THIS 16-YEAR-OLD girl was admitted to the Emergency Department after she was impaled by a large metal object. Her history revealed that she was in the rear of a top-down convertible that was traveling at highway speed when the injury occurred. Initially the patient was conscious with stable vital signs, but she was sedated and intubated by the emergency personnel to prevent movement. Visual acuity on admission was not able to be obtained because the patient was unresponsive. Examination revealed left eyelid and forehead lacerations and a large metal rod protruding from the left temporal area (Figure 1). Proptosis was noted in the left eye, with intraocular pressures of 16 mm Hg OD, and 42 mm Hg OS. Results of pupillary examination showed a reactive pupil in the right eye of 4 mm, and a nonreactive 8-mm, fixed, and dilated pupil in the left eye with reverse afferent pupillary defect (Figure 2). Findings from portable slitlamp examination were normal in both eyes. Dilated fundus examination findings for the left eye were remarkable for preretinal hemorrhages and posterior pole commotio retinae (Figure 3). An emergent left lateral canthotomy was performed in the Emergency Department, which decreased the intraocular pressure to 18 mm Hg OS. A computed tomographic scan of the head and orbits revealed a large metallic rod coursing through the greater wing of the sphenoid bone to end in the left orbit, displacing the globe anteriorly (Figure 4). Findings from the remaining physical and neurologic examinations were unremarkable. The patient received a tetanus shot and was started on a regimen of intravenous cefazolin. She underwent a left orbitotomy with removal of the metal rod, reconstruction of the left lateral wall and orbital rim, and repair of the eyelid and forehead lacerations.
Large metallic rod penetrating the left temporal region.
Proptosis and fixed dilated pupil in the left eye.
Retinal examination of the left eye revealed preretinal hemorrhages and commotio retinae.
A computed tomographic scan of the head and orbits revealed a large metallic object coursing through the greater wing of the sphenoid bone to end in the left orbit, and displacing the orbit anteriorly.
One month after the original injury, retinal examination of the left eye showed mild optic disc pallor, mottled fovea pigmentation, and a pseudomacular hole with a visual acuity of 20/30.
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