An 18-year-old Bullet Was Still Trying to Kill Him

When Dr. Scott Goldstein carefully pressed with his fingertips under the patient’s right eye, he felt a hardness, a mass. Something was in the eye socket. Something was expanding so far forward that it pushed outside of the rim and displace the eye upward.

He sat back and asked the patient how it felt. Pressure, the patient said. Aching. Discomfort. The patient’s frustration shook in his voice. How could he still be so affected by an injury so long in the past? Eighteen years ago, a stray bullet had struck him in the face. It destroyed his left eye, traveled through his nasal cavity, and lodged behind his right eye where it damaged his vision, leaving him with some sight but functionally blind.

Six years after the initial injury, long before the patient came to Wills Eye, a cyst had formed in the eye socket.

Orbital surgery had been necessary to remove it. Dr. Goldstein thought this new problem might be related. Although rare, cells from the nasal mucosa could be growing there after being picked up as the bullet traveled through the patient’s nose. Surgery was going to be necessary again.

Dr. Goldstein ordered diagnostic imaging. Magnetic resonance imaging (MRI) was out of the question since the bullet being metallic, so a CT scan was performed. Unfortunately, the presence of metal also affects the quality of CT imaging. Dr. Goldstein could see the bullet lodged in the back of the patient’s eye socket, but random shapes on the image around the bullet called “artifact” made it impossible to know exactly how much danger the bullet’s position posed. Could removal damage the eyeball? Could injuring the optic nerve take away the last of the patient's vision? Could the bullet actually be resting against his brain? Very cautious surgery was needed.

In the operating room, Dr. Goldstein retracted the patient’s eye and entered the socket. No, it was not a cyst. It was not cells of nasal mucosa that had been transplanted by the trauma. The pressure was caused by an active infection. A large amount of pus was filling the eye socket.

Dr. Goldstein went to work clearing and cleaning the area to defeat the infection. He saw the bullet way in the back of the orbit. Over the last sixteen years, the bone had tried to repair itself, like a tree might grow over and around a metal fence. Dr. Goldstein tugged on the bullet, but it wouldn’t budge. The bone surrounded the edges and hugged it tight. Rather than risk further serious injury, Dr. Goldstein once again left the bullet in place. He hoped that the infection would now be resolved.

Over the next year, however, the infection returned multiple times. As Dr. Goldstein explained, once a biofilm forms on a solid object, in this case the bullet, it can be difficult to remove the bacteria completely. It had become clear that the bacteria wasn’t being entirely eradicated by the courses of antibiotics. Where the infection came from precisely after so many years will never be known. Perhaps it came from the patient’s sinus. Perhaps bacteria from a skin wound found its way into the cavity.

The patient and Dr. Goldstein agreed. Despite the risks, the bullet had to go. Back in surgery, Dr. Goldstein retracted the patients eyeball again, this time as far as safely possible to protect it from harm. He took up a high speed burr and began to cut away the grown-over bone. He went slowly, removing small amounts before continuing. After finishing the cutting process, over the course of 45 minutes, Dr. Goldstein worked to free years' worth of scar tissue. He kept checking the eye and the bullet. Would it come free? At last, finishing the job with a hammer and chisel, Dr. Goldstein released the bullet from its long resting place without any additional trauma. After hiding and resisting so long, the bullet was finally clamped in the surgeon's hemostat.

Today, the infection is gone, the recurrences have ended, and no collateral damage was done. The patient keeps that bullet with him as the final chapter in this story. So long, it defined him. It represented that terrible injury that would not stop hurting him.

With this new sense of lightness, he can finally move on.