The Ophthalmology Department,  Universiti Malaysia Sarawak (UNIMAS), Kuching, Sarawak.

The Ophthalmology Department, Sarawak General Hospital, Kuching, Sarawak, East Malaysia.

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Case 36a

by Professor Chua Chung Nen & Dr. Ngo Chek Tung

 

A 12 year-old boy fell at home against the wall where a fishhook was hanging. The fishhook entered the  right upper eyelid (Figure 1) through the upper fornix (Figure 2). The local doctor attempted retrograde removal ie. removing the eyelid through its original track but without success. He was given tetanus injection and referred to our eye department. Examination showed normal vision in both eyes measuring 6/6 and the ocular movement was full which excluded extraocular muscles involvement (Figure 3). The X-rays showed the possibility of frontal sinus penetration by the point of the fish hook (Figure 4) and a CT scan was ordered to better localize the position of the point. The reconstructed CT scans showed the point of the fishhook was extracranial and spare the frontal sinus (Figure 5).

 

Figure 5. Reconstructed CT scans show the skull and frontal sinus were not penetrated

by the fishhook.

 

a. Why can't the hook be removed by the retrograde method?

To understand why a fishhook can't be removed by the retrograde method ie. along its entry site, one needs to understand its structure (Figure 6).

Figure 6. Terminology of a fish hook.

The part of the hook that prevents retrograde method is the barb which keeps the point embedded in the fish’s mouth, and if the point is deep in the tissue as in our patient retrograde removal is difficult and may cause serious damage to adjacent structures.

 

b. How may the fishhook be removed?

There are two methods1 suitable for removing the fish hook in this case (See Figure 7):

 

a. Method 1: The advance and cut method. In this method, the hook is advanced through the skin and the barb is then cut off. The remaining hook is backed through the entry wound. This method is best for hook with a single barb.

 

b. Method 2: The cut and advance method. The eye of the fish hook is cut off and the remaining hook is pulled through the skin by advancing the point of the hook. This method is especially suitable by hook with multiple barbs.

Although the fishhook in our patient has a single barb, we chose method 2 over method 1 because the position of the hook is such that if we were to advance it the shank will press on the globe and additional pressure transmitted during cutting of the barb may damage the globe.

 

The fishhook in this case was thick and several cutting instruments were used before we eventually cut off the eye using a large size bone cutter borrowed from the orthopaedic theatre (Figure 8). A suprabrow skin incision was made near the point of the hook and the hook was advanced through the skin (Figure 9). A lid guard was inserted between the shank and the globe to protect the eye during removal of the hook (Note: This is an important step to avoid accidental globe perforation by the hook. Figure 10). The hook was removed by grasping the point using a pair of artery forceps and pulled through the skin incision. All the procedures were performed using topical ocular anaesthesia and skin and fornix infiltration with 1% lignocaine. Apart from some postoperative eyelid swelling, the patient recovered well (Figure 11).

Figure 8. Several cutting instruments were tried before a large size bone cutter succeeded in

removing the eye of the hook.

 

Figure 9. An incision was made near the point of the hook. The hook was then advanced through

the incision.

 

Figure 10. A lid guard was inserted to protect the globe before the hook was removed by grasping

the point with a pair of artery forceps.

 

Figure 11. Post-operative lid swelling and the offending hook.

 

An alternative method of removal was described by Ma and Lin2: The tip of the hook is advanced through the anaesthetised skin to expose the barb and the point. The barb is cut off using the needle holder. The barbless hook is gently withdrawn through the entry site (Figure 12). Because the barb is smaller than the point or the eye, a smaller instrument and less force is needed to cut the barb. Additionally, removing the hook through the entry site rather than advancing the whole hook reduces tissue trauma.

 

 

Reference:

1. Gammons MG, Jackson E. Fishhook removal. Am Fam Physician. 2001 Jun 1;63(11):2231-6.
2. Ma HP and Lin ACM. A simple method for removal of fish hooks in the emergency department. Br. J. Sports Med. 2005;39;116-117.