A young man, 27, in the greater Boston area got a steely shock when a nail flung by his weed whacker pierced his right eye. The man, a professional landscaper, called 911 and landed in the emergency department 20 minutes after the accident.
Beyond the obvious symptom of excruciating pain, the patient had a nose bleed that started and stopped for unknown reasons. He also couldn't open his eye. Otherwise, he was alert and in good health.
At no point did the man pass out, neurologist , of Massachusetts General Hospital in Boston, and colleagues, reported in the .
A team of radiologists suggested a dual-source CT scanner in dual-energy mode to avoid "streak artifacts from the metal in the indwelling nail." Still, the scans still produced some streak artifacts, which inhibited visualization around the nail..
Nonetheless, the physicians were able to see that the tip of the nail, sitting close to the left carotid siphone, the left optic nerve, and the left ophthalmic artery, didn't penetrate the left internal carotid artery or the left ophthalmic artery.
Overall, there was a surprising lack of cranial bleeding from the nail's sharp path. This was remarkable considering the tip of the nail was less than 1 mm from these arteries, Gupta's group observed.
However, the doctors were concerned the nail was perhaps corking an active bleed. This was the "central question driving the management of this injury," the authors wrote.
The course of the nail shot at a medial, posterior angle into the inferior, medial right orbit near the medial canthus. It traveled into the right globe and right inferior orbital rim, penetrating the right lamina papyracea, extending through right ethmoid air cells and the left sphenoid sinus until it terminated at the inferior margin of the left optic groove close to the left anterior clinoid process.
Gupta's diagnosis was "penetrating orbitocranial trauma due to a nail, without globe rupture or injury to the carotid artery or brain."
To provide access to the intracranial internal carotid artery in case the need for an emergency vessel repair arose, a pterional craniotomy approach was used, much like when aneurysm repairs are done in this region. This approach also left the man's neck exposed for access to his vertebral carotid artery in the event of problematic blood flow during surgery, the authors stated.
The surgeons took a "carefully-remove-the-nail-and-wait-for-problems" approach.
Postoperative scans showed some soft-tissue swelling, and the path of where the nail had been, but no bleeds.
Vascular injury, infection, and seizures were the greatest postop concerns. A delayed pseudoaneurysm, an arteriovenous fistula, and cerebrospinal fluid leaks were the long-term concerns.
Fortunately, a CT angiogram at 3 months showed no delayed vascular trauma.
Other than a tetanus shot and a 5-day course of antibiotics, the man required no postop treatments. "The patient did not have any brain injury," the group said.
At his 8-week check-up, the man's sight appeared fully restored.
The authors noted that the patient was "extremely fortunate," as the margin of 1 mm was the only thing that stood in the way of "serious functional loss."
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Disclosures
Gupta disclosed relevant relationships with the Defense Advanced Research Projects Agency (DARPA), the Department of Defense (DOD), Boston Scientific, and Siemens Medical Solutions.
One co-author disclosed relevant relationships with Medtronic and Functional Neuromodulation.
Primary Source
New England Journal of Medicine
Gupta R, et al "Case 15-2015 -- a 27-year-old man with a nail in the eye" N Engl J Med 2015; DOI: 10.1056/NEJMcpc1310007.