Penetrating injury of the cornea by a barbed fish hook and its surgical management by "Cut-it out technique".

Fishing is a worldwide pastime enjoyed by millions of people. Ocular fishing injuries though uncommon may cause potentially devastating ocular trauma. We report a rare case of penetrating injury of the cornea by a barbed fish hook and its successful surgical management by "cut-it out technique". We are discussing the various techniques available for removal of fish hooks. The hook can be successfully removed with minimal trauma to ocular structures by understanding the structure of the fish hook and by employing the appropriate method of extraction.

Fishing is a worldwide pastime enjoyed by millions of people. Indeed, in 1653, Sir Isaac Walton described fishing as “the contemplative man's recreation.”[1] Although incidence rate has not been reported, case reports agree that penetrating ocular fish hook injuries are rare.[2] Penetrating ocular trauma with fish hooks is an uncommon scenario, and safe removal of the hook can be challenging.[3]

We report a rare case of penetrating injury of the cornea by a barbed fish hook and its successful surgical management by “cut-it out technique”.[4] We are discussing the various techniques available for removal of fish hooks. The terminologies associated with various parts of the fish hook are also illustrated.

Case Report

An 11-year-old boy was struck in his right eye by a barbed fish hook while fishing with friends. The father cut off the fishing line and tried to remove the hook but failed. The child was brought to the hospital 12 hours after the injury. On examination, he had the best-corrected visual acuity (BCVA) of perception of light and projection of rays in all four quadrants in right eye. The fish hook had penetrated the cornea obliquely, 3 mm away from limbus at 9'0 clock [Fig. 1a]. Slit-lamp examination of the RE revealed, a shallow irregular anterior chamber filled with exudates due to which tip of fish hook was not clearly visible [Fig. 1b]. Fundus examination showed no fundal glow. B scan was not done as patient was highly unco-operative for examination. It was penetrating type of open globe injury of grade 4 involving zone 1 in right eye. The left eye was normal.

Figure 1

a: The fish hook had penetrated the cornea obliquely, 3 mm away from limbus at 9'0 clock. b: Slit lamp image of the right eye

The patient was given inj.Tetanus Toxoid 0.5 cc intramuscular Surgical Technique and started on oral antibiotics and advised for corneal FB removal and corneal tear repair under general anaesthesia. A written consent was obtained from the parents for removal of the fish-hook under general anaesthesia (GA). Under GA, first we tried to remove barbed fish hook with help of forceps through same entry wound but the attempt was failed because of lack of visibility of tip due to exudates filled in irregular anterior chamber and incarceration of iris tissue in the tip. Then we made side port incision at 2 O clock at limbus and anterior chamber tap was taken, then anterior chamber was washed with help of saline and viscoelastic injected [Fig. 2a]. The iris tissue plugged in the tip was separated with the help of iris repositor [Fig. 2b]. The entry wound was extended with help of 15 number blade to facilitate smooth removal of tip of barbed fish hook [Fig. 2c].[4] The configuration of the wound after enlarging it with the blade was curvilinear. After filling anterior chamber with viscoelastic material, fish hook was removed from same wound by oblique movement (cut-it out technique)[4] without damaging adjacent structures [Fig. 2d], the wound sutured with six interrupted10-0 nylon sutures [Fig. 2e] and side port hydrated. Bandage contact lens (BCL) was placed at the end as there was epithelial damage during removal of fish hook [Video 1]. On first postoperative day, the best-corrected visual acuity (BCVA) of perception of light and projection of rays in all four quadrants in right eye. The corneal sutures were intact and the anterior chamber was showing presence of exudative membrane with superior one third filled with air bubble [Fig. 3a]. B scan of right eye was normal with attached retina. The patient was started on topical antibiotic (Moxifloxacin 0.5% eye drops 6 times a day) and cycloplegic (Atropine 1% eye drops three times a day) and oral antibiotics were continued for 1 week duration. After confirming micro reports of exudative material after 3 days (i.e., no evidence of infection), the patient was started on topical steroids (prednisolone acetate 1% eye drops 6 times a day).

Figure 2

a: The viscoelastic substance injected in anterior chamber through side port incision made at 2 o'clock position. b: Iris tissue plugged in the tip of barbed fish hook was separated with the help of iris repository. c: The entry wound was extended with help of 15 number blade. d: Fish hook was removed from same wound by oblique movement. e: The wound sutured with six interrupted10-0 nylon sutures

Figure 3

a: Slit lamp image on first post- operative day. b: Slit lamp image on seventh post- operative day

At 1 week of follow-up, the best-corrected visual acuity (BCVA) was perception of light and projection of rays in all four quadrants in right eye. The intraocular pressure was digitally normal. The BCL was removed. The eye showed resolving exudative membrane in anterior chamber with damage to the iris at the pupillary margin and a traumatic cataract was visible [Fig. 3b]. The parents were counselled for the need of a cataract extraction in the future.

Discussion

Fishing is a popular leisure activity in many parts of the world. Ocular fishing injuries though uncommon may cause potentially devastating ocular trauma. It is vital to understand the various parts of the fishhook before any attempt is made to remove it. Many different types and sizes of fishhooks are available. All hooks are made up of same basic parts. The basic parts of the fish hook are the eye, shank, bend, barb, point and fishing line [Fig. 4]. When examining the hook, it is important to note if the fish hook is single, multiple or treble, whether the hook is barbed, and the number and locations of the barbs, these detail will help determine the best removal technique.[5] Often persons will know the type of hook they were using and may be able to provide a sample for inspection.

Figure 4

Terminology for various components of a barbed fish hook. The eye (e), shank (s), bend (Bnd), barb (b), point (p), fishing line/thread (l) and gap (g) are illustrated

Four techniques for the removal of fish-hooks embedded in non-ocular tissues have been reported in the medical literature.[6789] Their advantages, drawbacks, and use in ophthalmic injuries are detailed below.

The back-out method refers to backing the hook out through its entrance wound. It is primarily useful for barbless hooks and as the final manoeuvre in the advance and cut technique. When a barb is present and engaged in ocular tissues, excessive damage can occur if this method is attempted.

The snatch technique is a modification of the back-out method where downward pressure on the hook shank and rapid extraction are used to diminish pain during the removal procedure in non-ocular tissues. It is relatively traumatic technique and unadvisable for penetrating ocular injuries.

The advance and cut method is the most useful technique in anterior segment fish-hook injuries. The procedure has been previously photographically documented.[10] Briefly, the hook shank is grasped firmly, and a controlled surgical incision is placed to allow atraumatic delivery of the point and barb. Sterile wire cutters are used to transect the hook at a location between the barb and bend, and barbless hook is easily removed using the back-out technique described previously. The corneal wounds are closed with 10-0 nylon sutures. Advantages of the advance and cut method include a surgically controlled second wound, no enlargement of the primary wound, and minimal traumatic manipulation.

The usual method of choice for hook penetrations of the retina is the needle-cover technique described by Grand and Lobes.[8] This procedure entails passing a large bore needle into the eye through the hookentry wound. The fish-hook barb is then engaged within the lumen of the needle and both are withdrawn together.

We used “cut-it out technique”,[4] to remove the barbed fish-hook and avoid major damage. Since only one penetrating wound was present, before removing the hook, we preferrred to enlarge the primary corneal laceration surgically with a straight 15 number blade. The hook was removed backing through the entrance wound by oblique movement. (“cut- it out technique”). This technique can be considered as a safe approach for such specific pattern of ocular penetrating fish-hook injury avoiding further damage to ocular tissue. Finally, prevention is the key. Adequate personal eye protection is necessary to prevent such untoward accidents.

Conclusion

Our unusual case shows “Cut-it out technique” of a barbed fish-hook removal from the cornea. The hook can be successfully removed with minimal trauma to ocular structures by understanding the structure of the fish hook and by employing the appropriate method of extraction.

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.