CASE REPORT
Unusual Intraorbital Foreign Body A Case Report JASPREET SUKHIJA, MS, SUPRATIK BANDYOPADHYAY, MS, JAGAT RAM, MS, SVATI BANSAL, MS, PRANAB DAS, MS, GAGANDEEP S. BRAR, MS
ABSTRACT Penetrating eye injury is an important cause of ocular morbidity in India, especially in the pediatric and adolescent age group. Sometimes these injuries are associated with retained intraorbital foreign body. We report herein for the first time a child who had an open globe injury with a retained unusually large intraorbital foreign body (iron nut).
INTRODUCTION Eye injuries are an important cause of ocular morbidity in children (1). The commonest type of injury is blunt trauma (65%), followed by penetrating eye injuries (24%) (2). These injuries are commonly sustained during domestic activities, at play, or in school (2). Occasionally patients of eye injuries may present with retained intraorbital foreign bodies (3). We report an 11-year-old boy who presented with an extremely unusual intraorbital metallic foreign body. He had suffered trauma to the eye with an explosive material while playing with friends.
CASE REPORT
REPRINTS Dr. Jagat Ram, Professor of Ophthalmology, Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012 India. E-mail:
[email protected]. Drs. Sukhija, Bandyopadhyay, Ram, Bnsal, Das, and Brar are from the Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article. The authors also do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices. Submitted for publication: 12/15/05. Accepted: 2/24/06. Annals of Ophthalmology, vol. 38, no. 2, Summer 2006 © Copyright 2006 by ASCO All rights of any nature whatsoever reserved. 1530–4086/06/38:145–147/$30.00. ISSN 1558–9951 (Online)
An 11-year-old boy presented with loss of vision in the left eye following an injury while playing with some explosive material. He was taken to a local practitioner where a scleral laceration was sutured. The patient presented to us 9 days after injury with no light perception in the injured eye. He had severe lid edema with conjunctival chemosis (Fig. 1A). The ocular movements were absent. Slit-lamp examination revealed an area of repaired scleral wound at the temporal limbus extending from the 12- to 6-o’clock position. Dense hyphema precluded the view of the anterior and the posterior segment. The patient was started on intravenous ciprofloxacin (250 mg twice daily) for 7 days and a radiograph of the orbit was done. The radiograph showed a large foreign body in the orbit resembling a nut (Fig. 1B). The foreign body was ANN OPHTHALMOL. 2006;38 (2) ...................................................145
Figure 1—(A) Full-face view of the patient on presentation. Note the conjunctival chemosis and periorbital edema around the left eye. (B) Radiograph lateral view of skull on presentation. Note the metal nut within the orbit oriented along its long axis.
removed from the orbit under general anesthesia with the help of an electromagnet. The nut measured 5.4 cm in length and 1.2 cm in height with a diameter of the head of the nut measuring 3.1 cm (Fig. 2A). Intraoperatively, the globe was found to be markedly hypotonous and disorganized and no intraocular structures could be identified. A computed tomography scan of head (Fig. 2B) was done postoperatively to rule out any intracranial complications. The prognosis and the risk of sympathetic ophthalmia were explained to the parents. As no useful vision could be gained in that eye, the globe was enucleated and sent for histopathological examination. Histopathology revealed fragmented retina, choroidal detachment with vitreous hemorrhage.
COMMENT Retained intraorbital foreign bodies are not an uncommon presentation of ocular trauma. Commonly intraorbital ANN OPHTHALMOL. 2006;38 (2) ...................................................146
Figure 2—(A) Close-up view of the foreign body following removal. Note the large size and rusted state of the nut. (B) Postoperative noncontrast computed tomography scan, coronal view. Note the disorganized left global with hemorrhagic soft tissue extending inferolaterally.
foreign bodies are metallic in nature, followed by nonmetallic and organic types (3). However, various unusual types of foreign bodies in the orbit have been described in literature (4). Large foreign bodies may be present in the orbit despite only minute trauma to the anterior segments, a fact that may easily lead to a false diagnosis. Foreign bodies usually slide between the eyeball and the orbital walls, but sometimes cause severe trauma to the eye (4). They can also be associated with severe intracranial complications (5). It is thus extremely important to obtain a complete radiological evaluation in all cases of severe ocular trauma. Many indigenous dangerous play activities have been reported that are played on an informal and unsupervised basis resulting in severe ocular trauma (6). Injuries from explosives commonly cause conjunctival and corneal foreign bodies and lacerations (7). In the present case, the child was injured while playing with some
unknown explosive material, resulting in an open globe injury. The possibility of an intraorbital foreign body was not suspected by the local practitioner who repaired the scleral laceration. Radiological examination showed a large nut-like structure reaching almost up to the orbital apex. There was no intracranial penetration and the patient did not have any neurological complications. The intraocular structures were completely distorted and there was no way the globe could be salvaged. Eye injuries in children are largely preventable by careful supervision during various play activities. Public education on the potential hazards of dangerous play activities should be carried out and the use of suitable eye protection should be encouraged.
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