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Traumatic retinal dialysis resulting from Nerf foam bullet

2018; Elsevier BV; Volume: 54; Issue: 3 Linguagem: Inglês

10.1016/j.jcjo.2018.08.008

1715-3360

Tyler Henry, Mathew M. Palakkamanil, Uriel Rubin, Matthew Tennant,

Intraocular Surgery and Lenses

Retinal dialysis is a common complication of blunt force ocular trauma.1Scott JD Retinal dialysis.Trans Ophthalmol Soc UK. 1977; 97: 33-35PubMed Google Scholar Thirty percent of the retinal dialyses present in the inferotemporal quadrant, typically involving less than 3 clock hours of retina.2Mastropasqua L Carpineto P Ciancaglini M Falconio G Gallenga PE Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study.Br J Ophthalmol. 1999; 83: 1046-1049Crossref PubMed Scopus (55) Google Scholar, 3Shunmugam M Shah AN Hysi PG Williamson TH Characteristics of rhegmatogenous retinal detachments secondary to retinal dialyses.Can J Ophthalmol. 2014; 49: 196-199Google Scholar The majority of retinal dialyses are sequalae of significant trauma to the affected eye.1Scott JD Retinal dialysis.Trans Ophthalmol Soc UK. 1977; 97: 33-35PubMed Google Scholar,4Zion VM Burton TC Retinal dialysis.Arch Ophthalmol. 1980; 98: 1971-1974Crossref PubMed Scopus (40) Google Scholar, 5Williams DF Mieler WF Williams GA Posterior segment manifestations of ocular trauma.Retina. 1990; 10: S35-S44Crossref PubMed Scopus (94) Google Scholar, 6Ross WH Traumatic retinal dialyses.Arch Ophthalmol. 1981; 99: 1371-1374Crossref PubMed Scopus (44) Google Scholar, 7Johnston PB Traumatic retinal detachment.Br J Ophthalmol. 1991; 75: 18-21Crossref PubMed Scopus (64) Google Scholar, 8Kennedy C Parker C McAllister I Retinal detachment caused by retinal dialysis.Aust NZ J Ophthalmol. 1997; 25: 25-30Crossref PubMed Scopus (32) Google Scholar Here we discuss the presentation, management, and clinical course of a retinal dialysis caused by a small caliber Nerf foam bullet (Nerf N-Strike Elite dart; Hasbro, Pawtucket, R.I.) shot from a high-speed Nerf rifle (N-Strike Elite Rampage Blaster; Hasbro). A 43-year-old female presented to a group retina practice after being struck to the nasal aspect of her left eye with a Nerf foam bullet fired from a distance of approximately 6 meters (Fig. 2). The patient complained of a new onset of floaters but denied flashes or deteriorating visual acuity. There was no previous history of ocular surgery or other ocular trauma. Upon examination, visual acuity was 20/20 in each eye. Intraocular pressures were within normal limits (14 OD, 09 OS). Anterior segment examination showed no evidence of a macroscopic hyphema, although a few cells were identified in the aqueous of the left eye. Posterior segment examination of the right eye was unremarkable. Posterior segment examination of the left eye demonstrated a retinal dialysis of approximately 3 clock hours in the temporal periphery. Adjacent commotion retinae with intraretinal hemorrhage were also identified (Fig. 1A). The patient underwent same-day encerclage of the dialysis with indirect argon laser retinopexy. The patient was seen 2 weeks later in follow-up. At that time the retinal dialysis was found to be well demarcated with laser with no additional retinal pathologies noted (Fig. 1B).Fig. 2The Nerf N-STRIKE Elite dart (Hasbro, Pawtucket, R.I.).View Large Image Figure ViewerDownload Hi-res image Download (PPT) High velocity projectile toys are relatively common in Canada. Airsoft guns and Nerf guns are 2 of the most popular such toys. Airsoft gun pellets have been known to cause a variety of ocular injuries. In a case series of ocular trauma from airsoft gun pellets, anterior segment injuries included traumatic hyphema, corneal abrasion, lid contusion, traumatic iritis, and traumatic mydriasis. Commotio retinae has been described, although we could not find reports of retinal dialysis, tears, or detachments.9Ramstead C Ng M Rudnisky CJ Ocular injuries associated with Airsoft guns: a case series.Can J Ophthalmol. 2008; 43: 584-587Abstract Full Text PDF PubMed Scopus (0) Google Scholar Airsoft guns shoot plastic pellets. These pellets measure 6.0 mm in diameter and their mass ranges from 0.12 to 0.25 g.9Ramstead C Ng M Rudnisky CJ Ocular injuries associated with Airsoft guns: a case series.Can J Ophthalmol. 2008; 43: 584-587Abstract Full Text PDF PubMed Scopus (0) Google Scholar With speeds of 90−120 m/s, airsoft pellets can impact with a kinetic energy (KE) of anywhere from 0.5 Nm to 1.8 Nm. There has been a single published report describing 2 cases of ocular injury caused by Nerf gun foam bullets.10Bizrah M Verma S Nerf gun eye injuries: traumatic hyphema.BMJ Case Rep. 2017; 18: 2017Google Scholar In both cases, the patient presented with reduced vision from hyphema. In one case the hyphema was associated with corneal edema, anterior uveitis, localized angle recession, and commotio retinae. Neither case described retinal dialysis, tear, or detachment. The potential for ocular injury from Nerf projectiles is greater today than in the past due to increases in potential energy density (0.22 Nm/cm2) that approaches the 0.25 Nm/cm2 standard set by the American Section of the International Association for Testing Materials (ASTM International) for projectile toys.11Kaufman A. www.industryhk.org/upload/media/file/fbf4133bbe561ad7dd22cc0c441cfcb3.pdfGoogle Scholar Improvements in gun spring technology, aerodynamic design, and increased weight for foam bullets (1.78 gm) and foam balls (1.94 gm) allows speeds to reach 110 kilometers per hour and 160 kilometers per hour, respectively. Scott et al. found retinal avulsion at a KE of 1.20 Nm and retinal tear damage at 1.69 Nm in porcine eye models, illustrating the damage such energies can produce.12Scott W Lloyd W Benedict J Meredith R Ocular injuries due to projectile impacts.Annu Proc Assoc Adv Automot Med. 2000; 44: 205-218PubMed Google Scholar Given the weight and suggested velocity of the Nerf bullet in this case, the energy on impact was calculated at 0.4 Nm. Despite this relatively low kinetic energy a retinal dialysis with commotio occurred. This result suggests that Scott et al.'s KE porcine model may be in need of reevaluation when assessing human ocular trauma. Interestingly, today's Nerf high velocity ball projectile technology enables projectile speeds to reach 45 m/s with a kinetic energy of 1.92 Nm. This increase in kinetic energy is sufficient to cause both anterior and posterior segment injury. Such an injury has the potential to cause permanent vision loss. This case highlights the importance of eye protection when playing with foam projectiles and suggests that particular caution should be exercised when playing with high velocity Nerf bullets or balls. The authors have no proprietary or commercial interest in any materials discussed in this article.