Year : 2003 | Volume
: 51 | Issue : 1 | Page : 83--84
Late spontaneous extrusion of a wooden intraorbital foreign body.
A Banerjee, A Das, Pankaj Kumar Agarwal, Asit Ranjan Banerjee
Regional Institute of Ophthalmology, Kolkata, India
Regional Institute of Ophthalmology, Kolkata
Wooden intraorbital foreign body is characteristic for delayed manifestation, silent progression and unpredictable outcome. A silent wooden intraorbital foreign body is difficult to diagnose clinically. Spontaneous expulsion of entire foreign body is rare.
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Banerjee A, Das A, Agarwal PK, Banerjee AR. Late spontaneous extrusion of a wooden intraorbital foreign body. Indian J Ophthalmol 2003;51:83-84
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Banerjee A, Das A, Agarwal PK, Banerjee AR. Late spontaneous extrusion of a wooden intraorbital foreign body. Indian J Ophthalmol [serial online] 2003 [cited 2020 Jul 7 ];51:83-84
Available from: http://www.ijo.in/text.asp?2003/51/1/83/14730
The orbital cavity can host an unexpected foreign body for a considerable length of time without causing any symptoms, but the retention of organic material especially wood frequently causes problems. Penetrating injury of the orbit with a wooden stick or a branch is not an uncommon finding in ocular emergencies. A portion may have broken off and remained embedded within the soft orbital tissues. Diagnosis of an impacted organic substance is often difficult even with the use of advanced investigative procedures. Vegetative materials must be removed as they serve as a nidus for orbital infection. The patient may present with various complications like granuloma, abscess or chronic discharging sinus through the palpebral skin. The removal of foreign body from the orbit, which is crowded with delicate structures, is not safe. Removal of vegetative substances which may fragment easily, is more difficult. However, it is not unusual for a foreign material to extrude partially, along the sinus track spontaneously. We present here a case of a branch of a plant extruded automatically after 6 months of orbital confinement.
A 23-year-old male presented with swelling in the left upper lid and purulent discharge for the past two months. He had sustained an injury by a plant branch as he bent to pluck some flowers in a garden about 6 months earlier. Consequently he developed severe pain with bleeding in the left upper lid and was treated elsewhere. After an asymptomatic period of four months, he gradually developed throbbing pain and swelling at the site of injury. When the ocular symptoms persisted even after 2 months of treatment by a local practitioner, he was ultimately referred to this hospital.
On examination, visual acuity was 6/6 in either eye, ocular movements were full and fundus was within normal limits. There was a discharging sinus in the inner part of the left upper lid just below the superior orbital margin, i.e., just below the eyebrow and 2 cm above the upper lid margin. The margin of the sinus had granulation tissue and there was crusting on the neighboring skin. Another fungating white mass was present, protruding just below the sinus. The mass was 2 cm x 2.5 cm in size with irregular margins and was elevated from the surface. It was mobile but adherent to the skin [Figure 1].
The discharge from the sinus was collected for culture and sensitivity. Fine needle aspiration cytology (FNAC) of the fungating mass was done. The smear showed plenty of acute inflammatory cells, lymphocytes and plenty of foamy macrophages, suggestive of infective granuloma. A plane X-ray of the orbit did not show any radio opaque or soft tissue shadow. A CT scan of the orbit was advised. The patient was admitted for investigation and management. Investigations were done according to the common causes of discharging sinus in that location. He was put on systemic antibiotic (Cap. ampicillin and cloxacillin 250mg each) and anti-inflammatory drug (Tab Ibuprofen 400 mg three times daily and Tab Ranitidine 150 mg twice daily). The very next day morning after admission, spontaneous partial extrusion of a stick was seen through the sinus [Figure 2]. The stick was removed completely with the help of an artery forceps. The extracted stick measured 3.8 cms and was nearly round in shape with a node [Figure 3]. To rule out any more foreign body, probing was done. The sinus tract was irrigated with gentamicin sulfate and the opening was cauterised with carbolic acid. The sprouting fungating mass was excised and cauterised with carbolic acid. The CT scan and ultrasonography did not show any residual foreign body in the orbit. The discharge from the sinus grew Staphylococcus epidermidis, and was sensitive to chloramphenicol, cloxacillin, rifampicin and vancomycin. The histopathological examination of the fungating mass showed foreign body granulomatous inflammation. The follow-up course was uneventful. The visual acuity and ocular movements were unaffected.
An orbital foreign body may lead to variety of signs, symptoms and clinical findings according to its size, location, velocity and composition. The patient may not recollect a history of foreign body penetration. Often the entrance site of an organic foreign body is small and self-sealing, and a quiescent period of days to years may pass before the patient becomes symptomatic. In many instances the foreign body per se excites no specific symptoms. Organic foreign bodies, most commonly wood, tend to cause granulomatous reactions. The radiolucent nature of wood prevents localisation by routine orbital radiography, but with the aid of CT and ultrasonography, the presence and location of the foreign material can often be detected., Spontaneous extrusion of the disintegrated part of the wooden object occurs occasionally,, but the expulsion of the entire length of the foreign body is unusual.
To our knowledge one similar case was reported by Coleman et al. Ours is an interesting case of a large wooden foreign body retained for 6 months without symptoms. An intraorbital foreign body usually slides between the ocular surface and bony orbital wall, but rarely damages the eyeball. Probably the stick penetrated into the orbit while bending and broke at the hinge of the superior orbital edge due to the weight and jerky movement of the head. The incident was probably too sudden for the patient to feel the impact of the retained piece of the stick.
A history of injury and discharging sinus indicates a possibility of impacted foreign body. Another unusual feature was a sprouting granuloma at the adjacent site lower than the discharging sinus. It is possible that an orbital abscess formed after the blockage of the portal of entry either by foreign body itself or by the exudates. The abscess burst and the pus discharged through the most dependent part, ultimately causing a granuloma. Probably the localisation of the pus in the dependent part away from the foreign body prevented its decomposition. The pus discharged from another site.
Spontaneous escape after 6 months' confinement within the orbit is most unusual. Probably the route of entry was plugged initially with hard exudates and appropriate antibiotic controlled the infection as well as the inflammation initially. The natural defensive mechanism of the body helped the automatic extrusion of the complete stick.
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