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   Table of Contents      
ORIGINAL ARTICLE
Year : 1993  |  Volume : 41  |  Issue : 3  |  Page : 125-127

Unusual orbital foreign bodies


Department of Opthalmology and Radiotherapy, King George's Medical College, Lucknow, India

Correspondence Address:
P K Agarwal
Department of Ophthalmology, Kings George's Medical College, Lucknow 226003
India
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Source of Support: None, Conflict of Interest: None


PMID: 8125544

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  Abstract 

Retained intraorbital organic foreign bodies, particularly wooden, are commonly encountered in ophthalmologic practice. We treated two children who had sustained such injury while playing. They presented to us with non-healing sinus with purulent discharge. In one of the patients, X-rays and CT scan helped to clinch the diagnosis, whereas in the other patient diagnosis was possible by correlating history with clinical findings. Surgical exploration in both patients helped us to remove the foreign bodies. Surprisingly, both the foreign bodies were 7 cm long wooden pieces. We, however, caution that management of such cases should be conservative and that surgical exploration be done only in case of complication. From our experience, we recommend proper localisation by all possible means, blunt dissection, careful haemostasis coupled with excellent lighting and exposure in the atraumatic removal of intraorbital foreign bodies.

Keywords: Orbital foreign bodies - Wooden foreign bodies -- Orbital trauma


How to cite this article:
Agarwal P K, Kumar H, Srivastava P K. Unusual orbital foreign bodies. Indian J Ophthalmol 1993;41:125-7

How to cite this URL:
Agarwal P K, Kumar H, Srivastava P K. Unusual orbital foreign bodies. Indian J Ophthalmol [serial online] 1993 [cited 2019 Oct 19];41:125-7. Available from: http://www.ijo.in/text.asp?1993/41/3/125/25606

Retained intraorbital organic foreign bodies, particularly wooden, are commonly encountered in ophthalmologic practice. Their presence gives rise to different type of clinical picture in which after an initial quiescent period of variable duration the patient may present with complications such as granuloma, orbital cellulitis, orbital abscess, osteomyelitis, periosteitis, or chronic fistula. Foreign bodies in these situations are usually occult because of their posterior location within the orbit and relative radiolucent property. [1]

Two such cases are reported here. A detailed history and physical examination aided with all possible diagnostic adjuncts are required for proper management of such cases.

Case Reports

Case
1. An 8-year-old boy reported with a swelling in left upper lid associated with purulent discharge, for the previous two months. History disclosed an injury of 21/2 months duration sustained by a wooden piece following which the patient developed swelling and a sinus with purulent discharge off and on. On examination a well-defined tender swelling was present on the medial side of left upper lid with purulent discharge from an opening on it. The skin over it was oedematous and inflamed [Figure - 1]. There was no perception of light in the left eye, pupil was non-reacting, dilated and fixed. The left eye was divergent, the extraocular movements were restricted, and an axial proptosis of 3 mm was present. X-ray of the skull and CT scan did not show any abnormality in either of the orbits.

Correlating the clinical history and physical examination, a clinical diagnosis of foreign body granuloma was made. On exploration, under general anaesthesia, a 7 cm wooden piece was removed [Figure - 2][Figure - 3]. The sinus tract was scraped and cauterised. A tarsorrhaphy was done to prevent exposure of the cornea in the postoperative period. Histopathology of the scraped tissue showed features of foreign body granuloma.

Case 2. A 9-year-old boy was referred to our ophthalmic plastic surgery unit with complaints of a sinus with purulent discharge in the middle of right lower lid of seven months' duration [Figure - 4]. A detailed history revealed injury sustained by a pencil while the patient was playing at school. At the time of injury, he was holding a pencil in his hand which entered below his right eye through the middle of the lower lid. The wound healed initially, but three weeks later the patient developed a sinus with purulent discharge at the site of entry. During this period the orbit was explored twice, and fragments of enamel coating and lead were removed, but the purulent discharge persisted.

On examination visual acuity in both eyes was 6/6. The right eye had full movements, equally reactive pupil, and a normal appearing fundus.

Conjunctival chemosis and cicatricial ectropion were seen at the site of the sinus. Plain X-ray of the skull and CT scan revealed a large linear radiodense shadpw in the floor of the right orbit extending posteriorly breaking through the lateral orbital wall [Figure - 5]. Contrast CT scan showed a linear enhancing lesion extending intracranially in the floor of middle fossa upto the level of optic chiasma, pushing the bony fragments and the meninges ahead of it, thus preventing the cerebrospinal fluid leakage [Figure - 5].

The exploration of the sinus tract and removal of foreign body was planned taking great care not to break the foreign body during manipulation. Intraoperatively the foreign body was blindly localised and gently pulled out through the opening [Figure - 6]. After an initial resistance the entire impacted foreign body came out of the opening. It was found to be a 7-cm long broken part of a pencil [Figure - 7]. The sinus tract was irrigated with gentamicin. The mouth of the tract was cauterised with carbolic acid, sinus tract was packed and dressed for 48 hours.

In the immediate postoperative period the pupil was reacting briskly but limitation of ocular movements was present in the direction of action of inferior rectus muscle. The patient was put on oral steroids (prednisolone 15 mg) along with oral antibiotic (cephalexin 250 mg four times a day). On the tenth postoperative day, visual acuity in the right eye was 6/6, full ocular movements in all gazes were seen along with a mild cicatricial ectropion of right lower lid.


  Discussion Top


Orbital foreign bodies are commonly encountered in ophthalmologic practice. Such foreign bodies are often difficult to localise despite advanced investiga­tive tools such as CT Scan. In this article, the retained foreign bodies were seen in two children who had sustained injury while playing. Large intraorbital foreign bodies usually slide between the eyeball and the orbital walls, but rarely cause severe trauma to the eye. However, immediate direct trauma to important intraconal structures may even damage the optic nerve (case 1). Paresis of the extraocular muscles and anaesthetic immobile globe have been reported. [2] Rarely do the foreign bodies traverse the orbit into the cranium (case 2) or to adjacent paranasal sinuses causing extensive damage to surrounding structures. [2]

X-rays and CT scans have their limitations in localising organic foreign bodies because of similar attenuation coefficient as of the orbital contents [3],[4] (case 1). As seen in case 2, the radiolucent lead of the central part of the pencil cast a shadow on plain X-ray. The pencil's enamel coating also cast a relatively less radiodense shadow. Plain CT scan showed a linear tract extending from the right orbit chiasma, which on contrast showed a surrounding tract of contrast enhancement as a result of increased vascularity and fibrosis around it.

From our experience, we suggest that management of such cases should be conservative unless any one of the following complications occur: (1) severe inflammation (abscess, cellulitis, fistula); (2) compres­sive effects on the eye, and (3) communication of the orbit with the paranasal sinuses or intracranial space. We further suggest that a careful localisation of the foreign body should be done with all possible techniques before attempting surgical removal so as to avoid damage to important intraconal structures. Another reason is that many foreign bodies, particularly organic and wooden ones, fragment easily during surgical removal leaving behind splinters that cause inflammation even after long quiescent period.

Based on our experience, we recommend blunt dissection, careful haemostasis coupled with excellent lighting and exposure in the atraumatic removal of intraorbital foreign bodies.

 
  References Top

1.
Fergusan EC III : Deep wooden foreign bodies of the orbit: A report of two cases. Trans. Am. Acad. Ophthal­mol. Otolaryngol. 74: 778, 1970.  Back to cited text no. 1
    
2.
Peyman GA, Sanders DR, and Goldberg MF : Principles and practice of Ophthalmology : Vol. III, W.B. Saunders, p-2466,1987.  Back to cited text no. 2
    
3.
Lloyed GAS: Radiology of the orbit. Philadelphia, W.B. Saunders, 1975.  Back to cited text no. 3
    
4.
Lanpert VL, Zelch JV, and Cohen DN: Computed to­ mography of the orbits. Radiology : 113: 351, 1974.  Back to cited text no. 4
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]


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