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   Table of Contents      
ARTICLE
Year : 1968  |  Volume : 16  |  Issue : 4  |  Page : 253-257

A case of intra-ocular foreign body - Broomstick


Ram Krishna Mission Seva Pratishthan, Calcutta, India

Date of Web Publication24-Dec-2007

Correspondence Address:
R N Basu
Ram Krishna Mission Seva Pratishthan, Calcutta
India
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How to cite this article:
Basu R N. A case of intra-ocular foreign body - Broomstick. Indian J Ophthalmol 1968;16:253-7

How to cite this URL:
Basu R N. A case of intra-ocular foreign body - Broomstick. Indian J Ophthalmol [serial online] 1968 [cited 2020 Aug 9];16:253-7. Available from: http://www.ijo.in/text.asp?1968/16/4/253/37569


  Introduction Top


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 Top


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 Top


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 Top


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.

Pathological Reports.

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.

Histopathological section­-

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 Top


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.

Follow up

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 Top


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 Top


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.[5]

 
  References Top

1.
Duke-Elder, S (1954), Text Book of Ophthalmology, Vol. VI, Henry Kimp­ton, London.  Back to cited text no. 1
    
2.
Duke-Elder, S. (1966), System of Oph­thalmology, Vol. IX, Henry Kimpton, London  Back to cited text no. 2
    
3.
Hill, A. F. (1952), Economic Botany, Second Edition, McGrew-Hill, U.S.A.  Back to cited text no. 3
    
4.
Hogan M. J. and Zimmerman L. E. (1962) Ophthalmic Pathology, Second Edition W, B. Saunders company, U.S.A.  Back to cited text no. 4
    
5.
Sorsby, A. (1964), Modern Ophthal­mology, Vol. 3, Butterworths, London.  Back to cited text no. 5
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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  In this article
Introduction
Case report
Examination
Investigations
Comment
Summary
Acknowledgements
References
Article Figures

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