Seven-Year Follow-Up of a Patient With a Retained Needlefish Jaw Fragment Abutting Against His Left Internal Carotid Artery

Photo and Video Essay Section Editors: Melissa W. Ko, MD Dean M. Cestari, MD Peter Quiros, MD Seven-Year Follow-Up of a Patient With a Retained Needlefish Jaw Fragment Abutting Against His Left Internal Carotid Artery Patrick Daigle, MD, FRCSC, Sonul Mehta, MD, Rajesh Bhayana, MD, FRCPC, Sunit Das, MD, PhD, Aditya Bharatha, MD, FRCPC, DABR, Navdeep Nijhawan, MD, FRCSC, DABO FIG. 1. Orbital computed tomography showing 2 retained needlefish jaw fragments after the same trajectory, the first (A, B) pushing against the left lateral rectus muscle (arrowhead) and the second (A) extending through the superior orbital fissure (arrow). Abstract: A 51-year-old man presented to the ophthalmology service with binocular diplopia and facial numbness. The patient was returning from a trip to Mexico. He reported having been hit in the left periocular region by a fish while swimming. Local doctors repaired a laceration in the left lateral canthus shortly after the incident. Orbital imaging revealed 2 needle-like foreign bodies corresponding to retained pieces of a needlefish jaw in the left orbit. Given the location of the foreign bodies, observation with repeat imaging was deemed more appropriate than surgical exploration. Subsequent imaging studies showed no migration of the foreign body, and the patient did not suffer from any related complications more than 7 years after the initial injury. Journal of Neuro-Ophthalmology 2021;41:e228–229 doi: 10.1097/WNO.0000000000001060 © 2020 by North American Neuro-Ophthalmology Society A 51-year-old man presented to the St. Michael’s Hospital of Toronto for evaluation of new-onset diplopia Departments of Ophthalmology and Vision Sciences (PD, SM, NN), Medical Imaging (RB), Neurosurgery (SD), and Interventional Radiology (AB), St. Michael’s Hospital, University of Toronto, Toronto, Canada. The authors report no conflicts of interest. Address correspondence to Patrick Daigle, MD, FRCSC, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada; E-mail: [e-mail] e228 and facial numbness. The patient was returning from a trip to Mexico. He reported that his symptoms started on his flight back to Canada. The diplopia was described as binocular and worse when looking up or left, and the numbness was limited to the distribution of the left supratrochlear and supraorbital nerves, involving mainly the eyebrow. The patient reported having been hit in the left periocular area by a fish while swimming a few days earlier. A small wound in the left lateral canthus had been explored and repaired by local doctors after the incident. His ocular history and his medical history were uneventful. On examination, his visual acuity was 20/25 in both eyes. There was no afferent pupillary deficit. The left periocular region showed mild edema and bruising and bore the marks of the previous repair. The left eye showed 360° of subconjunctival hemorrhage and limitation of elevation (21/2) and abduction (21), but there was no chemosis, proptosis, or misalignment of the eyes in the primary position. Eye movements were otherwise smooth and symmetrical, and the dilated fundus examination was unrevealing. Computed tomography (CT) imaging revealed 2 needle-like foreign bodies (4 and 23 mm) corresponding to retained pieces of a needlefish jaw in the left orbit. The smaller fragment (Fig. 1) was pushing against the left lateral rectus muscle, and the longer fragment (Figs. 1 and 2) was lying deep in the left orbital apex, extending intracranially through the superior orbital fissure and abutting against the left internal carotid artery. Daigle et al: J Neuro-Ophthalmol 2021; 41: e228-e229 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay FIG. 2. Orbital computed tomography (A–C) showing a retained needlefish jaw fragment (arrow) abutting against the left internal carotid artery (asterisk). There was no retrobulbar fat stranding, but the left lateral rectus was mildly enlarged, leading us to believe that the motility deficits mentioned above were most likely related to a mechanical restriction. CT angiogram showed no evidence of vascular injury. After a discussion with neurosurgery and interventional radiology, conservative management with topical moxifloxacin and repeat imaging was deemed more appropriate than surgical exploration, given the location of the 2 fragments. The diplopia resolved entirely over the ensuing months, but some numbness remained. Subsequent imaging studies showed no migration of the foreign bodies, and the patient did not suffer from any related complications more than 7 years after the initial injury. The marine wildlife is full of breathtaking scenery, but humans become vulnerable to various threats when they are underwater. Needlefish are elongated fishes that affectionate the warm temperature of shallow subtropical water. They are often observed swimming near the surface or jumping out of the water. Generally speaking, they do not pose a significant threat to humans. However, their fine jaw equipped with sharp teeth is capable of inflicting severe puncture wounds (1). The tip of their long and narrow beak may also break and remain trapped in the tissues of the victim. These fragments can sometimes be small and may go unnoticed initially (2,3). Clinicians should consider imaging any suspicious case to help with the diagnosis, and the examination requisition should include all the relevant clinical information. The bone density of the needlefish jaw facilitates its identification on a CT scan. The current literature contains several reports of retained needlefish jaw fragments in the orbit, but only 2 of them showed a posterior extension within the skull. The first (4) resulted in the patient’s death, and the second (5) responded well to oral antibiotics alone. Although no complications occurred during the 3-month follow-up period of that second patient, doubts arose regarding the stability of Daigle et al: J Neuro-Ophthalmol 2021; 41: e228-e229 the foreign body in the future. To the best of our knowledge, our case is the first to establish the long-term safety of a similarly conservative approach in a patient with retained needlefish jaw fragments in the orbit. Ophthalmologists should counsel their patients about the importance of wearing eye protection when swimming in open water. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: P. Daigle, S. Mehta, R. Bhayana, S. Das, A. Bharatha, and N. Nijhawan; b. Acquisition of data: P. Daigle, S. Mehta, and A. Bharatha; c. Analysis and interpretation of data: P. Daigle and S. Mehta. Category 2: a. Drafting the manuscript: P. Daigle and S. Mehta; b. Revising it for intellectual content: P. Daigle, S. Mehta, R. Bhayana, S. Das, A. Bharatha, and N. Nijhawan. Category 3: a. Final approval of the completed manuscript: P. Daigle and N. Nijhawan. ACKNOWLEDGMENTS The authors of this article declare no conflicts of interest. They acknowledge the patient presented in this study, who generously granted them permission to share his story and photographs with the academic community. REFERENCES 1. Thakker MM, Usha KR. Orbital foreign body and ruptured globe from needlefish impalement. Arch Ophthalmol. 2006;124:284. 2. Gounder P, Perera C, Moore G, Powers N, Arashvand K. A fishy eyelid injury. Orbit. 2019;38:233–235. 3. Haider A, Minckler DS, Yonkers MA, Tao JP. Orbital injury from needlefish impalement. Ophthal Plast Reconstr Surg. 2015;31:e170. 4. McCabe MJ, Hammon WM, Halstead BW, Newton TH. A fatal brain injury caused by a needlefish. Neuroradiology. 1978;15:137–139. 5. Kum C, Chang JR, Gruener AM, McCulley TJ. Nonsurgical management of retained needlefish jaw. J Neuroophthalmol. 2018;38:190–191. e229 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.