Gunshot wounds to the eye represent some of the most devastating forms of ocular trauma. In Pakistan, these injuries occur in both civilian and military settings, but their causes and outcomes vary significantly from those reported in other parts of the world.
Patterns and Causes in Pakistan
Recent hospital studies and case series from across Pakistan have shown that low-velocity projectile weapons—particularly air guns, BB guns, and toy pellet guns—are responsible for the majority of civilian ocular firearm injuries. These are most commonly seen among teenagers and young men, often during festive seasons or recreational play.
Another major cause is stray bullets from celebratory aerial firing, which frequently occur on Independence Day (14 August), weddings, and New Year celebrations. During these events, hospitals in Karachi and other cities report dozens of firearm-related injuries in a single night—many involving the eyes.
In contrast, high-velocity military and combat-related injuries, such as those from rifles or shrapnel, are primarily reported in armed-forces medical centers and represent a smaller subset of cases in the general population.
This makes Pakistan’s pattern of ocular gun injuries distinct: the country faces a combination of accidental pellet-gun injuries typical of Western children and stray-bullet ocular trauma seen in Middle Eastern and South Asian celebratory settings.
Global Context
Worldwide, firearm-related eye injuries are most often linked to criminal violence or war.
- In high-income countries like the United States, most ocular gunshot wounds come from handguns or rifles. These carry a poor prognosis, often resulting in no light perception or enucleation (surgical removal of the eye).
- In low- and middle-income countries, nonlethal weapons such as air guns and pellet rifles are more common, but can still cause permanent blindness if the globe is penetrated.
Compared globally, Pakistan’s cases are highly preventable—stemming from poor regulation of toy and pellet guns and unsafe cultural practices like aerial firing—rather than intentional gun violence.
Understanding Visual Prognosis
Following gunshot wounds to the globe, the visual prognosis depends on multiple factors. The Ocular Trauma Score (OTS) can help predict outcomes but is not fully accurate.
Key prognostic indicators include:
- Location of the exit wound
- Associated optic nerve injury
- Presence of retinal detachment (the retina separating from its normal position)
- Submacular haemorrhage (bleeding beneath the central retina)
Even when initial visual acuity is poor (limited to light perception), good postoperative results are possible, particularly when vitreous haemorrhage (bleeding into the eye’s gel) is cleared and no further complications exist.
Injury Classification and Surgical Considerations
According to the Birmingham Eye Trauma Terminology System (BETTS), most gunshot eye injuries are open-globe wounds rather than closed-globe wounds.
Two common clinical types are:
- Penetrating injuries: with an entry wound and possibly a retained intraocular foreign body (IOFB)
- Perforating injuries: with both entry and exit wounds, and a foreign body impacted behind the eye
Initial management should always prioritize prompt closure of entrance wounds. Subsequent interventions depend on the injury type.
- Primary vitrectomy is not recommended for perforating wounds, as fluid infused into the eye can escape through the posterior exit wound, risking globe collapse.
- If the injury is penetrating with a retained IOFB, surgical removal and vitrectomy are considered, but may need to be delayed if corneal opacity limits visibility.
Timing and Secondary Vitrectomy
The timing of secondary surgery depends on several healing factors:
- Sealing of exit wounds
- Return of corneal clarity
- Watertight closure
Modern visualization tools such as wide-angle BIOM systems allow surgery even through partially opaque corneas. If visibility remains impossible, a temporary keratoprosthesis (artificial cornea) can be used.
A secondary vitrectomy is generally advised after 1 to 3 weeks, allowing wound stabilization and posterior vitreous detachment, which makes surgery safer and more effective.
Immediate Action and Follow-Up Care
Immediate steps following gunshot eye injury:
- Do not apply pressure to the injured eye.
- Shield the eye gently (avoid bandages that apply pressure).
- Seek emergency ophthalmic care immediately — ideally within the first few hours.
- Avoid rinsing or probing the wound and do not remove any visible foreign objects.
Follow-up care after initial surgical repair may include:
- Serial examinations to monitor intraocular pressure and retinal status.
- Imaging (ultrasound or CT) for retained foreign bodies.
- Secondary procedures such as cataract extraction, membrane peeling, or retinal repair.
- Rehabilitation and low-vision support, depending on visual recovery.
Early and consistent follow-up can make the difference between partial visual recovery and irreversible loss.
With Pakistan’s internationally trained and most experienced cataract surgeons, corneal transplant surgeons and eye surgeons specializing in every single sub specialty in ophthalmology, The Eye Center – Dr. Mahnaz Naveed Shah & Associates in Karachi provides guidance for both routine and urgent eye care needs. Their team can advise whether you should schedule a screening or seek immediate attention, ensuring safety and comfort.
For expert consultation, contact The Eye Center – Dr. Mahnaz Naveed Shah & Associates at 03041119544 to book an appointment.
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