A Game of Paintball Leads to a Potentially Devastating Eye Injury

Jessica Lee, MD; Ronald C. Gentile, MD


January 24, 2017

Clinical Presentation

A 15-year-old boy was transferred to an ocular trauma center with periocular erythema, pain, and blurry vision in his right eye after getting accidentally shot in the face with a paintball during a tournament. He sustained the injury while his eye protection was briefly removed. He was transferred from a local emergency department, where a CT scan of the orbits revealed no orbital fractures. The patient had no significant medical or surgical history.

External examination revealed a circular periocular welt with superficial dermal hemorrhages involving the right upper cheek and lateral aspect of the right lower eyelid. Dried fragments of the paintball casing and remnants of paint were present surrounding the lesion and in his hair, brow, and lashes. Visual acuity was 20/80 in the right eye and 20/20 in the left eye with no improvement on manifest refraction. Amsler grid testing revealed a central scotoma with metamorphopsia in the right eye and a normal left eye. Confrontational visual fields were full in all four quadrants in both eyes. Color vision using Ishihara plates were 3/6 and 6/6 in the right and left eye, respectively. The pupil in the right eye was slightly larger than the left pupil, with no obvious sphincter tears or relative afferent pupillary defect. Intraocular pressures were 24 mm Hg in the right eye and 16 mm Hg in the left eye.

Anterior segment examination of the right eye revealed a subconjunctival hemorrhage involving the inferior temporal conjunctiva, with an adjacent corneal epithelial abrasion measuring approximately 1 mm in diameter. The cornea had mild stromal edema, and the anterior chamber was normal depth with +1 flare and +2 pigmented cells within it. The vitreous was clear. Gonioscopic examination of the right eye revealed a microhyphema layered inferiorly and slight enlargement of the ciliary body band in one quadrant.

Fundus examination of the right eye (Figure 1) revealed two subretinal hemorrhages involving the posterior pole. One hemorrhage was 3 mm X 2 mm in size involving the fovea, and the other was 1 mm in diameter located inferior to the optic disc. Peripheral retinal examination revealed two large circumferentially oriented symmetric patches of retinal whitening centered at the equator involving the superior nasal and inferior temporal quadrants of the eye. The retinal whitening involved the outer retina and was without any associated vitreous opacities or inflammation. Examination of the left eye was normal.

Figure 1. Subretinal hemorrhage of the right eye, under the fovea and inferior to the optic disc, with peripheral areas of retinal whitening.

Optical coherence tomography (OCT) of the right macula revealed detachment of the inner neurosensory retina with hyperreflective material in the subretinal space (Figure 2). OCT of the left eye was normal.

Figure 2. Detachment of the neurosensory retina of the right eye. The corresponding infrared fundus image is inset into the top left of this figure.


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