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Orbital impalement by ballyhoo fish beak

A 27-year-old woman snorkeling in Barbados surfaced and was struck in the left lower eyelid by an airborne fish, later identified as a ballyhoo (Figure 1A). Six days later, she presented with increasing left orbital pain. On examination, visual acuity and pupillary reactions were normal. External examination revealed a healing small puncture wound and resolving ecchymosis (Figure 1B). Although no diplopia was appreciated, left ocular abduction and adduction were restricted. Computed tomography revealed two superonasal left orbital occult foreign bodies, readily visualized in a three-dimensional reconstruction (Figure 1C, arrow). Following surgical removal of the foreign bodies via anterior orbitotomy (Figure 2A), clinical findings normalized, and no infection ensued. The orange-tipped specimens were readily identified by local fishermen as belonging to a ballyhoo bait fish (Hemiramphus brasilensis), also known as a “halfbeak.” The lower elongated jaw, or “dentary” (Figure 2B), of this fish easily fractures into its two bone-like components, well visualized on the CT image. Though rare, fish beak impalement injuries have been reported in multiple anatomic sites, with at least one periocular penetration resulting in death