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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 137-140

Multidisciplinary Approach for Vision Recovery after a Diving Accident with a Needlefish in Cancun


Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, Mexico

Date of Submission17-Apr-2020
Date of Acceptance23-Jun-2020
Date of Web Publication8-Dec-2020

Correspondence Address:
Sergio David Vallejo
Department of Plastic and Reconstructive Surgery, Hospital Gea Gonzalez, Mexico City
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_18_20

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  Abstract 


Needlefish (Strongylura Notata) are known to cause painful injuries in humans. There are several reports of serious puncture wounds to the chest, abdomen, neck, and extremities. In this report, we describe an impressive puncture lesion to the face that resulted in unilateral partial loss of vision with perforation of the cranial vault secondary to an encounter with a fish while diving. A 39-year-old female presented to the emergency department 1 week after a diving trip to Cancun with pain and swelling in the right orbital region. She had associated right-sided partial vision loss and a puncture wound on the right malar region. Computed tomography scan of the head showed two foreign bodies; one which crossed the orbit from the inferior lateral side displacing medially the optic nerve and into the cranial cavity. The second foreign body was located in the inferolateral side of the malar bone. Multidisciplinary surgical removal of the objects resulted in complete resolution of visual acuity deficits as well as total recovery of her diplopia. Fortunately, minimal limitation in the abduction of the right eye persisted.

Keywords: Needlefish accident, optic nerve, vision loss


How to cite this article:
Garcia MA, Vallejo SD, Haro NE, Martinez-Wagner R. Multidisciplinary Approach for Vision Recovery after a Diving Accident with a Needlefish in Cancun. J Head Neck Physicians Surg 2020;8:137-40

How to cite this URL:
Garcia MA, Vallejo SD, Haro NE, Martinez-Wagner R. Multidisciplinary Approach for Vision Recovery after a Diving Accident with a Needlefish in Cancun. J Head Neck Physicians Surg [serial online] 2020 [cited 2021 Jan 17];8:137-40. Available from: https://www.jhnps.org/text.asp?2020/8/2/137/302620




  Introduction Top


Needlefish (Strongylura Notata) are known to cause painful injuries in humans, sometimes even fatal encounters. This fish belongs to the Belonidae family whose natural habitat is the surfaces of tropical seas of the Atlantic, from Bermuda to Central America, including the Caribbean and Mexican coast. Most of these places are attractive locations for divers and marine fish enthusiasts, placing them at risk for injuries. Needlefish have a very slender body and their main characteristic is the two fine-pointed, sharp, large, and conical elongated jaws which are filled with sharp and unequal backward pointing teeth. On an average, adults are 50 cm long, with the largest specimens found being up to 2 m in length.[1] Its behavior, when undisturbed, is calm and usually moves along with the flow of marine currents, but when disturbed and endangered, they are capable of swimming at extreme speeds toward the surface and “fly” out of the water at several centimeters high (50–60 cm) and for a few meters long.[2] In these excitement bursts, they are known to have inflicted injuries to humans by plunging their sharp and elongated jaws into their victims. There are reports of serious puncture wounds in humans to the face, chest, abdomen, neck, and legs. There is a report of a fatal case in which the lesion into the neck created a carotid-cavernous fistula.[3],[4],[5] In this case report, we describe the case of a woman [Figure 1] who sustained a severe lesion into the face that occasioned the unilateral partial loss of vision with perforation of the cranial vault through the orbit. The patient has consented to publish her identifiable photographs archives by a signed statement.
Figure 1: Thirty-nine-year-old female patient. The picture was taken on arrival at the emergency department. Image showing the two sites of puncture lesions at the right malar region, also periorbital ecchymosis and edema

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This patient was treated with a complex surgical procedure by a multidisciplinary team consisting of a plastic surgeon, a neurosurgeon, and an ophthalmologist with a successful outcome. This report adhered to the ethical principles outlined in the Declaration of Helsinki, as amended in 2013.


  Case Report Top


A 39-year-old female presented to the emergency department (ED) 1 week after sustaining a diving injury. She described an encountered with an unidentified fish, after which she had pain in the right orbital region. On her visit, she reported persistent pain and swelling in the right orbital region, right-sided partial vision loss, and diplopia. On physical examination, she was found to have two puncture wounds on the right malar region with edema, erythema, ecchymosis, and severe tenderness to the area. She was unable to laterally move her right eye and had severe pain with ocular and mandibular movements. She had a visual acuity of 20/50 in the right eye and 20/20 in the left eye. The rest of her examination was normal, including light and accommodation ocular reflexes, motor, and sensory examination of the face. There was no discharge over the wounds. She was previously seen at an outside hospital and treated with analgesic and broad-spectrum antibiotics with no improvement of her symptoms [Figure 1]. Several pictures were taken of the patient during her hospital stay, with the appropriate patient confidentiality protection and signed informed consent, with the purpose of documenting her progress.

Workup included a head computed tomography (CT) scan, which showed periorbital soft-tissue edema and two foreign bodies, both of them reported as hyperdense and a long pointed shape. The first object had 4.6 cm in length. It crossed the orbit from the inferior lateral side to the medial aspect of the roof of the orbit, to then reach the cranial cavity causing an opening in the subarachnoid space and ending with its tip located in the middle orbital gyrus of the right frontal lobe. The ventricular system appeared intact. The foreign body was close to the ocular globe and was displacing the optic nerve medially. The second foreign body had similar radiological features and measured in 4.3 cm in length. It crossed the inferolateral side of the malar bone through the pterigoideal apophysis of the right sphenoid bone into the pterigopalatine fossa [Figure 2].
Figure 2: Three-dimensional head computed tomography scan reconstruction. Left image as arrival to the emergency unit, foreign bodies in the right orbital cavity. Right image, postoperative imagining

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A multidisciplinary team, including plastic surgery, neurosurgery, and ophthalmology, developed a surgical plan to resect both foreign bodies. The planed surgery consisted of a lateral supraorbital craniotomy with the opening of the orbital roof for foreign body extraction and subsequent closure of the dura. During the removal, the eyeball and optic nerve were carefully examined, and fortunately, no lesions were found. The second foreign body was removed by a subciliary approach to explore the lateral orbital wall. A 2 cc collection was found in the area and was sent for culture. During visual inspection of the foreign objects in question, we noted that they were from a biological origin, and due to the diving accident with a fish, we could relate those pieces to the jaws of a needlefish [Figure 3].
Figure 3: Foreign bodies surgically obtained located in the right orbital cavity next to a 21-G needle for size comparison. Note the serrated border appearance consistent with needlefish jaw characteristics

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The patient stayed for 5 days after the surgery under close neurological and ophthalmologic surveillance. During the first 48 h, the patient had a notable recovery of her right vision, with visual acuity of 20/20 (compared to 20/50 on admission) and a partial recovery of the extraocular movements, however, with some deficit in the lateral gaze still present. She reported a total recovery of the diplopia. The microbiological culture of the collection showed no growth. Postsurgical CT of the head showed a remaining 4 mm fragment from the first foreign object located in the medial vertex of the orbital roof, which was not in contact with any ocular structures [Figure 2]. On the postoperative day 6, the patient was discharged home. Due to her right lateral gaze deficit, a consultation with a strabismus specialist was obtained; however, no further intervention was recommended due to the minimal deficit encountered in that visit. She was closely followed at the outpatient clinic for 4 months with no other reported complications [Figure 4].
Figure 4: The patient photograph was taken at the 3-month follow-up. No strabismus is detected

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  Discussion Top


In our practice, orbital foreign bodies are mostly associated with traffic or work-related accidents. There are five other reports describing orbital injury due to a needlefish accident.[5] To the best of our knowledge, this is the first reported case of needlefish accident with orbital and cerebral parenchyma involvement. In a case report of a similar diving accident in Australia, the patient presented 1 week after, with a puncture wound in the eyelid, fish jaw fragments were surgically removed with no posterior deficits.[5] Another case reported in South America, a young surfer, presented with 17 pieces of fish teeth that were surgically removed through a superior orbitotomy.[4] The case we present here is particularly interesting due to the optic nerve involvement and its penetration into the cranial vault which required a more aggressive surgical approach due to the perforation of the dura.

The reported cases of orbital wounds by needlefish usually present as a nontender, few millimeter-long puncture wound associated that occur after marine activities that usually cause little to none patient distress. It is common for these patients to later present to ED with functional deficits, tenderness, and important edema in the area. The persistence of the symptoms is usually caused by the presence of a biologic foreign body causing a potent inflammatory response and, in the case of our patient, progressive neurological symptoms.

Due to their nature, injuries can be seen as insignificant and due to their characteristics, the fragments inside can be overlooked by patients and physicians. A thorough physical examination and imaging studies are important in making the diagnosis. CT scans and MRI are the studies of choice to determine the location, size of the foreign bodies, as well as to determine the integrity of the ocular structures.

Some foreign bodies will be located closer to important structures and this will determine the presentation. It will also determine the severity and, as a result, how soon will the patient present symptoms severe enough to seek medical attention. In our case, initially, the foreign body was not noticed, even by the medical staff. Later, she presented visual and extraocular movement deficits, severe pain, and periorbital edema, suggesting an inflammatory process 1 week after the diving accident. The location of the lesion will also determine the surgical approach and its difficulty. Some cases are technically easier to remove due to the superficial location of the foreign bodies. In our case, we had a more posterior location in the orbit that also perforated the orbital roof, dura, and cerebral parenchyma, so a transcranial approach was chosen by the surgical team. If left untreated or if treatment is delayed, foreign bodies in orbit could cause permanent visual and extraocular movement impairment, bulbar infection, meningitis, osteomyelitis, and cerebral abscess amongt other serious long-term complications.

It is highly recommended that all orbital foreign bodies be totally removed to lessen the risk of infection and compromise of the surrounding structures. In this particular case, a 4 mm piece was found in the postoperative CT scan inside the orbit, but due to the technical difficulty of the previous surgical approach, the surgical team decided to manage it with a very close follow-up. We considered that the risk of re-intervention was greater than its benefit.


  Conclusion Top


It is important for medical staff to be aware of this type of injury, especially in coastal regions. A high index of suspicion should be present when evaluating a patient that presents with an injury after diving, especially if a fish was involved. Most of these puncture injuries are underestimated due to their size by the patient and inexperienced medical personnel. It is also important to manage these cases in a multidisciplinary manner to guarantee the best outcome for the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

1.
Collette BB. Belonidae. Needlefishes. In: Carpenter KE, Niem VH, editors. FAO Species Identification Guide for Fishery Purposes. The Living Marine Resources of the Western Central Pacific. Vol. 4. Bony Fishes Part 2 (Mugilidae to Carangidae). Rome: FAO; 1999. p. 2151-61.  Back to cited text no. 1
    
2.
Porter H, Motta P. A comparison of strike and prey capture kinematics of three species of piscivorous fishes: Florida gar (Lepisosteus platyrhincus), Redfin Needlefish (Strongylura notata), and great barracuda (Sphyraena barracuda). Marine Biol 2004;145:989-1000.  Back to cited text no. 2
    
3.
Mills GC, Alperin JB, Trimmer KB. Studies on variant glucose-6-phosphate dehydrogenases: G6PD Fort Worth. Biochem Med 1975;13:264-75.  Back to cited text no. 3
    
4.
Ward CW. Aminopeptidases in webbing clothes moth larvae. Properties and specificities of the enzymes of intermediate electrophoretic mobility. Biochim Biophys Acta 1975;410:361-9.  Back to cited text no. 4
    
5.
Robinson JV, James AL. Some observations on the effects produced in white mice following the injection of certain suspensions of corroding bacilli. Br J Exp Pathol 1975;56:14-6.  Back to cited text no. 5
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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