MILITARY MEDICINE, 181, 8:e962, 2016

Penetrating Orbital Injury From a Needlefish

LCDR Kyle E. Miller, MC USN*; LCDR Erin B. Coan, MC USN†

ABSTRACT Orbital penetrating injuries are an unfortunately common occurrence; however, those from marine
animals are rare. Injuries from marine animals can be quite profound and there are no known reports of complete
visual recovery after an orbital penetrating injury. Complications range from secondary infection to a carotid-cavernous
fistula, which can complicate the management of these patients. We report a case of penetrating orbital injury from
a needlefish with complete return of visual function after surgical removal of foreign debris and an extended course
of antibiotics.

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CASE REPORT
A 30-year-old male presented to an overseas military hospital
after being struck in the right eye while scuba diving. He was
night diving and after surfacing had removed his mask. He
heard a splashing sound in the water to his right side when he
turned and shined his flashlight in that direction. He was
struck by an object near his right eye, had an immediate onset
of pain, loss of vision, and bleeding from the eye.
Initial examination revealed a visual acuity of 20/80 in
the right eye, minimal extraocular muscle motility, a full
thickness right upper eyelid laceration, and a subconjunctival
hemorrhage. An orbital computed tomography scan revealed
multiple radiopaque intraorbital foreign objects. The patient
was taken to the operating room for further evaluation.
Examination under anesthesia revealed an intact globe with a
partially lacerated right superior rectus. Further orbital explo-
ration was deferred at that time. The patient was started on
intravenous antibiotics ampicillin/sulbactam and cefazolin,
oral ciprofloxacin, and topical moxifloxacin. He was trans-
ferred for further evaluation and treatment to a tertiary mili-
tary medical center in the United States.
On arrival, 2 days after the initial injury, the patient was
noted to have diplopia in all gazes, pain in the right eye, and
right eye ptosis (Fig. 1). Repeat imaging revealed multiple
calcific foreign bodies near the superior rectus and also pos-
terior to the globe (Fig. 2). Although his white blood cell
*Department of Ophthalmology, Naval Medical Center Portsmouth,
620 John Paul Jones Circle, Portsmouth, VA 23708.
†Department of Ophthalmology, Walter Reed National Military Medical
Center, 8901 Rockville Pike, Bethesda, MD 20889.
Presented at the Naval Medical Center San Diego Academic Research
Council, San Diego, CA, April 19, 2012.
The views expressed in this article are those of the author(s) and do not
necessarily reflect the official policy or position of the Department of the
Navy, Department of Defense, or the U.S. Government.
The authors are military service members (employees of the U.S.
Government). This work was prepared as part of our official duties. Title
17 U.S. Code § 105 provides that “Copyright protection under this title is
not available for any work of the U.S. Government.” Title 17 U.S. Code
§ 101 defines a U.S. Government work as a work prepared by a military
service member or employee of the U.S. Government as part of that
person’s official duties.
doi: 10.7205/MILMED-D-15-00449
count decreased on the initial antibiotic regimen, this was
adjusted in consultation with the Infectious Disease service to
better cover possible marine species. Cefazolin was discontinued
and ampicillin/sulbactam was changed to piperacillin/
tazobactam. After 1 week of close observation, the patient
underwent an orbital exploration and foreign body removal.
The surgery was performed in two parts: a superior lid
crease approach and a lateral orbitotomy. The superior
approach allowed removal of several pieces of debris that
were in immediate apposition to the superior rectus muscle.
The superior rectus muscle was inspected and found to be
intact. Using a lateral orbitotomy, approximately 50% of the
foreign debris was able to be identified and removed. Gross
inspection revealed the debris to be consistent with pieces of
the teeth and jaw of a needlefish (Fig. 3). Intraoperative cul-
tures of the orbit and the pieces removed were negative.
Postoperatively, the patient continued his antibiotic regimen
for a total of 12 weeks; at 1 week postoperative, oral predni-
sone was initiated at a dose of 1 mg/kg and tapered over the
course of 6 weeks. By postoperative week 6, the patient’s
visual acuity improved to 20/20 and his diplopia signifi-
cantly diminished affecting only his peripheral vision. He
was returned to full duty after an 8-week course of intrave-
nous meropenem and 12 weeks of oral ciprofloxacin.
DISCUSSION
Needlefish, also known as garfish, have a long beak and can
travel up to 40 miles per hour1 on the surface of water. The
majority of injuries occur at night and are to the chest, abdo-
men, or extremities in fishermen.1,2 Known to be attracted
by bright lights at night, incidental penetrating injuries can
cause significant morbidity or death.3–5
This case represents a rare facial injury and presented
several challenges in its management. First, the decision for
surgical intervention needed to be balanced against the risk
of persistent inflammation or infection developing from
retained foreign debris. The proximity of some of the debris
to the optic nerve precluded the removal of 100% of the fish
beak and teeth. One school of thought was that if all of the
debris was not going to be able to be removed that the risk
and trauma of surgery should be avoided altogether. Ideas in

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 Case Report
FIGURE 1. Preoperative motility photographs.
favor of surgery included the potentially decreased burden
of inflammatory material, opportunity for direct antibiotic
treatment to be applied in the orbit via irrigation, and repair
of a potentially partially lacerated superior rectus. Ultimately,
after careful and detailed counseling of the patient and his
family, orbital surgery was performed and successful removal
of more than 50% of the fish debris was achieved.
This decision for surgery was also supported by Fulcher’s
description6 of a series of 40 patients with intraorbital foreign
bodies. Those with retained organic material are recommended
for surgical removal because of the potential for significant
inflammation or spread of infection directly to central nervous
system structures. Patients with inorganic material can be safely
monitored without surgical removal in many instances.6,7 Safe
monitoring of inorganic material was also demonstrated in a
FIGURE 2. Computed tomography scan.
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series of 50 patients with up to 68 years of follow-up, where
95% of patients had no late complications.7
Second, the choice of antibiotic coverage was also puz-
zling. There is limited information about successful treatment
of similar injuries and prior case reports note the needlefish to
be a likely carrier of Vibrio species1; therefore, we chose anti-
biotics appropriate for that organism. We also determined that
extended antibiotic coverage would be required because of
retained foreign debris that was not able to be removed during
surgery. Cooperation with the infectious disease specialists
was the key in the success of this treatment.
The third clinical challenge in this case was the choice and
timing of systemic steroid treatment. After directly inspecting
FIGURE 3. Foreign objects removed from orbit.
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 Case Report
the superior rectus during the orbital surgery, we determined
that the limitation in extraocular motions was related to orbital
inflammation, not to muscle laceration. However, using steroids
to treat this patient who had retained marine animal debris in
his orbit risked infection. Balancing the potential increased
risk of infection versus treatment of the orbital inflammation
causing the motility decrease and diplopia, the patient and his
family opted for steroid treatment under close observation.
The patient was observed first on a daily and then weekly
basis. After 2 weeks, the follow-up periods were extended to
monthly. After 6 weeks postoperatively, the patient was able
to return to his overseas duty station and establish follow-up
care with the local comprehensive ophthalmologists.
Our patient did well; however, this is not always the case
with needlefish injuries.1–5,8 To prevent sight- and life-threatening
injuries, we recommend that those diving at night in areas with
needlefish keep their masks on until out of the water. This
case also demonstrates that not all organic material must be
e964
removed; however, close monitoring and the individual
tailoring of antibiotics are required.
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