The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Lindsey R. Baden, M.D., Editor

Ptosis after Swimming in the Red Sea

A B C

A
52-year-old man presented with ptosis and limited ocular and Wolf A. Lagrze, M.D., Ph.D.
eyelid elevation in his left eye (Panel A). A swollen and droopy eyelid had Albert Ludwigs University Freiburg
developed after the patient collided with a school of fish while he was Freiburg, Germany
swimming at a Red Sea beach 4 weeks earlier. Magnetic resonance imaging re- wolf.lagreze@uniklinik-freiburg.de
vealed a granuloma in the upper eyelid and anterior upper orbital region (Panel B), Matthias Schaber, Ph.D.
with no foreign body visible. During surgical excision of the granuloma, two
Thnen Institute of Sea Fisheries
transparent tubular structures pointing toward the orbital apex were detected and Hamburg, Germany
extricated (Panel C). These foreign bodies were thought to have pinned and im-
mobilized the levator muscle and superior rectus muscle. Taxonomic analysis
identified the objects as mandibles of the halfbeak fish. Halfbeak fish, which are
members of the family Hemiramphidae, are mostly surface-dwelling fish that are
common in shallow and coastal waters, including such waters in the Red Sea.
Within 3 months after surgery, the ptosis and the restriction of ocular motility had
resolved completely.
DOI: 10.1056/NEJMicm1411119
Copyright 2015 Massachusetts Medical Society.

n engl j med 373;12 nejm.org September 17, 2015 1153

The New England Journal of Medicine
Downloaded from nejm.org on January 17, 2016. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.