Fragmented pellet in the orbital apex: a dilemma to remove o
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21-year-old man presented to the ophthalmology casualty with sudden diminution of vision in the right eye for the past 7 days. He gave a history of being shot by an airgun following which a pellet had entered his right eye.

On ocular examination, his best-corrected visual acuity (BCVA) in the right eye was finger counting close to the face and 6/6 in the left eye with accurate projection of rays in both eyes. However, there was a relative afferent pupillary defect in the right side. Intraocular pressure was 15 mm Hg in the right eye and 17 mm Hg in the left eye. There was an ecchymosis over the lower lid skin on the right side. On slit-lamp examination, in the right eye, there was a localized temporal conjunctival congestion, the rest of the anterior and posterior segments were within normal limits in both eyes. X-ray of the orbit and the paranasal sinuses (anteroposterior and lateral views) revealed the presence of radiopaque multiple foreign bodies in the posterior aspect of the right orbit near the apex. A CT scan revealed features of multiple metallic foreign bodies near the apex without any obvious evidence of orbital wall fracture.

The patient was diagnosed to have right eye retained intraorbital foreign bodies with traumatic optic neuropathy. The location as well as the number of foreign bodies made it difficult to plan for removal without damaging the optic nerve. On explaining the situation to the patient, he refused to undergo any form of surgery. He was treated conservatively with oral steroids (tablet prednisolone 1 mg/kg, tapered gradually), the foreign bodies were left untouched. After 3 weeks, his BCVA in the right eye improved to 6/9. However, he had reduced contrast sensitivity, reduced visual field on automated perimetry and partial red-green deficiency in his right eye. The patient has been on regular follow-up ever since and there has been no change is his visual fields or contrast sensitivity at 6-month follow-up.