|Year : 1968 | Volume
| Issue : 4 | Page : 253-257
A case of intra-ocular foreign body - Broomstick
Ram Krishna Mission Seva Pratishthan, Calcutta, India
|Date of Web Publication||24-Dec-2007|
R N Basu
Ram Krishna Mission Seva Pratishthan, Calcutta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Basu R N. A case of intra-ocular foreign body - Broomstick. Indian J Ophthalmol 1968;16:253-7
| Introduction|| |
Broomsticks are fibres obtained from the leaf of coconut trees. They are used to clean floors in India, specially in Bengal. These leaves have veins which consist of very strong, stiff, coarse and elastic fibres. They are bristle like, durable and retain their resiliency even when wet; therefore, suitable for sweeping rooms.
Often children are found playing at how and arrow with broomsticks and accidentally one of them pierces into the eyes causing irrepairable injury. External ocular injury, caused by broomsticks, is common but a perforating posterior segment injury with its retention is comparatively rare.
The following case report will illustrate an uncommon case of retained intraocular foreign body, a broomstick in the posterior segment of the eye, which presented a different clinical picture in the beginning.
| Case report|| |
T.K.D. 10 years male presented in the ophthalmic outpatients' department of R. K. Mission Seva Pratishthan on 11th March 1968, with the complaint of severe pain in the left eye, with swelling of the lids and restricted painful movements of the eve ball for the last 2 days.
| Examination|| |
Right eye : Nothing abnormal was detected and the vision was 6/6.
Left eye : There was proptosis of the eyeball with swelling of the lids and conjunctival chemosis. The cornea was hazy, the anterior chamber slightly deep with turbid aqueous. The iris was muddy and the pupil irregular due to posterior synecha;. The ocular movements were restricted and painful. Perception of light was doubtful.
A diagnosis of acute orbital cellulitis with septic uveitis in the left eye was made. [Figure - 1].
The history revealed that about 36 hours earlier the left eyeball was hit by a broomstick from the temporal side. The mother was definite that the broomstick was out. Inflammatory signs started about 6 hours after the injury. On admission, the patient was found febrile (102°F) with a toxic look. X ray examination of the orbit revealed no radio opaque foreign body in the eye. Intravenous Mannitol and Reverin were started after admission, with steroids by mouth. Locally, Penicillin drops at 15 minutes intervals were given in that eye with cold mag. sulph. compresses. With this treatment the general toxic appearance of the patient improved but proptosis of the eyeball and conjunctival chemosis remained the same and also there was no improvement of vision. A full course of Crystamycin by injection was given next. There was further improvement of the general condition but conjunctival edema remained the same and corneal haziness increased. There was also hectic rise of temperature (99°-102°F). On 21-3-68 under general anesthesia multiple punctures were made over the oedematous conjunctiva around the limbus to improve the corneal nutrition. An orbital puncture through the conjunctiva between the inferior and lateral recti muscles was done to let out any retrobulbar collection of pus if there was any. Only some serous fluid came out. The material was sent for culture. This improved the corneal nutrition and the cornea become clear. Gradually, his general condition improved. The patient became afebrile. The eye became quiet and movements of the eye ball got restored. The pupil could not be dilated beyond 1 mm even after 3 subconjunctival injections of mydricaine. There was occlusio pupil with no perception of light. The tension was normal. Patient was discharged from the hospital on 3-4-68.
On 9-4-68, the patient came to the out-patients department again, with a painless hyphaema. [Figure - 2] There was no deterioration of his general condition. On examination, circumcorneal congestion and scleral pigmentation near about the openings of the perforaing branches in the upper part of the eyeball were seen. The patient was advised complete bed rest and coagulants were prescribed. By 13-4-68, the hyphaema had increased (painless and causeless) inspite of treatment.
An enucleation of the left eye was done on 22-4-68. The patient made an uneventful recovery. The indication for enucleation in this case was a suspected retained intraocular foreign body in a blind eye.
| Investigations|| |
a) X' Ray examination of the orbits, P-A and lateral views revealed no intra-ocular foreign body.
b) Blood counts
a. R.B.C.- 4.18 millions/cmm.
b. W.B.C.- Total count - 15,000/cmm, with 90% of neutrophils.
c. E.S.R.- 1st hour - 28mm.
2nd. hour - 60mm.
c) Conjunctival swab culture - Growth of few colonies of staphylococcus Albus (Coagulase negative).
d) Culture of the fluid collected from the retrobulbar space after orbital puncture showed no growth.
Morbid anatomy of the eyeball-
Size and shape of the eyeball was normal. There were patches of migratory pigments on the sclera at the entrance of the canals for the perforating vessels. The cornea was hazy and clotted blood could be seen in the anterior chamber.
When the section of the eyeball was made, one small piece of broomstick was found in the vitreous. [Figure - 3] There was no external sign of scleral perforation for the entry of foreign body. Possibly the foreign body got entry through the ciliary region on the temporal side of the eyeball.
Cornea- Epithelium was normal. Blood could be seen in the stroma (blood staining of the cornea).
Anterior chamber- It was full of clotted blood.
Iris- Stroma as thickened. There were clumps of pigments in the anterior and posterior layers. It also showed granulation tissue along with lymphocytic infiltration and at places neovascularisation. Angle of anterior chamber was closed.
Ciliary body and choroid- The whole coat was thickened and there was infiltration by lymphocytes. Perivascular cuffing with lymhocytes and pigment dispersion was also seen. One Dalen-Fuchs like nodule was also seen with phagocytosis of pigment by epithelioid cells. No giant cell could be seen in the section. [Figure - 4].
Sclera- There was lymhocytic infiltration in the inner layers of sclera. Localised tracks of pigmentary dispersion were also seen.
Retina- All the retinal layers were disorganised due to profuse infiltration.
Vitreous- Full of lymphocytic infiltrations, haemorrhage and granulation tissue.
Pathological diagnosis- Sympathetic Irritation.
| Comment|| |
Retention of a foreign body within the eye which is not very common causes a great deal of anxiety. The reasons are (a) mechanical damage caused at the time of accident, (b) complications of a perforating ocular injury, (c) danger of subsequent development of sympathetic ophthalmia, (d) slow destruction of vision (sometimes sudden) by chemical changes and also irritative local reaction caused by most foreign bodies within the eye.
There is a disproportionate incidence of penetrating ocular injuries in childhood. These are mainly nonoccupational domestic injuries, which are due in part to the child's natural curiosity but also to lack of awareness of potential danger on the part of parents.
Organic material is rarely met with as an intraocular foreign body. The literate contains few case reports. Common case reports are of splinter of wood, thorn, cotton fibres from clothing etc. after explosions especially in war wounds. We have not found, in the literature, any case report of an intraocular retention of broomstick as a foreign body. Reaction of the posterior segment of the eye is always marked with organic materials (compared to mettalic foreign bodies) because these are always unsterile.
Pyogenic infection is usually introduced at the time of injury, leading to the formation of a vitreous abscess and the development of phthisis bulbi. Usually, entry of such a foreign body into the eye is through the ciliary region. Diagnosis of such an intraocular foreign body is equaly difficult because radiological investigation is usually negative. Prognosis of these cases is not good because the foreign bodies are almost always infected and they produce an acute fulminating panophthalmitis or alternatively, a less acute endophthalmitis which may ultimately develop into a condition of phthisis bulbi. Sometimes prognosis may be good if the infection is controlled by antibiotics and if the foreign body is extracted. or gets extruded from the globe. If the pyogenic infection is not introduced into the eye at the time of accident, a granulomatous inflammation may develop shortly after the injury leading to sympathetic ophthalmia.
In our case, there was severe orbital cellulitis with septic uveitis when the patient presented in the out patients' department. X'ray of the orbit did not reveal any radio opaque foreign body. With treatment inflammation subsided but recurrent attacks of hyphaema gave suspicion of a retained intraocular foreign body. When the eyeball was cut the foreign body was found in the vitreous. Possibly, the site of entry was the ciliary region on the temporal side. Histopathological section showed general uniform infiltration of the entire uveal tract and also infiltration of the posterior layers of the iris, lymphocytic infiltration in the walls of the veins invading and occluding their lumen; and also infiltration of the emissary veins, destruction of the pigment epithelium and phagocytosis of pigments and the presence of a nodule very much similar to Dalen-Fuchs nodule and absence of giant cells. Pathological diagnosis of Sympathetic Irritation was made because of absence of keratic precipitates, giant cells and organic changes in the iris which are distinctive of Sympathetic Ophthalmia.
Regular monthly follow up of the case was done. The patient was last examined in November, 1968. The other eye is normal with full vision and healthy fundus oculi.
| Summary|| |
A case of intraocular foreign body (broomstick) is described. The literature is briefly reviewed. The different layers of histopathological section of the eyeball are discussed.
| Acknowledgements|| |
My thanks are due to Dr. S. K. Sarker for his help in pathological studies, to Dr. N. C. Bhattacharya, my house surgeon for his constant help. I am extremely grateful to my chief, Dr. N. K. Munshi, for his valuable advice.
| References|| |
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Text Book of Ophthalmology, Vol. VI, Henry Kimpton, London.
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System of Ophthalmology, Vol. IX, Henry Kimpton, London
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Economic Botany, Second Edition, McGrew-Hill, U.S.A.
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Ophthalmic Pathology, Second Edition W, B. Saunders company, U.S.A.
Sorsby, A. (1964), Modern Ophthalmology, Vol. 3,
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]