Nonsurgical Management of Retained Needlefish Jaw

While scuba diving, the left medial canthus of a 53-year-old man was pierced by a needlefish. He immediately lost vision in his left eye. An orbital computed tomographic scan showed the needlefish jaw in the left optic canal. The left medial orbit was explored surgically but no foreign object was removed. One month later, MRI confirmed the presence of the retained needlefish jaw. A conservative approach was taken and the patient remained stable over 3 months of follow-up.

Photo Essay Section Editor: Timothy J. McCulley, MD Nonsurgical Management of Retained Needlefish Jaw Clarissa Kum, OD, Jessica R. Chang, MD, Anna M. Gruener, MBS MSc, FRCOphth, Timothy J. McCulley, MD FIG. 1. Needlefish. Courtesy of George Grall, National Aquarium, Baltimore, MD. Abstract: While scuba diving, the left medial canthus of a 53-year-old man was pierced by a needlefish. He immediately lost vision in his left eye. An orbital computed tomographic scan showed the needlefish jaw in the left optic canal. The left medial orbit was explored surgically but no foreign object was removed. One month later, MRI confirmed the presence of the retained needlefish jaw. A conservative approach was taken and the patient remained stable over 3 months of follow-up. Journal of Neuro-Ophthalmology 2018;38:190-191 doi: 10.1097/WNO.0000000000000576 © 2017 by North American Neuro-Ophthalmology Society A 53-year-old man reported a 1-month history of no light perception (NLP) in his eye after an injury sustained while scuba diving off the coast of the United Arab Emirates (UAE). After surfacing and removing his diving mask, he The Johns Hopkins Hospital, Wilmer Eye Institute, Baltimore, Maryland. The authors report no conflicts of interest. Address correspondence to Clarissa Kum, OD, The Johns Hopkins Hospital, Wilmer Eye Institute, 600 N Wolfe Street, Woods 457A, Baltimore, MD 21287; E-mail: [e-mail] 190 was struck in his left medial canthus by a needlefish (Fig. 1). Immediately after the injury, he lost vision in the left eye. He had an orbital computed tomography (CT) showing a foreign body in the orbital apex and underwent emergent orbital surgery but no foreign material was identified. He was given a 3-week course of antibiotics. One month later, the patient was evaluated at our institution. Visual acuity and examination of the right eye was normal. Acuity was NLP in the left eye, with a normal appearance to the anterior segment, no proptosis, but limited elevation and adduction. A scar extended from the left medial canthus to the left upper lid margin. Funduscopy was notable for mild left optic disc pallor. Review of CT images from the UAE revealed a foreign body within the left optic canal (Fig. 2). MRI showed the fish jaw extending from the left optic canal into the prechiasmatic suprasellar cistern with inferomedial displacement of the optic nerve and enlargement of the left medial and superior rectus muscles (Fig. 3). No further intervention was pursued given the location of the fish jaw, stability of symptoms, and little chance of visual recovery. The patient's clinical course remained unchanged over 3 months of follow-up. Needlefish (family Belonidae) are slender predatory fish with pointy beak-like jaws, most often found in shallow warm waters. They generally pose little threat to humans, but Kum et al: J Neuro-Ophthalmol 2018; 38: 190-191 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo Essay FIG. 2. Axial CT scan shows needlefish jaw (arrow) in the left optic canal extending intracranially. they have been reported to cause puncture injuries (1-11). Often the tip of the fish jaws breaks off and remains embedded in the injury site. It is believed that the fish mistake shiny objects such as jewelry and human eyes as prey. Approximately, one-half of the reported cases involve the head and neck, including several periorbital cases and 1 intracranial case (6-11). Limb and torso injuries also have been described (1,2). The patient reported by McCabe et al (6) parallels our patient in that the fish jaw penetrated the intracranial space. It punctured the lateral canthus and extended into the cavernous sinus, and the patient ultimately died of this injury. Our patient was fortunate that no significant vascular injury occurred despite intracranial penetration. In previously described cases, management almost always involved urgent removal of the fish jaw fragments that comprised bone, teeth, and some flesh. Because of location, the jaw fragment was not retrieved in our patient. Haider et al (8) described a patient who was initially managed similarly with observation, but because of persistent orbital inflammation days after injury, the fish jaw was ultimately retrieved. Our patient was managed successfully with antibiotics and observation. Although inflammation and/or infection were not encountered during our patient's follow-up period, the possibility remains that complications may be encountered in the future. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design, C. Kum, J. R. Chang, A. M. Gruener, and T. J. McCulley; b. Acquisition of data, C. Kum, J. R. Chang, A. M. Gruener, and T. J. McCulley; c. Analysis and interpretation of data, C. Kum, J. R. Chang, A. M. Gruener, and T. J. McCulley. Category 2: a. Drafting the manuscript, C. Kum; b. Revising it for intellectual content, J. R. Chang, A. M. Gruener, and T. J. McCulley. Category 3: a. Final approval of the completed manuscript, C. Kum, J. R. Chang, A. M. Gruener, and T. J. McCulley. REFERENCES FIG. 3. Axial (A) and coronal (B) postcontrast T1 MRI with fat suppression reveals the fish jaw (arrow head) in the left optic canal with enlargement of the left medial rectus (MR) and superior rectus (SR) muscles and inferior displacement of the left optic nerve (ON). Kum et al: J Neuro-Ophthalmol 2018; 38: 190-191 1. Rouvillain JL, Donica A, Gane C, Zekhnini C, Garron E, Uzel AP. Windsurfing hazard caused by needlefish. Eur J Orthop Surg Traumatol. 2013;23(suppl 2):S295-S297. 2. Clark JJ, Ho HC. 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