Clinical Review & Education

JAMA Ophthalmology Clinical Challenge

Penetrating Ocular Fishhook Injury Daniel L. Chao, MD, PhD; Benjamin P. Erickson, MD; Aleksandra V. Rachitskaya, MD

Figure 1. External photograph showing a 3-pronged treble hook lodged in the cornea and lower eyelid; visual acuity is hand motions.

A man in his 30s presented with a fishhook injury to his left eye and lower eyelid after fishing in Everglades National Park. His visual acuity was hand motions, and intraocular pressure measurement was deferred in that eye. Findings from examination of the left eye Video at showed a penetrating injury with a 3-pronged barbed jamaophthalmology.com fishhook, with 1 prong lodged in the anterior chamber and another lodged in the lower eyelid (Figure 1). Quiz and Supplemental The status of the crystalline lens was unclear owing content at to corneal edema. No hypopyon was visualized. jamaophthalmology.com The patient was brought to the operating room for removal of the fishhook, closure of the cornea and eyelid lacerations, and injection of intracameral antibiotic drugs.

WHAT WOULD YOU DO NEXT?

A. Back-out technique: remove the fishhook in a retrograde manner through its entry wound B. Advance-and-cut technique: rotate the hook anterogradely, clip the barb, and back out the hook retrogradely through the entry wound C. Needle-cover technique: use the bevel of a large bore needle through the entry wound to engage and “cover” the barb, then withdraw together D. Cut-and-push-through technique: cut the lure, make a corneal exit wound next to the distal end of the hook, and rotate the hook through the exit wound

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Clinical Review & Education JAMA Ophthalmology Clinical Challenge

Answer D. Cut-and-push-through technique

A

B

Discussion A cut-and-push-through technique would likely minimize damage to the anterior chamber. A barbed hook, if removed in a retrograde manner, can cause significant tissue damage. An advance-and-cut technique would require significant manipulation of the fishhook in the anterior chamber, which could cause damage to the lens given the gauge of the hook. A needle-cover technique would cause damage to the cornea and has, to our knowledge, only been used for posterior segment penetrating fishhook injuries. Fishing is a popular recreational sport worldwide, with fishingrelated ocular injuries constituting 20% of sports-related ocular trauma in the United States.1 It is important to note whether the fishhook is barbed, the number and location of these barbs, and the number of prongs (Figure 2A) in determining one’s surgical approach. Three general methods for approaching ocular fishhook injuries have been described (listed in answer choices A-C) (Figure 2).2,3 The back-out technique may be best suited for barbless hooks. Advantages of the advance-and-cut technique include a controlled exit wound and minimal enlargement of the entry wound. However, this approach requires additional manipulation of the hook in the anterior chamber, especially if the proximal end is short. In our case, a large contaminated lure necessitated preoperative clipping of the lure, and the remaining proximal end was too short for a safe advance-and-cut technique. Moreover, the large gauge of the hook would make intraoperative clipping challenging. The needle-cover technique, reported for use in the posterior segment,3 was not applicable in our case given the gauge and the location of the fishhook. In this case, we used a novel cut-and-push-through technique. The fishhook was first clipped using large wire clippers, which can be found in orthopedic surgical trays, to separate the lure and allow for sterile ophthalmic preparation (eFigure, A, in the Supplement). The anterior chamber was filled with viscoelastic; an exit wound was then made in the temporal cornea using a paracentesis blade (eFigure, B) and the entire barbed hook was rotated through the exit wound using 2 curved hemostats (eFigure, C-D) (Video). Intracameral antibiotic drugs were given, and the prong in the lower eyelid was removed. At the 6-week follow-up, the patient’s visual acuity had improved to 20/25 (eFigure, F). ARTICLE INFORMATION Author Affiliations: Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Corresponding Author: Aleksandra V. Rachitskaya, MD, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17 St, Miami, FL 33136 ([email protected]).

348

C

D

E

Figure 2. A, Treble hook (left), barbed fishhook (center), and double-barbed fishhook (right). B, Back-out technique, in which the fishhook is rotated retrogradely through the wound. C-E, Advance-and-cut technique: the fishhook is rotated anterogradely through exit wound, the barb is cut, and the fishhook is rotated retrogradely through entry wound.

The prognosis for corneal and anterior chamber large fishhooks is generally poor, but good visual acuity outcomes are possible. In a cohort of 63 patients with open globe injuries caused by fishhooks, cited in the US Eye Injury Registry, about 50% had visual acuity greater than 20/200, with 12% achieving visual acuity greater than 20/40.1 However, in a separate case series, more than 75% of patients were able to attain visual acuities of 20/30 or better.2,4 As with any ruptured globe repair, the patient should be followed up closely for complications of the ocular trauma, including endophthalmitis, traumatic cataract, and retinal detachment. Five cases of endophthalmitis have been reported after fishhook injury.2,5 The surgical approach should be determined on a case-by-case basis, depending on the location of the entry and, if present, exit wounds, the type of fishhook, the surgical instruments available, and the comfort of the surgeon with various techniques, with the goal to minimize additional trauma and corneal scar formation. A cut-and-push-through technique for management of penetrating ocular barbed fishhook injuries should be considered in the armamentarium of surgical approaches when encountering a penetrating fishhook injury. Also, the importance of eye protection to patients when engaging in or observing this popular sport should be stressed.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

2. Aiello LP, Iwamoto M, Guyer DR. Penetrating ocular fish-hook injuries. Ophthalmology. 1992;99 (6):862-866.

Additional Contributions: Jack Stringham, MD, Bascom Palmer Eye Institute, provided helpful discussions and literature review. He did not receive financial compensation.

4. Bartholomew RS, Macdonald M. Fish hook injuries of the eye. Br J Ophthalmol. 1980;64(7): 531-533.

Conflict of Interest Disclosures: None reported.

REFERENCES

Funding/Support: This study was supported in part by Florida Lions Eye Bank, Miami Florida National Institutes of Health Center Core grant P30EY014801, a Research to Prevent Blindness unrestricted grant, and Department of Defense grant W81XWH-09-1-0675.

1. Alfaro DV III, Jablon EP, Rodriguez Fontal M, et al. Fishing-related ocular trauma. Am J Ophthalmol. 2005;139(3):488-492.

3. Grand MG, Lobes LA Jr. Technique for removing a fishhook from the posterior segment of the eye. Arch Ophthalmol. 1980;98(1):152-153.

5. Mohan N, Sharma S, Padhi TR, Basu S, Das TP. Traumatic endophthalmitis caused by Shewanella putrefaciens associated with an open globe fishhook injury. Eye (Lond). 2014;28(2):235.

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Penetrating ocular fishhook injury.

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