Abstract

Background: Orbital bullet injuries resulting from high-velocity trauma pose significant clinical challenges due to the potential for severe ocular and systemic complications. This meta-analysis consolidates the existing body of knowledge on direct orbital bullet injuries with respect to clinical outcomes, management strategies, and long-term effects.

Methods: The literature search was conducted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using databases such as PubMed and Scopus. Seventeen articles were reviewed, out of which six studies met the inclusion criteria. Extracted data included details on study design, sample size, patient demographics, projectile type, clinical presentation, imaging modalities used in establishing the diagnosis, surgical interventions performed, duration of follow-up, and the outcomes achieved. Data synthesis was done using fixed and random effects models; heterogeneity testing was assessed using the I² statistic.

Results: A total of 688 patients with orbital bullet injuries were analyzed. The average age years ranged from 7 to 58, with a predilection for the male gender, about 70%. These injuries caused marked visual impairment, which included optic nerve injuries, legal blindness, cornea injuries, hyphema, orbital fractures, vitreous hemorrhage, lid lacerations, cataracts, and retinal injuries. Optic nerve injuries exhibited substantial variability (I² = 100%, H² = 1.254 × 10⁸). Legal blindness was common (I² = 100%, H² = 1.628 × 10⁷), with high rates reported in conflict zones. Corneal injuries and hyphema were also prevalent, with significant heterogeneity observed (I² = 100%, H² = 8.183 × 10⁶ for corneal injuries and I² = 99.861%, H² = 721.638 for hyphema). Only orbital fractures, vitreous hemorrhage, lid lacerations, cataracts, and retinal injuries showed very high heterogeneity with varying clinical presentation. Early surgical intervention and advanced imaging techniques played a very vital role in the management of these injuries and those which improved the prognosis of outcome.

Conclusion: Orbital bullet injuries remain a great clinical challenge and are very variable in nature. This huge variability of injury patterns and outcomes enjoins that treatment must be individualized, with very early intervention, evolved imaging modalities, and thorough surgical management for the best possible improvement in the patient’s outcomes and prevention of long-term sequelae. Further studies should be done to come up with unified guidelines regarding the evaluation and treatment of such complex injuries.

Keywords: Bullet injury, Meta-analysis, Ocular trauma, Orbital trauma, Surgical management, Visual outcomes

INTRODUCTION

Orbital bullet injuries are a type of high-velocity trauma that creates the most challenging clinical situations because it is associated with a very poor prognosis in ocular and systemic complications. In an overall sense, such injuries would depend on factors such as projectile velocity, entry point, and relation to vital orbital structures. For example, Pacio et al.[ 18 ] reported a toy gun injury that led to monocular blindness in a 9 year old child. Similarly, marking cartridge from military training incidents led to complete vision loss in some cases and accounted for the need to some cosmetic interventions.[ 6 ]

Nonlethal missiles, rubber, and plastic bullets utilized during riot control also considerably cause orbital trauma. According to some studies, these projectiles range from lid lacerations to globe ruptures and, even further on, orbital fractures in conflict zones.[ 16 ] The high incidence of serious injuries necessitates a re-evaluation of their use in civilian settings. In Switzerland, plastic bullet shotguns have caused severe ocular damage, including traumatic cataracts and retinal detachment.[ 20 ]

Management of these injuries often requires prompt surgical intervention, especially in cases involving intraorbital foreign bodies. The decision to remove or observe these foreign bodies depends on their size, location, and associated risks.[ 5 ] Despite advances in surgical techniques, the prognosis for severe orbital bullet injuries remains guarded, emphasizing the need for early intervention and comprehensive management.

We aim to consolidate existing knowledge on direct orbital bullet injuries, evaluating clinical outcomes, management strategies, and long-term effects. By synthesizing data from various studies, we aim to provide a clearer understanding of best practices and areas for further research in managing these complex injuries.

METHODS

Literature search

A comprehensive literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines[ 17 ] using databases such as PubMed and Scopus to identify studies on orbital bullet injuries using the combination of the Boolean operators “OR” and “AND” and search keywords: “bullet injuries,” “ocular trauma,” “intraorbital,” and “orbit.” Reference lists of the identified 179 articles, articles were uploaded to Rayyan, and duplicates were deleted. The articles were then screened and the included articles number was reduced to 17. The selection process is summarized in Figure 1 .

Figure 1:

PRISMA flow diagram for the included articles.

Inclusion and exclusion criteria

Inclusion and exclusion criteria were established to select the relevant studies. Studies were included if they reported cases of direct orbital bullet injuries, provided detailed clinical outcomes, management strategies, and long-term follow-up, included human subjects, and were published in peer-reviewed journals. Conversely, studies were excluded if they involved deceased and nonhuman subjects, lacked detailed clinical data or outcomes, or were review articles, commentaries, or editorials without original data.

Data extraction

Data extraction was conducted independently by two reviewers using a standardized form. The extracted information encompassed study design, sample size, patient demographics (including age and sex), type of projectile and its velocity, clinical presentation, imaging modalities used, surgical interventions and management strategies, follow-up duration, and outcomes, as well as complications and long-term consequences.

Quality assessment and bias assessment

The quality of the included studies was assessed using the Oxford Centre For Evidence-Based Medicine guidelines.[ 12 ] Discrepancies in quality assessment were resolved through discussion. The risk of bias was assessed by two authors using the Joanna Briggs Institute checklists for case reports and case series.[ 14 ] The bias assessment of the included studies came low. Supplementary File 1 demonstrates the assessment of the risk of bias.

Data synthesis and statistical analysis

Data were synthesized narratively and quantitatively. A meta-analysis was performed using fixed and random effects models to pool outcomes across studies. Heterogeneity was assessed using the I² statistic. Subgroup analyses were conducted based on the type of projectile and surgical intervention.

RESULTS

We included 6 articles in this meta-analysis out of 17. The analyses included assessing the prevalence and severity of optic nerve injuries, legal blindness, corneal injuries, hyphema, orbital fractures, vitreous hemorrhage, lid lacerations, cataracts, and retinal injuries. The results are illustrated in Table 1 .[ 1 - 11 , 13 , 15 , 16 , 18 - 20 ]

Table 1:

Comprehensive overview of direct orbital bullet injuries.

Demographics and clinical presentation

The additional data incorporated from the second file included a total of 693 patients. The average age varied across studies, with specific age ranges from 7 to 58 years. The gender distribution showed a predominance of male patients (85.425%), reflecting a higher incidence of orbital bullet injuries in males. The types of projectiles causing injuries included lead alloy pistol bullets, rubber bullets, plastic bullets, airsoft gun pellets, and metallic shrapnel fragments. These details are well illustrated in Table 2 .

Table 2:

Infographic data.

Clinical presentations

The clinical presentation of injuries included a range of ocular and orbital complications. The most common injuries were hyphema, vitreous hemorrhage, orbital fractures, and optic nerve injuries. For example, Bullock et al.[ 1 ] reported frequent hyphema, vitreous hemorrhage, and orbital fractures, while Lavy and Abu Asleh[ 16 ] found high incidences of lid lacerations, ruptured globes, and retinal damage. Each clinical presentation, along with its statistical data, is listed next, and these statistical data and percentages are illustrated in Tables 3 and 4 . The relevant forest plots are illustrated in Figure 2 . Figure 3 illustrates how bullets can damage the orbit.

Table 3:

Statistical information related to each clinical presentation of direct orbital injuries.

Table 4:

An overview of each clinical presentation.

Figure 2:

Forest plots for the clinical presentations of direct orbital injuries.

Figure 3:

Illustration of bullet injuries to the orbit.

Optic nerve injuries

The meta-analysis of optic nerve injuries included data from multiple studies. The omnibus test of model coefficients was not statistically significant (Q = 3.397, df = 1, P = 0.065), indicating no significant overall effect. However, the residual heterogeneity was significant (Q = 1.79 × 10^7, df = 3, P < 0.001), suggesting substantial variability among the included studies. The estimate for the intercept was 7.110 with a standard error of 3.858 (z = 1.843, P = 0.065). The I² value was 100%, indicating high heterogeneity, and the H² value was 1.254 × 10⁸. The forest plot for optic nerve injuries showed wide confidence intervals for most studies, highlighting the variability in reported outcomes, particularly in studies by Bullock et al.,[ 1 ] Detorakis et al.,[ 5 ] and Jaouni and O’Shea.[ 13 ]

Legal blindness

The meta-analysis for legal blindness demonstrated a significant omnibus test of model coefficients (Q = 7.167, df = 1, P = 0.007). The residual heterogeneity was also significant (Q = 1.421 × 10⁸, df = 3, P < 0.001), reflecting high variability. The estimate for the intercept was 17.513 with a standard error of 6.542 (z = 2.677, P = 0.007). The I² value was 100%, indicating complete heterogeneity and the H² value was 1.628 × 10⁷. The forest plot for legal blindness indicated that while some studies reported high rates of blindness, others showed lower incidences, contributing to the overall heterogeneity, particularly in studies by Bullock et al.,[ 1 ] Jaouni and O’Shea,[ 13 ] and Lavy and Abu Asleh.[ 16 ]

Corneal injuries

For corneal injuries, the omnibus test of model coefficients was highly significant (Q = 7.175 × 10⁶, df = 1, P < 0.001). The test of residual heterogeneity also showed significant results (Q = 8.183 × 10⁶, df = 2, P < 0.001). The estimate for the intercept was 17.504 with a standard error of 0.007 (z = 2678.651, P < 0.001), indicating a strong effect size. The I² value was 100%, showing high heterogeneity, and the H² value was 8.183 × 10⁶. The forest plot for corneal injuries illustrated that nearly all studies reported significant injury rates, although with varying effect sizes, including studies by Endo et al.,[ 7 ] Sutter,[ 20 ] and Feichtinger et al.[ 8 ]

Hyphema

The hyphema meta-analysis revealed a significant omnibus test of model coefficients (Q = 13595.339, df = 1, P < 0.001) and significant residual heterogeneity (Q = 721.638, df = 1, P < 0.001). The intercept estimate was 40.826 with a standard error of 0.350 (z = 116.599, P < 0.001). The I² value of 99.861% indicated substantial heterogeneity, and the H² value was 721.638. The forest plot showed consistently high rates of hyphema across studies, with relatively narrow confidence intervals, particularly in studies by Bullock et al.,[ 1 ] Lavy and Abu Asleh,[ 16 ] and Sutter.[ 20 ]

Orbital fractures

The analysis of orbital fractures indicated a significant omnibus test of model coefficients (Q = 493.655, df = 1, P < 0.001) with significant residual heterogeneity (Q = 186492.005, df = 2, P < 0.001). The intercept estimate was 36.167 with a standard error of 1.628 (z = 22.218, P < 0.001). The I² value of 99.998% showed high heterogeneity, and the H² value was 46445.653. The forest plot for orbital fractures highlighted the varying severity and frequency of fractures reported in different studies, including those by Bullock et al.,[ 1 ] Detorakis et al.,[ 5 ] Lavy and Abu Asleh,[ 16 ] and Sutter.[ 20 ]

Vitreous hemorrhage

The vitreous hemorrhage analysis showed a significant omnibus test of model coefficients (Q = 14.124, df = 1, P < 0.001) and significant residual heterogeneity (Q = 6.600 × 10⁶, df = 3, P < 0.001). The intercept estimate was 44.216 with a standard error of 11.765 (z = 3.758, P < 0.001). The I² value was 100%, indicating high heterogeneity, and the H² value was 2.481 × 10⁶. The forest plot depicted wide confidence intervals for vitreous hemorrhage rates, suggesting varied reporting among studies, including those by Bullock et al.[ 1 ] Detorakis et al.,[ 5 ] and Jaouni and O’Shea.[ 13 ]

Lid lacerations

For lid lacerations, the omnibus test of model coefficients was highly significant (Q = 2.301 × 10⁷, df = 1, P < 0.001), and the test of residual heterogeneity also showed significant results (Q = 9.766 × 10⁶, df = 2, P < 0.001). The intercept estimate was 24.878 with a standard error of 0.005 (z = 4797.296, P < 0.001). The I² value was 100%, showing high heterogeneity, and the H² value was 9.766 × 10⁶. The forest plot for lid lacerations showed consistent findings across studies, with high effect sizes reported, including those by Lavy and Abu Asleh,[ 16 ] Sutter,[ 20 ] and Riyadh et al.[ 19 ]

Cataracts

The cataract meta-analysis demonstrated a significant omnibus test of model coefficients (Q = 233.659, df = 1, P < 0.001) with significant residual heterogeneity (Q = 4772.779, df = 1, P < 0.001). The intercept estimate was 21.400 with a standard error of 1.400 (z = 15.286, P < 0.001). The I² value was 99.979%, indicating substantial heterogeneity, and the H² value was 4772.779. The forest plot indicated variable but generally high rates of cataracts reported in the studies, including those by Sutter[ 20 ] and Bullock et al.[ 1 ]

Retinal injuries

The analysis for retinal injuries showed a highly significant omnibus test of model coefficients (Q = 2.337 × 10⁷, df = 1, P < 0.001) and significant residual heterogeneity (Q = 9.660 × 10⁶, df = 3, P < 0.001). The intercept estimate was 22.013 with a standard error of 0.005 (z = 4834.295, P < 0.001). The I² value was 100%, showing high heterogeneity, and the H² value was 9.660 × 10⁶. The forest plot for retinal injuries demonstrated wide confidence intervals and varied effect sizes across studies, including those by Bullock et al.,[ 1 ] Lavy and Abu Asleh,[ 16 ] and Sutter.[ 20 ]

Visual acuity and clinical outcomes

Visual acuity outcomes varied significantly among the patients. For instance, Bullock et al. reported[ 1 ] that the average visual acuity was 20/30, whereas, in Lavy and Abu Asleh’s study,[ 16 ] some visual acuities were as good as 6/6 and as poor as no perception of light. In more serious injuries, the cases of Jaouni and O’Shea[ 13 ] and Riyadh et al.[ 19 ] show that a significant number of patients, 43.1% and 72.2% at respective percentages, suffer profound loss of vision, including legal blindness and complete loss of perception of light.

Imaging modalities

Imaging modalities such as computed tomography (CT) and ultrasound biomicroscopy were in frequent use for ascertaining the extent of the injuries and planning surgical intervention. CT was especially helpful in picking up fractures and foreign bodies within the orbit. For example, orbital floor fractures and foreign bodies were shown in CT imaging by Bullock et al. study.[ 1 ]

Management strategies and surgical techniques

Most of the management strategies included surgical interventions. Detorakis et al.[ 5 ] described a case that had metallic foreign bodies along the floor of the orbit and was managed surgically. In severe cases, open sinus surgery with enucleation was required for removing projectiles, just like in the studies by Jaouni and O’Shea[ 13 ] and Donegan et al.[ 6 ]

The surgical interventions varied according to the extent and nature of the injury. The most common surgeries undertaken were evisceration with orbital implant, removal of bullet, and laceration repair, according to Lavy and Abu Asleh.[ 16 ] A few secondary surgeries, such as orbital reconstruction and retinal detachment repair were also carried out in those with complicated injuries.

Complications and long-term outcomes

Such complications were common and included infections, wound dehiscence, enophthalmos, and flap failure. Other long-term consequences included serious visual impairment in some patients, with partial or complete recovery achieved by others. For instance, Riyadh et al.[ 19 ] stumbled upon a report that stated 72.2% of patients have a poor outcome in terms of their vision-less than counting fingers at 1 m.

These results underline that orbital bullet injuries are a formidable clinical challenge with a very wide range of outcomes. Hence, the importance of early intervention, proper surgical management, and state-of-the-art imaging techniques in improving prognosis and reducing long-term morbidity cannot be overemphasized. The variability in injury types and outcomes underlines the individualization of treatment plans and further research into the optimization of management strategies. The overall bias assessment for the study was determined to be good, indicating a low risk of systematic errors that could impact the validity of the findings [ Tables 5 and 6 ].

Table 5:

Joanna Briggs Institute Checklist for case reports assessment.

Table 6:

Joanna Briggs Institute Checklist for case series assessment.

DISCUSSION

These meta-analysis results underline the comprehensive and diversified effect of orbital bullet injuries. The findings also reflected a significant heterogeneity across different types of injury, reflecting that a huge number of factors, such as projectile type, velocity, and initial medicamentous interventions applied, influence the injuries. Although most of the results ranged from damage to the optic nerve and retinal injuries, high variability in the outcome indicates that treatment should be individualized. Such results underline the fact that orbital bullet injuries can be very complicated and require advanced imaging techniques, surgical interventions, and follow-up care if an improvement in patient outcome is wished to be attained.

Effects of orbital bullet impact on the optic nerve are also highly variable, with significant residual heterogeneity (I² = 100%, H² = 1.254 × 10⁸). Such kinds of injury are really related to high-velocity missile injuries that usually result in very serious consequences, including optic neuropathy and blindness. Bullock et al.,[ 1 ] Detorakis et al.,[ 5 ] and Jaouni and O’Shea[ 13 ] cited severe optic nerve damage due to being shot by high-velocity missiles; our findings validate these results. From looking at the forest plot, one observes what seems like wide confidence intervals, which may arise from variability in the severity of injury and clinical outcomes across studies. This variability could be a result of individual differences in projectile type, entry point, and immediate management of the injury. These are factors suggesting that an individualized approach to treatment may be required to optimize patient outcomes with optic nerve injuries.

Legal blindness, I² = 100%, H² = 1.628 × 10⁷ – the heterogeneity here is very large – implies very severe vision loss due to orbital-bullet-induced causes. Bullock et al.,[ 1 ] Jaouni and O’Shea,[ 13 ] and Lavy and Abu Asleh[ 16 ] quote rates of blindness that are remarkably high, particularly in areas of conflict where rubber bullets have been commonly used. This result does indeed suggest a fair amount of heterogeneity regarding the type of projectile or missile, its velocity at the time of impact, and even the quality of medical intervention. For instance, rubber bullets, supposedly nonlethal, are said to yield extensive ocular trauma, leading to blindness. Drawing from this is the imperative of severe restrictions on their use and an increase in protections afforded against such munitions among persons in conflict zones.

Corneal injuries were highly prevalent with significant heterogeneity (I² = 100%, H² = 8.183 × 10⁶). Endo et al.,[ 7 ] Sutter,[ 20 ] Feichtinger et al.[ 8 ] variously reported abrasions to severe corneal edema and scarring with high heterogeneity basic differences in projectile types and immediate management of injuries, therefore resulting in variable outcomes. Prompt surgical intervention and protective measures are important factors in managing such injuries. For example, Endo et al.[ 7 ] emphasized the importance of early medical treatment so as to prevent sequelae such as corneal scarring, which can cause irreversible visual loss.

Hyphema was another common injury with high heterogeneity (I² = 99.861%, H² = 721.638). Bullock et al.,[ 1 ] Lavy and Abu Asleh,[ 16 ] Sutter[ 20 ] all show a high hyphema rate. This mirrors the vulnerability of the anterior chamber to blunt trauma. There is significant heterogeneity that calls for early intervention and careful monitoring to avoid serious complications such as glaucoma and permanent loss of vision. Hyphema can lead to increased intraocular pressure, thereby causing more damage in the eye if it is not managed in time. Thus, very early detection and timely intervention are the keys to preventing adverse outcomes.

Orbital fractures indicated significant results (I² = 99.998%, H² = 46445.653). Bullock et al.,[ 1 ] Detorakis et al.,[ 5 ] Lavy and Abu Asleh,[ 16 ] and Sutter[ 20 ] documented various types of orbital fractures resulting from high-velocity impacts. The forest plot highlighted the diverse clinical presentations, ranging from minor fractures to complex fractures involving the orbital floor and walls. Surgical reconstruction and the use of advanced imaging techniques are critical in managing these injuries and restoring functionality. The variability in fracture patterns suggests that individualized surgical approaches are necessary to address the unique anatomical disruptions caused by different projectiles.

Vitreous hemorrhage showed significant heterogeneity (I² = 100%, H² = 2.481 × 10⁶). The reports by Bullock et al.,[ 1 ], Detorakis et al.,[ 5 ], and Jaouni and O’Shea[ 13 ] described varying degrees of vitreous hemorrhage with significant visual disablement. Again, variable outcomes resulted from differences in projectile type, impact velocity, and timely medical intervention. A surgical approach to vitreous hemorrhage requires early intervention for the preservation of vision. For instance, it could be performed to evacuate the hemorrhage and prevent retinal detachment where vitrectomy would have to be undertaken, reflecting specialized surgical knowledge in handling such cases.

Lid lacerations were highly prevalent with significant heterogeneity (I² = 100%, H² = 9.766 × 10⁶). Studies by Lavy and Abu Asleh,[ 16 ] Sutter,[ 20 ] and Riyadh et al.[ 19 ] demonstrated quite clearly the frequent occurrence of lid lacerations in orbital bullet injuries. More importantly, the large effect sizes across studies point out that these are common injuries often needing meticulous surgical repair to avoid attendant functional and cosmetic complications. Such variability in techniques, including microsurgical methods in management, underlines further the need for specialized training in oculoplastic surgery if optimal outcomes are to be achieved.

The cataract meta-analysis demonstrated substantial heterogeneity (I² = 99.979%, H² = 4772.779). According to Sutter[ 20 ] and Bullock et al.,[ 1 ], there were high rates of traumatic cataracts, reflecting severe blunt trauma to the lens. This again underlines that significant variation exists and that factors such as the projectile itself and quality of care influence the development and management of traumatic cataracts. Early surgical intervention may usually be necessary with phacoemulsification to restore vision. Furthermore, postoperative care with anti-inflammatory medications is required to prevent secondary complications.

Retinal injuries showed significant results with high heterogeneity (I² = 100%, H² = 9.660 × 10⁶). Bullock et al.,[ 1 ], Lavy and Abu Asleh [ 16 ], and Sutter[ 20 ] documented rather a diversity of injuries to the retina, ranging from simple tears of the retina to serious detachment. The variability in outcomes makes notice of early identification and intervention necessary for preventing permanent vision loss. Advanced imaging techniques, such as optical coherence tomography, and timely surgical repair through scleral buckling or vitrectomy are critical to the management of retinal injuries.

The gross heterogeneity seen across all types of injury does not suggest that individual patient factors, projectile characteristics, and medical interventions play no role. The findings underscore the need for comprehensive management that includes prompt surgical intervention, advanced imaging techniques, and long-term follow-up to optimize clinical outcomes. For example, high-resolution CT and magnetic resonance imaging aid in the correct diagnosis and planning of surgical intervention, hence improving prognosis in patients with complex orbital injuries.

The present meta-analysis has several limitations. The included studies were of different designs, and sample size and quality differed considerably, as reflected by the significant heterogeneity. Moreover, differences in outcome reporting – in combination with the diversity of applied imaging and surgical techniques – might have had a conceivable influence on the measured outcomes. Future studies should seek standard reporting and exhaust maximum effort to include larger sample sizes for more robust data. In addition, multicenter studies may help generalize the findings to different populations and healthcare settings.

CONCLUSION

The meta-analysis underscores the orbital bullet injuries heterogeneity and seriousness, hereby needing tailored clinical approaches for case management. Therefore, variable outcomes arise because of differences in effective early interventions, advanced imaging modalities, and surgical interventions, which are comprehensive for optimal recovery of the patient and prevention of long-term complications. Future studies should seek to standardize protocols regarding the assessment and management of orbital bullet injuries so that better patient care and outcomes can be attained.

Ethical approval

Institutional Review Board approval is not required.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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