Fishhook Injury of the Anterior Chamber Angle of the Eye

Abstract

A 36-year-old man presented with a corneal penetrating fishhook injury with the tip embedded in the inferior anterior chamber angle of the eye. Complete removal was achieved with extension of the wound at the limbus using the “cut-out” technique. Intraocular fishhook injuries are common in fishing communities and effective surgical removal may involve modified techniques previously described for skin or mucosal tissue.

Introduction

Fishhook injuries of the eye are common occurrences in fishing communities like Hawai‘i.^1–9 In a retrospective study, 143 (19.5%) of 732 cases of sport-related ocular trauma were relatedto fishing.¹⁰ Fishhook removal from the eye presents a unique challenge due to the barbed tip of the hooks. Techniques of fishhook removal from the skin, eyelids, and periocular tissues should be modified for fishhook injuries involving the eye globe.^11–12 Here, we describe the step-by-step surgical approach to remove a fishhook barb embedded in the anterior chamber angle of the eye.

Case Report

A36-year-old man was fishing at night in Galveston, Texas, one hour prior to presentation and experienced acute onset of pain and vision loss after a projectile fishhook penetrated his right eye. The patient stated that the hook and line were stuck on a rock, leading him to pull on the line until the hook disengaged, recoiled back, and embedded itself in his eye. The patient was not wearing eye protection at the time. Best corrected visual acuity on presentation was 20/200. Ophthalmic examination revealed a full-thickness corneal penetration at the limbus with a large fishhook (Figure 1). The tip and barb were embedded in the inferior anterior chamber angle of the eye. The patient was brought to the operating room where the fishhook was removed with the “cut-out” technique by extending the limbal wound with a small sideport blade followed by careful removal through the larger incision (Figure 2). The wound was closed with interrupted 10-0 nylon sutures (Figure 3). The next day, best corrected visual acuity had improved to 20/100, the incision was well sealed, and the patient was safely discharged home. Unfortunately, the patient was lost to follow-up.

Figure 1.

External Color Photograph: A large fishhook with full thickness corneal penetration at the nasal limbus embedded in the inferior chamber angle of the eye.

Figure 2.

Magnified External Color Photograph of the “Cut-Out Technique”: Extension of the penetration site with a 1.0 mm blade facilitates complete removal.

Figure 3.

External Color Photograph: The incision is well sealed and the anterior chamber is formed after 3 interrupted 10-0 nylon corneal sutures are placed.

Discussion

Most fishhooks are composed of a barb which is used to “snag” and secure the oral tissue of a fish so that it can be retrieved without coming loose. This same barb can have the same effect on human tissue, providing a unique challenge when it comes to foreign body removal without significant damage to the surrounding tissue. Five techniques are described for removing a fishhook from skin and mucosal tissue.¹¹ We will summarize these five techniques and present the reasoning for the chosen technique in our patient.

The “advance and cut” approach involves advancing the tip of the fishhook through the tissue until both the tip and barb are externalized. The shaft of the hook is then cut and the fishhook is removed in two pieces.11 In our patient, the tip and barb of the fishhook were embedded in the anterior chamber angle, so advancing the hook further would have only caused more damage to iris and angle structures.

The “back-out” approach involves carefully retracting the hook through the same entrance site.¹¹ The problem with this method is that the barb can catch or drag along the tissues before being removed, an option that may have posed significant damage to the angle structures in our patient.

The “snatch” technique is similar to “back out” technique but involves applying external pressure to the entrance site to enlarge the opening before pulling the hook out. We did not employ this technique to avoid further damage to the iris base and anterior chamber angle.

The “needle-cover” approach involves advancing a large-boreneedle through the entrance site to cover up the barb before retracting the hook through the original entry site.¹¹ This technique has the advantage of reducing damage caused by the barb during removal, as the needle neutralizes the barb’s sharp edge and should prevent it from dragging or catching on adjacent tissue. The “needle-cover” technique has been reported with success in penetrating injuries of the posterior segment.¹³ This may potentially have been an option in our patient if the barb was facing away from the angle and there was potential space to fit the needle over the barb. We decided that the barb was embedded deep in the angle and advancing another needle into the area would have only caused more damage to the surrounding tissues.

We decided to use the “cut-out” technique, which involves enlarging the entry site to allow space for the hook and barb to be safely removed while causing minimal collateral tissue damage. The hook was successfully removed and the incision was closed with standard anterior segment suturing techniques.

Fishhook injuries of the eye are not uncommon, and practitioners need to be equipped with the techniques to address unique challenges facing such intraocular foreign bodies. Late complications includecornealscar and endothelialcellloss, acuteand delayed hyphema, peripheral anterior synechiae, recession of anterior chamber angle with subsequent glaucoma, cataract, and posterior segment trauma. General practitioners should be able to distinguish ocular fishhook injuries from periocular injuries in order to expedite appropriate consultation to avoid further ocular complications.

Conflict of Interest

None of the authors identify any conflict of interest.