 A lot of us have seen v-begun injuries on call, and I'm sure a lot of the attendings here throughout their careers have also had some experience with these horrible injuries. So I just want to go into a little bit more depth about these injuries that we'll inevitably see throughout our careers. So a little review of eye trauma, some estimates of the 1977, there's an estimated 2.4 million eye injuries of all types occur in the US every year. These are all comers of eye injuries, about a 1 million Americans have permanent significant vision loss due to this injury, and more than 75% of these individuals are monocularly blind from the injury. Eye injury is the leading cause of monocular blindness in the United States. Also injury is the leading cause for eye-related hospital admissions. There is a high cost to this eye trauma, about $300 million annually. And also, interocular form bodies accompany estimates from 18 to 41% of these open globe injuries. Another interesting side is that medical legal liability, up to 56% of these trauma cases in ophthalmology are associated with missed interocular form bodies. So this is something to really consider and make sure you take a good history when you come into patient with eye trauma. BB guns, ball bearing guns. We're all familiar with these, a lot of us had them as children. I had one and about 3.2 million of these BB guns are sold in the United States every year. A lot of them are marketed as toys to children. They're sold in toy stores or sporting goods stores. 80% of these guns, just a little statistic about how these guns work. These muzzle velocities that these guns can shoot are about 350 feet per second, but about half of them have even higher velocities of about 500 to 900 feet per second than how they can fire. This range of the muzzle velocities for these, they call them non-powder guns, actually overlap with those of the traditional firearms. So they do have quite a bit of kick to them, especially when fired from close range. There was a study that they did on pig eyes and they found that about 246 feet per second from 10 feet away was about the speed needed in order to penetrate the human eye. BBs are typically made of steel. They sometimes have a copper as in coating and a lot of these are magnetic. BB gun injuries, some estimate from about 30 years ago. Air powered guns responsible for over 22,000 of injuries treated in the ERs. These are injuries of all types to the entire body. Over 1,000 of these were high injuries. Fast forward to 1999, 76% of all the people with BB gun related injuries were treated in the US, were quite young, 19 years old or younger. In year 2000, there was an estimated, still over 21,000 injuries related to non-powder guns. So there's not really a big change in the number of these injuries that are occurring despite everybody's best efforts to educate people about eye protection and policy changes on who can buy these guns. In terms of how the BBs actually injure the eye, it's a pretty small pellet about three to five millimeters. And we saw it without the velocities fired. And the way it hits the eye is that it really imparts a large conducive force on the globe. It's not a sharp object, therefore, the amount of force necessary to penetrate the eye is pretty high. The type of injuries we see are globe rupture with disruption of tissues and projectile path, intraocular form bodies. This almost makes you think that the worst type of injuries that can occur are those that penetrate the eye and then the BB ricochets within the eye itself and causes even more damage than if it was just a through and through injury. Again, optic nerve injuries, people leading to optic neuropathies, optic atrophy. And then the orbit, lids, and the nexal structures. Initial visual acuity does not correlate with the final visual acuity in several studies. I'll show you a study later that shows the many of the people that present with hand motions or light perception vision ended up with that poor of visual acuity at the end. But some of the studies that have been in the past did not show any correlation or significant association with initial visual acuity and final visual acuity. We just studied back in the 80s a review of BB gun injuries and they report at a nucleation rate of 86%, that's very, very, very high. All these remaining eyes had quite poor visual acuity past the legal blindness range. As you can see the nucleation rates range quite a bit in the literature, but you can think of maybe about 50 to 60% as an average for the studies. In 1991, Martin, a retinal surgeon, also did a series in his experience of all these perforating injuries that he had. These were all types of injuries, knives, hammering on nails, metal on metal injuries, pellet gun, shotgun, BB gun. And they actually found that BB gun injuries had the worst prognosis, had the worst prognosis in terms of all these penetrating injuries. This is from the journal Injury. This is another series on BB gun injuries, it's a journal I'd never heard of, but it's out there. They found this was back in 2011. They still found the visual prognosis was still very poor. Most of their patients ended up in the hand motions to light perception, to no light perception range. But however they did have less frequent inuculation rate, about 15%. They attributed this to modern surgical techniques in vitrectomy and staged repair of the globe. Here's a typical CT scan, just showing here of a pretty obvious intraocular form body. This is a stock photo I took off the internet. I'm not sure if that's a BB, but you could perceive it as probably a BB sitting right up against the retina. Probably some hemorrhage in the vitreous as well. This is a video taken on the iPhone from the OR monitor, but I just wanted to show you a case. Sorry, it's kind of bloody for this early in the morning, but just wanted to show you a case of a BB extraction just done recently with Dr. Bernstein. So this is late in the case when we had finally isolated the BB, made a large corneal incision. That tip on the right is a rare earth magnet that was used to lift the BB up, and there's the lens loop taken, the actual BB out. So pretty impressive that you can tell that there's, you know, that I had a very poor prognosis. So brief review of intraocular form bodies. You have organic versus inorganic materials. We think of organic materials like vegetative matter or wood that can be coming off a saw injury or something like that or a grinding injury. Inorganic materials, all the metals you can think of, hammering is a very common injury to have metal on metal, wewack or injuries, things like that. Metals reported in about 60 to 88% of intraocular form bodies, and up to 90% of these may be magnetic. So that's why we always have the earth, rare earth magnet available in the ORF that's in the posterior pole, and we need to get the form body out of there. Interactive form bodies are found in the anterior segment in a minority of cases, but it just goes to show that there's an important aspect of alternate imaging like anterior segment, OCT and ultrasound to be able to detect these in the clinic. There's a difficult view in a lot of these form body cases as the residents and I know. A lot of them are associated with vitreous hemorrhage and a lot of them do have traumatic cataracts so you might not be able to visualize the form body at the slit lamp. That just also proves that you do need to do imaging as a further step in your work up. Well, it was another study that showed that the entry site in the globe was only observed in about 86% of the cases. So even if the patient says, oh, nothing hit me, and they have a kind of a vague story of trauma, you really need to try to tease that out of their history to make sure that they, there's no possibility of an intracular form body. And then to find out, always go to imaging. So just a brief run through the management of intracular form bodies, make sure to assess all of their injuries. A lot of these patients have been involved in pretty significant trauma and they're being managed in the emergency room and being assisted by our emergency room doctors. So the next step would be imaging. A lot of these patients do have open globes with gaping wounds, primary closure of the open globe within hours. Is paramount in these cases. If inoplamitis is present, if they're presenting later, when you consider a tap and inject, systemic antibiotics are recommended throughout the literature, tetanus prophylaxis, and then eventually a stage removal and repair of all the other injuries. Traditionally, the intracular form body management literature has said that it's an urgent or emergent case to be able to remove the form body in order to avoid inoplamitis and other complications. This view has been challenged. There's a study that I'll show you in a little bit here about Iraq war veterans experiencing intracular form bodies and how they manage that. So choices for imaging. CT scan, in my mind, I think, is this is the kind of go-to imaging. They have very high sensitivity. It can detect up to 100% of metallic form bodies, greater than 0.05 millimeters in volume. Sensitivity is lower for non-metallic material. This can be mistaken for intraocular air, intraorbital air, if it's organic material. Plain films are not the imaging of choice anymore. They can miss a lot of these form bodies. Another thing to consider, as long as you don't put too much attention on the globe, if it is open, is an ultrasound. Now, it's definitely more user dependent than the CT scan, but it can be quite sensitive in detecting these. Interior segment OCT, like I mentioned, in select cases, if something is lodged in the angle or on the posterior surface of the cornea, you're not sure. This is, there's an advantage to that because it's a non-contact scan, so you're not gonna be expressing any intraocular contents with that type of imaging modality. And of course MRI is contraindicated because of the risk of this metallic objects moving around within the eye, causing more damage. In terms of antibiotics, what we recommend, the systemic antibiotics administered before or during intraocular form body removal. The third generation fluoroquinolones like levoquine, levofloxacin, have been shown to have superior intraocular penetration after systemic administration. And also prophylactic and travitrial antibiotics, just like myosin, septazidine, have been used during surgery with low reported endothelitis rates. Some complications of these form bodies endothelitis is a wide, wide range in the literature, but up to 30% for retained form bodies. And that's why a lot of people pushed towards early removal, these they don't wanna promote an infection if it's a dirty, dirty form body. Retinal detachment, a lot of these patients present with retinal detachment. Our patient that showed you before had a total retinal detachment that was unable to be repaired, unfortunately. Rates of proliferative vitro retinopathy are also cited in the literature and have a wide range of incidents as well. Calcosis and ceterosis from retained form bodies of copper and iron. Some people with intraocular form bodies presenting years and years down the road can present with a chronic, smoldering low grade uveitis or even a hypopion type uveitis. So it's always something to consider on your differential diagnosis as somebody with a remote history of trauma as well. And there's actually one report of acute retinal macrosis happening after a form body injury. And in the article, it doesn't really discuss if this is just a coincidence, but it seems to occur right after the form body injury. So it's a pretty interesting thing that occurred after the injury. Here's an article talking about risk factors for an ophthalminus and retinal detachment with these retained form bodies. They found that the increased risk for an ophthalminus was found in those that are non-metallic, so the organic type of materials. Those in the setting, if there was a dirty wound, someone was laying in a stream or a pond. Longer time into presentation as well. Prophylactic, intraventual antibiotics at the time of form body removal may lower the risk that they found. And also in terms of retinal detachment, they found it was associated with the posterior segment in track of the form bodies, obviously the entry side of the wound and ophthalminus and retinal impact sites. Here's the article that I was discussing earlier about the Iraq war veterans that had eventually initially been treated for intraocular form body and open globe injuries. So the way that it worked is they had an injury out in the field. It was repaired primarily at the base in Iraq. All their injuries were stabilized and then they were eventually evacuated to Germany and then came back state side to Walter Reed Army Medical Center. The primary intervention that most of these patients had was a three port 20 gauge vitrectomy with form body removal through either a limbo or a parsed plain incision. The end points of this study were to look at the final vitrocuti, the rate of endophthalminus and the rate of proliferative vitroretinopathy. These are all questions in the literatures. Does an earlier removal of the form body prevent these devastating complications down the road? In the study, the mean time of removal was actually 39 days. And you can think that that makes a lot more sense than somebody that's in Iraq that has to get flown back and has a lot of other injuries, maybe neurologic or neurosurgery injuries that need to be managed. So a lot longer than I would have expected. The mean preoperative visual cutie in this study was 2,400 and postoperative visual cutie is actually a lot better than some other previous studies was 20 over 120. They had no reported cases of sympathetic ophthalmia endophthalminus or cirrhosis from these retained form bodies even after an average of 39 days. They had a lower rate of NLP or nucleated eyes, about 10%. And they also, the main, most common regimen for systemic antibiotics was levoquine and topical Vigamox for about seven to 10 days. Is that, yeah. Were they doing the... So Germany was kind of like a staging area for them to get them back eventually to Walter Reed. I think if they had the ability to have a retinal surgeon there, they would do it there, but I think most of the cases were done at Walter Reed. So the results of the study, they found that postoperative visual cutie was associated only significantly with the extent of intraocular injury. All these other factors, initial visual cutie, where it entered, the type and size of form body, the source of it, whether you use eye protection or not, and the time to extraction did not play significantly in terms of postoperative visual cutie. In terms of the PVR rates, the only significant association found was the extent of intraocular injury and or presenting visual cutie with the rates of PVR. All those other factors I mentioned before were not statistically significant in terms of how much PVR forms in these patients. The conclusions of this... Iraq study. Delayed intraocular form body removal with combined systemic and topical antibiotics that can result in good visual cutie outcomes without an increased risk of endoplaminus or PVR, is what we can see. As long as primary closure is within hours like we do here in the middle of the night and then stage and repair of the intraocular injuries at a later time, there's no real advantage seen to early intraocular form body removal. So a lot of us on cough, we have an intraocular form body. It's an open globe. I think the better thing to do is to close it and then plan at a later time for removal of a form body or repair of a retinal injury, things like that. So future directions in intraocular form body removal. I'm gonna show you a video real quick of a technique. It's about a minute long. It's called the viscoelastic capture technique. I'm just gonna kinda talk through it a little bit here. So basically this patient had an intraocular form body sitting back on the posterior vitreous that they had to retrieve. You can see the CT scan there that's sitting right up against the retina. And this was penetrated through the cornea. There's a large laceration here. It's kind of hard to tell on the video. So they just do primary repair in their trocar. You'll be able to do their retrectomy, make their corneal incision. That's the site in which they're going to remove the form body. And that's a fairly small incision that they're doing. So it obviously depends on the size of the form body you're removing. And they go ahead and take the lens out. They go in, they can see the form body, do some treatment. This is where they go ahead and inject discovisc into the anterior chamber. And this discovisc actually acts as a medium for the form body to be suspended in. So when you bring the form body up, depending on the weight of it and the components of the viscoelastic you use, the form body can actually just be suspended in there. You don't have to switch hands to remove the form body. You can just take it out from there with forceps. So there's a little diagram of how it's suspended there. It's right about at the pupil level. It's captured in the anterior chamber and then eventually extracted. There's also another technique in the literature called the triple see-through technique. So a little bit similar, they do, they take the lens out and they make a posterior capsular rexis and then they eventually take it out through the posterior capsule, anterior capsule, and then through the corneal incision. There's also one last thing is in the literature they've done some experimental studies about silicone oil and viscoelastic used posteriorly to cushion the force of if you end up picking up the form body and then dropping it in the middle of the case to kind of cushion and prevent any hydrogenic injury. Any further injury to the retina. So conclusions from what I gleaned from all these BB gun injuries and looking at all these bad pictures. They still have a very, very grim prognosis. However the rate of a nucleation has seemed to drop in the years, so at least saving the eye itself has improved with modern surgical techniques. Also delayed form body removal does not worsen prognosis or increase complication rates. So something to consider during the middle of the night. And what I think is needed is education to patients and parents about how dangerous these weapons are and that they're being sold at toy stores and things like that. And eye protection is obviously a thing to counsel your patients about if their kids are gonna end up playing with these type of toys. All right, that's it. Dr. Keefer. Yeah, I mean a lot of them did have a lot of more serious injuries. Intracranial bleeds and limb injuries and things like that. So they had to be delayed. But a lot of them didn't. And it was interesting that they had actually zero cases of inoplamidus out of about 70, 77 form bodies. Tom. I do not think so of that. Cause there isn't really an explosion that comes out of the barrel of the gun, the BB gun. So I don't think that the metals heated up to a point where it'd be sterilized. And yeah, you're right. A lot of the IADs, they do consider those to be sterile but they have actually seen some reports of inoplamidus even with those IAD explosions. It's hard to tell exactly what was in those and what gets into the eye. Jim. Yeah, and actually airsoft rifle guns aren't as bad as BB guns. And obviously it's a plastic pellet. More of the injuries are high FEMA and things like that. And irritodialysis, more anterior segment type injuries. They aren't as devastating. The visual acuity in the reports is a lot better postoperatively in those more in the 2100 to 2040 range. Dr. Brunson. Yeah, but it's always difficult to decide. I'll take these four in one. All right, thanks.