A Game of Paintball Leads to a Potentially Devastating Eye Injury

Jessica Lee, MD; Ronald C. Gentile, MD


January 24, 2017


Approximately five million ocular injuries occur globally every year, with young males (<40 years) being affected nine times more often than females.[3,4]

Based on the Ocular Trauma Classification, this patient had a zone III closed-globe contusion injury. The globe is divided into three zones, with zone l being the most superficial portion and zone III the most posterior. Even though this patient had a corneal abrasion and microhyphema (respectively considered zone l and II closed-globe injuries), his most posterior zone of injury, the choroidal rupture, was used to classify his injury.[5,6]

More than five million people participate in paintball annually, using compressed gas-powered guns that fire paintballs at a velocity of 100-300 ft/sec. Ocular injuries represent one of the most common injuries suffered during paintball and can lead to severe damage and permanent loss of vision. The visual prognosis for paintball ocular injuries is poor, with nearly 30%-40% of patients becoming legally blind in the injured eye.[7,8]

Patients can present with hyphema, cataract, commotio retinae, choroidal rupture, vitreous hemorrhage, retinal detachment, and chorioretinitis sclopetaria. Experimental simulations have shown that paintballs traveling over 65 ft/sec can rupture a globe.[9] Besides the acute injury, eyes with paintball injuries can suffer long-term sequelae, including glaucoma, cataract, and retinal detachment. Most paintball ocular injuries are sustained when protective eyewear and masks were not being worn or were briefly removed, as was the case in this patient.[10]

Choroidal ruptures are indicative of the severity of the blunt trauma and can result from direct or indirect (contrecoup) trauma to the eye. Direct choroidal ruptures lead to ruptures close to the site of impact and occur anterior and parallel to the ora serrata. Indirect choroidal ruptures occur opposite the site of impact and occur posteriorly, as in this patient. Choroidal ruptures are usually crescent shaped and concentric to the optic disc, with 80% being located temporal to the optic disc. Multiple choroidal ruptures are present 25% of the time. Traumatic choroidal ruptures are commonly associated with subretinal hemorrhages, which are known to have a poor natural history. Pneumatic displacement of the hemorrhage with intravitreal injection of tpA and SF6% gas can expedite its displacement and theoretically limit the blood's toxicity to the retinal pigment epithelium.[11]

Choroidal rupture can be complicated by the growth of choroidal neovascularization, which occurs in 11%-37.5% of cases and is aided by risk factors such as older age, macular located ruptures, and longer length of the rupture.[12,13,14] Even though laser treatment, submacular surgery, and photodynamic therapy have been used to treat these choroidal neovascular membranes, intravitreal anti-VEGF injections are currently the treatment of choice.[15]

The majority of paintball-related eye injuries and blindness are preventable. The importance of protective eyewear should be emphasized not only by ophthalmologists and other eyecare providers but also by anyone involved in or around this activity. The best way to treat such devastating paintball eye injuries is to prevent them.

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