Fish hook injury to the eye

A unique presentation

Abstract

Fish-hook injuries are relatively uncommon and frequently involve upper extremities. A wide spectrum of ocular and adnexal trauma can occur following fish hook injury. We report an unusual presentation of ocular adnexal injury in a 34-year-old male who presented with a fish hook embedded in the lower eyelid margin with an intact anterior and posterior lamella. The fish hook was retrieved successfully without traumatizing both the lamellae by adopting a “sutureless, gray line split technique.” This case is being reported for its distinctive presentation and to emphasize the need to respect tissue anatomy and minimize surgical trauma while attempting removal of such sharp objects in order to achieve optimal functional and aesthetic outcomes.

INTRODUCTION

Fishing is considered a common leisure activity across the world, and it is a major source of income and livelihood, especially in the coastal regions of India. Ocular and adnexal trauma with fish hooks, though rare, can be sight threatening as in penetrating globe injury or nonsight threatening as in adnexal injury. We discuss an unusual case of fish hook injury ofthe eyelid margin with intact anterior and posterior lamella. This is the first case of fish hook injury repair using the “gray line split-cut it out” technique being reported.

CASE HISTORY

A 34 years old male presented with history of left lower eyelid pain and foreign body sensation following injury with a barbed fish hook 4h ago while watching his friend fishing. Ocular examination revealed best corrected visual acuity (BCVA) of LogMAR 0.00 in both the eyes. A fish hook foreign body was found to be trapped at the junction of medial two-thirds and lateral one-third of the left lower eyelid margin through a point entry posterior to the gray line [Figure 1a]. The overlying anterior lamella and underlying posterior lamella were intact, with no visible exit wound. Rest of the ocular examination was unremarkable except for minimal bulbar conjunctival congestion inthe left eye. The fish hook was removed under local anesthesia by gray line split approach. A 3 mm incision over the gray line on either side of the entry wound was made, and gentle dissection separating orbicularis oculi from the underlying tarsus was carried out up to 4 mm from lid margin thus exposing the barb and the sharp tip of the hook enabling easy removal of the hook [Figure 1b]. The anterior and posterior lamellae were well opposed by direct pressure. The eye was patched with an antibiotic eye ointment. Patient received intramuscular tetanus toxoid injection. He was prescribed nonsteroidal anti-inflammatory drugs for 5 days. The patient was lost to follow up.

Figure 1: (a) External clinical photograph showing the fish hook entering the patient's left lower eyelid margin at the junction of medial two-third and lateral one-third (b) Showing gray line split technique with anterior and posterior lamellae seen separately after fish hook removal

DISCUSSION

Commonly used fish hooks have a sharp point and a back-cutting sharp barb. A similar model of fish hook was found in our case [Figure 2a and b]. Purtskhvanidze et al.[¹] in their case series on fish hookrelated ocular injuries reported excellent postoperative outcomes in five out of nine cases. Various techniques of fish hook removal have been described in the literature.[²³⁴] They include:

Figure 2: (a) Photograph of various parts of a barbed fish hook (b) Clinical photograph of the fish hook foreign body following its removal

1. Back out or retrograde method: This method is used to remove barbless hooks where the hook is pulled backwards through the entry wound. This method can cause further tissue trauma in case of penetrating globe injuries. A modified version of this technique was adopted by Iannetti L et al.[⁵] in his case of penetrating globe injury by fish hook where the entry wound was enlarged before pulling out the hook.
2. Cut it out technique: The entrance wound is enlarged and dissected to expose the barb and sharp tip of the hook as described by Ahmad et al.[⁶] We have adopted a similar technique in our case as well.
3. Snatch or string yank technique: This technique was used for non-ocular fish hook trauma where a downward pressure is applied on the shank of the hook, and the hook is rapidly pulled out. This technique is significantly traumatic to the eye.
4. Advance cut method: This technique is less traumatizing as a second incision is made near the barb of the hook, and the hook is cut between the barb and the bend. The sharp tip along with the barb is then removed through the second incision, and the shank is removed through the entry wound using back out technique.
5. Advance without cut method: This method is similar to “Advance cut method” where the entire hook is advanced through a second incision made near the sharp tip of the hook without cutting the hook in between.
6. Needle cover technique: Described by Grand and Lobes for a fish hook penetrating the globe and the retina,[⁷] a wide bore needle is passed after enlarging the entry wound. The fish hook barb is then engaged within the lumen of the needle, and both are withdrawn together to deliver the hook out of the eye.

Our case, with a unique presentation adds to the existing literature of wide spectrum of presentation of fish hook–related ocular injury.

CONCLUSION

The choice of surgical technique for fish hook removal is dependent upon various factors such as the site of injury, type of fish hook, and severity of injury. Every attempt should be made to prevent further tissue trauma while attempting removal.

In our case, the “gray line split-cut it out technique” was employed for atraumatic removal of the hook.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgements

We would like to express our sincere gratitude to Dr. Vathsalya Vijay (Consultant Orbit and Oculoplasty, Department of Ophthalmology, Goa Medical College) for her invaluable guidance and encouragement in the successful completion of this case report.