A nail gun injury

A 36-year-old right-handed male construction worker presented 2 days after feeling a sudden pain in his right maxillary area while using a nail gun. At that time, he thought that the nail gun flew up and hit him in the face without discharging a nail. He noted only mild pain and a small abrasion on his right cheek. Over the subsequent days he developed progressively worse pain and swelling of his right maxilla and eye as well as a right visual field cut. He was seen by an ophthalmologist who referred the patient to our ED. On exam the patient had significant chemosis and rightsided palpebral edema with moderate ptosis. Further examination demonstrated decreased range of motion of the right eye in all directions and a right nasal hemianopsia. A CT scan of the head revealed a nail penetrating through the maxillary sinus and orbit missing the optic nerve and ophthalmic arteries and extending into the right frontal lobe (Figs. 1, 2, 3 and 4). He was taken to the operating room and had the nail removed by neurosurgery and plastic surgery. Follow-up ophthalmology examination on postoperative day 2 demonstrated temporal macular choroidal rupture responsible for the nasal hemianopsia with pre-retinal fibrosis and hemorrhage causing macular traction and retinal folds with vision 20/160 (compared to 20/25 of the unaffected eye) and a complaint of a mild headache. Int J Emerg Med (2009) 2:175–176 DOI 10.1007/s12245-009-0112-0