On exam the patient had significant chemosis and right-sided palpebral edema with moderate ptosis. Further examination demonstrated decreased range of motion of the right eye in all directions and a right nasal hemianopsia. A CT scan of the head revealed a nail penetrating through the maxillary sinus and orbit missing the optic nerve and ophthalmic arteries and extending into the right frontal lobe (Figs. 1, 2, 3 and 4). He was taken to the operating room and had the nail removed by neurosurgery and plastic surgery. Follow-up ophthalmology examination on postoperative day 2 demonstrated temporal macular choroidal rupture responsible for the nasal hemianopsia with pre-retinal fibrosis and hemorrhage causing macular traction and retinal folds with vision 20/160 (compared to 20/25 of the unaffected eye) and a complaint of a mild headache.