Globe Salvage After Emergency Primary Repair of A Transorbital Penetrating Intracranial Injury By A Fish Spear: Revisiting The Need For Secondary Surgical Management

Abstract

Introduction:

Transorbital penetrating eye injuries are uncommon and potentially vision-threatening. Rapid imaging assessment and coordinated multidisciplinary intervention are crucial to prevent irreversible ocular and neurological damage.

Case Presentation:

A 21-year-old man suffered an open-globe injury when a fish spear accidentally penetrated the right orbit. His initial vision was only light perception. CT angiography revealed a metallic foreign object passing through the orbital roof into the intracranial space, with the tip just 0.3 cm from the superior sagittal sinus, and no signs of bleeding or vascular involvement. Joint neurosurgical and ophthalmic procedure safely removed the foreign body through a dual approach, along with corneoscleral repair and intravitreal antibiotics. By day 16, his visual acuity improved to hand movement, but intraocular pressure dropped to 5 mmHg. After 8.5 months, the eye was quiet and painless, with an axial length of 17.33 mm compared with 24.22 mm in the healthy eye, indicating phthisis bulbi. Therefore, planned pars plana vitrectomy and lensectomy were not performed, as additional surgery was considered likely to accelerate the phthisical process.

Conclusion:

This case highlights the importance of prompt imaging and coordinated ophthalmology–neurosurgery management in transorbital penetrating injuries involving the globe and intracranial structures. It also shows that anatomical globe preservation does not always translate into visual recovery, and that a planned second-stage vitreoretinal procedure may appropriately be withheld once hypotony and phthisical change develop.