 But it chronicles an eight-year-old boy in his quest for a red-rider BB gun and everyone he goes to meets him with the same response Which is you'll shoot your eye out kid I'll spare you the YouTube video because we have some exciting Presentations today, but let me just start with that. So case presentation is Previously healthy eight-year-old male. He's a Native American boy who lives north of Montana who presented to an outside ma hospital in Missoula With bleeding pain vision loss in the right eye after being shot While playing with the family BB gun with his younger brother Some social history that is I think pertinent to this case. Like I said, he's from north of Missoula at a The Flathead Indian Reservation and prayers mom They actually had the BB gun around not just for fun or play But because they actually felt like they needed it for their safety in their area on examination at primary children's He was flown down here by a fixed wing plane Which is a whole nother discussion because he had absolutely no way of getting home and no means to do so But that's for another day He was pretty inconsolable. We had a really difficult time examining him but he did have an obvious three millimeter skin wound on his inferior eyelid and then Questionable to no light perception his examination again was very difficult very unreliable But we couldn't get him to reliably identify light at that time This is his examination under anesthesia in the operating room as you can see Penetrating wound that I was talking about here, which actually ended up being a full thickness Laceration once we were able to flip the lid and take a look at it safely. Of course. He's got 360 degrees of hemorrhagic Kemosis and then on further examination He has a large inferior scleral laceration with extensive uveal prolapse Which extended from the limbis? Inferiorly master rated the inferior rectus muscle complex and then extended posteriorly beyond which we couldn't identify He came with some imaging when he came from the outside hospital, which was actually a pretty poor quality CT scan But it was all we had Which identified at first what was named as a as a five millimeter pellet inside the globe? On further look it looked like it may have actually penetrated Anteriorly and posteriorly and maybe either residing on the optic nerve or somewhere in the posterior sclera We tried to get some better views and then thought we had convinced ourselves that perhaps it was actually sitting behind The eye and that there looked like there was a layer of scleral closed in front of it And again here we thought you know this looks like it's actually penetrated through and through the posterior aspect of the globe While we were in the OR in order to glean some more information We didn't have the amazing dr. Harry available because he was at the VA, but we did phone him in So I may ask for his input on these pictures, but we did Do a b-scan and we were concerned that we actually saw a couple of Hyperacoic spikes inside the vitreous in addition to the known pellet, which we believed was actually posterior In addition to the extensive posterior damage to the Choroid and retina And this is a better look at that Hyperacoic spike with what we felt like was within the vitreous Dr. Harry, I don't know if you have any particular thoughts I know these are kind of limited in terms of what pictures are available because they were interoperative, but Okay, that's exactly kind of the conclusion we We ended up with which is when we looked a little bit closer to the CT scan as we sliced from anterior to posterior what looked like there may be a fragment in The vitreous as well as then the larger pellet that we could not actually identify with the v-scan So that was the theory we kind of proceeded with and we ended up going with a primary globe closure here We did a so-as-you-go technique which is just revealing as much of that inferior scleral laceration as possible Until we could no longer go posterior and unfortunately that laceration just extended beyond our capability to close So we ended up closing the eye sending the patient with antibiotics and a plan to watch him very closely and The retina team had been involved at this point as had the oculoplastics team And their their call was to go ahead and just watch things as far as the posterior pellet and the intraocular piece So I think this brings up two important clinical questions With the management of this patient first. What is the timing then for going into the back of the eye? When do we need to get involved with retina if we have a presumed intraocular foreign body? We have likely a posterior scleral rupture How do we weigh the benefits and risks of going at a certain time? And then how do we manage this intra orbital foreign body? When do we go chasing after these pellets that are floating around the orbit? A little bit of background because in november of this year there was actually a case or a study that came out of Ohio that got a lot of news attention and that is that There's been a significant increase in the rate of injury from BB guns to children So estimations now say that a child is treated every hour from injuries from non powder guns, which includes airsoft guns BB guns pellet guns and baseball guns This is the study I was talking about that caught all of the attention And basically the study looked at cases from 1996 to 2012 sorry 1990 to 2016 And looked particularly at all injuries and then at eye injuries from BB guns and other non powder firearms And they saw that there was a 30% increase in in eye injuries BB guns account for the majority so 80% of these injuries and eye injuries account for 15% of the hospital visits in hospital stays from these injuries Not surprisingly boys ages 6 to 12 were the highest risk group accounting for approximately 87% Take from that what you will And here again shows the the trend which Demonstrates the number of firearm injuries on their left hand side and the rate Of firearm injuries on your right hand side showing kind of a steady decrease over that interim time period There's this interesting spike in 2006 which nobody's been able to really study enough to know why that may have happened And of course people presume that these numbers are under reporting the true scope of injuries from these BB guns and non firearms Certainly there's a couple of deaths every year and a couple of intracranial injuries This was a story also out of Ohio of a of a young man who ended up with a pellet in his brain But for us more pertinently and more commonly we see devastating ocular injuries From these projectile metallic foreign bodies Study in Vanderbilt of tertiary care centers in the area Estimated that 94 percent of patients end up with hand motion or worse vision at their final kind of visit And then 57 percent of patients down the line After all their surgeries actually ended up without any light perception So it's a real really dangerous problem for us and something we need to think about So to address the first question What is our timing of retinal surgery? And I hope there's a couple of our retina colleagues because a few of them were involved in this case, but this is a really delicate balance between Stabilizing the globe Temporizing inflammation, but also not leaving the eye too long to develop fibrosis and of course pvr Animal studies and other human studies have demonstrated that pvr develops usually within about four to six weeks of these types of injuries, which I think is a a tough Statement to actually make because we don't really know exactly what point this happens And I think each patient is different But that's certainly in the back of our mind as something that we're working against as far as time but Going in the eye early also has a risk of going into an unstable eye, especially if there's a posterior scleral rupture So a two-step approach is what's favored in the literature and what we tend to do here at Moran That is go ahead with a primary repair as we did Try to stabilize the globe itself re-establish its integrity prevent infection And then go back for a secondary repair with the retina team to go in the back of the eye assess for injuries And then go ahead and treat as needed The timing of this again is difficult. We used to in the old literature There's in the 1960s some evidence to suggest we should go in within the week within four days to again prevent viture retinopathy, but Data now suggests that we wait Four to six weeks at least allow the globe to stabilize and then go ahead and go in the back of the eye when we feel like it's more Kind of stabilized There were some questions about avoiding cryotherapy and these sorts of traumas just because the outcomes And of the burns from cryotherapy were actually worse And then there's also been questions raised of scleral buckling in this situation. When is it safe to go ahead and put that pressure on an eye That's been compromised I don't know if there's anyone from retina doesn't look like it in the room or anyone else that needs to come Oh, dr. Plunk any um any thoughts on on this Easier Okay I know gun culture is very different in germany from here. Uh, are there airgun injuries? Is that a thing? Do children have little air guns with metallic? Very rally This is definitely The eye of this version is available otherwise the next day or Also because of the pvr and that's the funnel So I wanted to see if the retina people still think this but it's a lot different if it's a penetrating injury That's not a piece of metal. I think that's probably some important members So you So if it's a piece of wood would you So if it was a piece of wood you'd be fine waiting a week or more With any piece I would be, you know, great. Thank you. Oh dr. Larshall Perfect. Perfect timing Yes, primary closure. Correct. Yes. Yes. All of these primary closures involved direct administration of antibiotics To the back of the eye at the time of surgery as well as Oral antibiotics for the duration of the eye was actually open That's a really really important question. I did not come across that Not something that was really mentioned in the literature But it would certainly be worth looking at as you're waiting, especially if there's a known foreign body inside the eye Thank you. Great. Thanks guys um The next step with this patient, of course, is then addressing the piece of the intra orbital foreign body So this kind of goes to what what dr. Stagg was talking a little bit about which is what is the material? How does this affect things? Now kind of quieter materials including plastic glass and most metals actually The data suggests that if they're intra orbital and beyond the equator where you can get to them easily are actually often best left within the orbit Obvious exceptions to that like dr. Stagg said organic materials So wouldn't plant matter that is a night is for infection IR copper and lead which can lead to systemic and local inflammatory responses Would would lead you to go and actually dive after a piece more readily Certainly optic nerve compression fistula formation and infection and abscess now It's difficult because in the literature some papers will say that actually leaving A pellet or piece of glass or something that's actually abutting the optic nerve Uh, doesn't change your visual outcome and in this situation I think that would be actually very important to consider because we do think this pellet is either sitting close to or on the optic nerve And I think the question at that point is well as as much damage It's been done already with the traumatic optic neuropathy of the initial injury Are you going to go in and worsen that by attempting to remove a pellet? That's abutting the nerve um and I don't know. Dr. Marx was in on the conversation with this patient and we elected to actually just watch this pellet certainly while the eye was unstable, but um In the future if we're going back in the eye, he actually elected to continue watching it given the poor visual prognosis I don't know if there's anyone from oculoplastics here who wanted to comment on that dr. Patel How do you see arms to locate the thorium body sometimes? So, uh, just going back to the Intriartocular thorium body, I think first before we get to the orbit The european approach is to remove all the thorium bodies in the eye as soon as possible Unless your invasion is going to cause more harm than good That's an excellent Think to start with with all the thorium bodies. If you uh have been part of Whether it's entirely compression bones or the retraction of the elaceration, you're going to do more harm than good So you're best leaving orbital thorium bodies behind and intraocular thorium bodies If you have the same access as Dr. Says the discussions about ionic compositions and the secondary effects by the ions To the surrounding tissue toxicity and so on And there is a list we discussed this in orbital conference about four years ago Of all the guns that are sold in the united states for what the bullets are composed of Actually, we have access to that. I think via the central body And some of them contain magnetic material some of them contain graphite Some of them contain lead All of which can cause graphite is much less toxic than some of the other things The question line would be business about oh the bullet is close to the opening there So yeah, take it out if you can easily don't take it out. Thank you, dr. Patel Wonderful. Thank you all so much I'll I'll kind of hurry through the rest of my presentation to get on to the other two But uh things that came up with this patient is actually making sure that the correct CT scans are ordered at the time of the injury Thin axial CT scans can be helpful in this situation So back to our patient. We saw him back in clinic about 10 days post operatively He had some questionable light perception at that time again unreliable, but a formed globe minimal discomfort Living his life normally per mom good compliance and the ability to follow up Which was a question again with his social history would the tribe actually provide transportation Which is an eight-hour drive from montana or not? So we considered three things a nucleation evisceration in the setting of a concern for Sympathizing in the other eye with a patient who lives in an aroma area Going in and exploring taking out that foreign body and then of course going in exploring and Taking out the orbital foreign body and of course we decided To go ahead and allow the glow to globe to continue to stabilize and then proceed with Exploration and surgery in the back of the eye And then just as dr. Patel said to go ahead and leave that foreign body at the time that we do so So he's coming back actually a week from friday and he'll be able to Get that done Last thing I was going to say is Ralphie I was going to call on dr. Mamelis and say well, why did Ralphie? This is him getting his red rider BB gun. Why did he not shoot his eye out? And that's because he was wearing his glasses So prevention is huge in this case briefly touching on what dr. Petty said there's actually No federal regulation of these non powder fire guns here in the united states That means it leaves it up to each state to determine what the safety regulations are for these guns And living in the state of utah, of course, there are no regulations or safety Standards for any of these guns here in the state of utah So Advocating for state level regulation at least safety guidelines and trainings when you actually purchase these guns is something important for us to keep in mind Promoting protective eyewear and then of course educating our children and parents in clinic when we have the chance So thanks to the amazing team that's taking care of this difficult patient. Few of you are in the room. I appreciate all your hard work