing the entry wound of the bullet, set lower than the exit wound (black arrow). Other orbital and facial fractures are also visible

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  Discussion Top


Bilateral globe sparing orbital perforation due to a single bullet is an extremely rare entity. Missiles can cross the facial midline, resulting in ocular motility disorders, and ocular injury may also result secondarily from mobile bony fragments.[1] Bilateral ocular injury is usually related to gunshot or blast injury, and bilateral optic neuropathy is especially rare. However, suicide attempts with bullets aimed at the temple can result in contralateral visual defects, prognoses, and extent of which depends on the passage of the bullet.[2] The integrity of ocular coats is usually breached though rarely it may remain intact as seen in our case.[3],[4]

Bilateral vision loss after globe sparing head trauma may be because of direct or indirect traumatic optic neuropathy, Terson syndrome, or chiasmal injury. In our case, NCCT of the head did not reveal any injury to the cranial cavity, chiasma, or the optic canals. Because of the accompanying efferent loss, direct traumatic optic neuropathy due to orbital injury appears to be the most likely cause of vision loss in this case. Vitreous hemorrhage resulted possibly from tangential trauma inflicted during the bullet's retroocular passage.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gönül E, Erdogan E, Tasar M, Yetiser S, Akay KM, Düz B, et al. Penetrating orbitocranial gunshot injuries. Surg Neurol 2005;63:24-30.  Back to cited text no. 1
    
2.
Medicke I, Müller-Jensen K. Prognosis in orbital gunshot injuries. Ophthalmologe 1998;95:172-5.  Back to cited text no. 2
    
3.
Angra SK, Padhy SC, Venkateswarlu K, Kalra VK. Bilateral orbital perforation-(a single bullet injury). Indian J Ophthalmol 1985;33:99-103.  Back to cited text no. 3
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4.
Schargus M, Kawa D, Elling M, Kunkel M. Management of suicidal orbital gunshot wounds to the temple. Ophthalmologe 2014;111:965-9.  Back to cited text no. 4
    


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