Cut-it-out technique for ocular fish-hook injury.

An 11-year-old boy was involved in an injury with a fish-hook to his eye. The hook had impaled itself to the cornea and deeper structures. There was associated corneal edema and hyphema, making visualization difficult. In this case, we performed the unusual "cut-it-out" technique to remove the hook from the eye.

INTRODUCTION

As an occupation or past-time, fishing is widely practiced around the world. However, surprisingly, despite such extensive prevalence, injuries to the eyes from fish-hooks are rarely reported. A literature search provided less than a dozen cases of fish-hook injuries to the ocular structures. So far, there has been no reported case of actually using the cut-it-out technique for fish-hook removal, even though, it is reported in the literature as an option. Thus, this case report focuses on a rather uncommon, though devastating form of injury and on an unusual technique to manage this situation.

CASE REPORT

Fish-hook injuries to the eye are rarely reported. However, when they do occur, they can be associated with corneal lacerations and scars, traumatic cataracts, choroidal hemorrhage, vitreous hemorrhage, retinal detachment, and even endophthalmitis. Once the fish-hook is impaled in the ocular structures, extraction can become a challenge for the attending surgeon. The most common method reported is the advance-and-cut technique.[1] However, we report a case where the uncommon technique of “cut-it-out” was successfully employed to remove the fish-hook out of the patient's eye.

An 11-year-old boy was referred to our clinic with a history of injury to the right eye while fishing the day before. Apparently while pulling the line, the fish-hook flew to the patient's right eye and got embedded in the cornea. Someone had cut the line and the dangling hook was taped to the cheek [Figures 1 and 2]. The patient was received by us in this condition.

Figure 1

Patient on initial presentation

Figure 2

The fish-hook on closer inspection

On examination, the visual acuity was a perception of light (PL); with projection accurate in all quadrants in the affected right eye and 20/20 unaided vision in the left eye. The fish-hook had penetrated the cornea and impaled itself in the deeper tissues. There was a settled hyphema and the deeper tissues were obscured by it and corneal edema.

A written consent was obtained from the parents for the removal of the fish-hook under general anesthesia. We planned to use the commonly employed method of advancement of the fish-hook tip outside the cornea and snipping off the tip with wire cutters. However, during the surgery, we found the hook stuck firmly to the underlying tissues. Advancement was difficult. The hyphema and edema were making visualization impossible. On trying to pull the fish-hook out, it got stuck in the cornea. Thus, we decided to abandon that approach.

The hook was pulled back toward the cornea. The point of entry was enlarged with a 15° slit knife. The same knife was then pushed in along the shank until the barb could be felt near the cornea. This was then used to guide the fish-hook out of the eye [Figure 3]. Subsequently, the corneal laceration was sutured with 10/0 nylon. An anterior chamber washout was carried out with balanced salt solution. A subconjunctival injection of dexamethasone and gentamicin was given to complete the procedure [Figure 4].

Figure 3

The fish-hook on extraction

Figure 4

Immediate post-extraction appearance

At 1 week of follow-up, the eye showed minimal inflammation [Figure 5]. The vision was still PL; with accurate projection of light in the affected eye. The cornea had cleared appreciably. The damage to the iris at the pupillary margin and a traumatic cataract was visible. The parents were counseled for the need of a cataract extraction in the future.

Figure 5

Appearance on one week after extraction

DISCUSSION

Fishing is an occupation or hobby for a vast number of individuals across the globe. The coastline of Malaysia itself extends for 4675 km and fishing is widely practiced here. However, surprisingly, ocular injuries from fish-hooks are rarely seen. A recent search of the literature provided just one report of two cases from Malaysia.[2] The clinical picture seems to be similar in other countries too.

Fish-hook injuries to the eye can involve the eyelids and the anterior- or posterior-segments. There are five methods mentioned for fish-hook removal from the para-ocular or ocular tissues.[3] These include the following: (i) Advance-and-cut technique. The hook is pushed forward until the tip and barb are outside the eye. Subsequently, wire cutters are used to cut the hook between the barb and the bend. The shank is then pulled out of the eye through the entry wound. (ii) Back-out or retrograde technique. In this method, the hook is removed by simply backing it out through the entrance wound. As the barb can inflict more ocular damage during this maneuver, it is employed only for barbless fish-hooks. (iii) Snatch technique. This method is employed for removal of the fish-hook from non-ocular tissues. Downward pressure is applied to the shank and the hook is quickly removed. (iv) Needle-cover technique. This method has been reported when the fish-hook penetrates the retina. A large bore needle is passed into the eye through the entry wound. The barb is covered with the needle to prevent it from entangling in the tissues and both are then withdrawn together. (v) Cut-it-out technique. In this method, the entrance wound is enlarged by a scalpel blade. Then, the blade is slid along the hook until it reaches the barb. Subsequently, the hook is backed out of the eye similar to the back-out technique.

Patients with fish-hook injuries usually have corneal lacerated wounds and penetration of the lens, leading to traumatic cataracts.[245] In our patient also, the hook had entered the cornea and was stuck in the deeper structures. We discovered a traumatic cataract once the cornea had cleared and the hyphema subsided. Most reports mention a good visual recovery after cataract extraction.[45678] We also wish to perform a cataract extraction for our patient, once the inflammation subsides.

As the cornea is usually involved in these injuries, the usual sequel is corneal scarring. Unless extensive, the visual results in most cases have been satisfactory.[45] Traumatic cataracts are often caused by the fish-hooks penetrating into the lens. Other complications reported include choroidal[9] and vitreous hemorrhages,[8] retinal tears,[8] and retinal detachments.[9] Endophthalmitis is also known to occur. In one patient, the endophthalmitis developed after three weeks of the injury.[2] Another case with endophthalmitis was also associated with delayed wound closure.[6]

Our patient had the fish-hook stuck in the cornea. There was associated corneal edema and hyphema, making visualization difficult. Advancement of the hook was abandoned, fearing further damage to the tissues. Subsequently, we employed the cut-it-out technique in this case.

Fish-hook injuries to the eye can be devastating. It is occasionally difficult to manage these cases. The cut-it-out technique for fish-hook removal is an ideal option in cases where visualization is difficult. Ultimately, prevention is the key. Adequate personal eye protection is necessary to prevent such untoward accidents.