|Year : 1989 | Volume
| Issue : 3 | Page : 146-147
Orbital wooden foreign bodies-A case report
SM Betharia, Harsh Kumar
R.P. Centre for Ophthalmic Sciences, All MS, New Delhi - 110 029, India
S M Betharia
R.P. Centre for Ophthalmic Sciences, All MS, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
A case of multiple wooden foreign bodies is presented. Any case presenting with a history of injury and a discharging sinus with osteomyelitis warrants a thorough exploration of the orbit. Anterior orbitotomy was performed and 4 pieces of arhar sticks were taken out. The guidelines for the management of the wooden foreign bodies are highlighted.
|How to cite this article:
Betharia S M, Kumar H. Orbital wooden foreign bodies-A case report. Indian J Ophthalmol 1989;37:146-7
| Case report
A 9 year old child presented with the history of injury 3 years ago with a discharging sinus in the right upper lid with extrusion of 2 small wooden foreign bodies. The injury was with an arhar stick while working in the field. The wound was explored 4 months later and no foreign body could be detected in the local hospital.
O/E - The visual acuity was 6/6 in both eyes. The ocular movements were normal. There was proptosis of the right eye. The right eye was displaced downwards and laterally. There was no bruit and the proptosis was not reducible. There was discharging sinus in the medial part of the upper lid 12 mm from the medial canthus and 1.5 mm from the lid margin. The margins of the sinus were Tuckered and there was crusting on the skin.
Fibrous bands were felt under the area of the sinus. There was cicatricial ectropion involving the medial 1 / 2 of the upper lid. The upper punctum was everted and displaced laterally. Bell's phenomenon was good. Exophthalmometry showed a proptosis of 6 mm in the right eye. There was a paramedian tarsorrhaphy in the right eye. Fundus was within normal limits.
Routine haemogram and urine examination was normal. The culture and sensitivity of the discharge from the sinus was positive for staphylococcus epidermidis sensitive to cloxacillin. Fungal culture was negative. Radiological examination of the orbit- did not reveal any foreign body. CAT was done with 4 mm cuts both in axial and coronal sections revealed only the presence of granulomatous mass and no foreign body could be detected. Ultrasonography did not reveal the presence of the foreign body.
As the sinus continued to discharge inspite of the proper antibiotic therapy a foreign body was suspected , and the case was taken up for exploratory anterior orbitotomy. During the exploration from the area of the sinus, after going deep towards the roof of the orbit, wooden foreign bodies were seen and were taken out with the help of the forceps. These were embedded in the soft tissue. 4 large pieces of the arhar sticks were taken out. The wound was then closed in layers after proper curretage of the sinus and carbolic acid cauterization. The puckered skin was excised and the edges of the skin were freshened before closure of the skin wound. The patient was put on systemic antibiotics and antiinflammatory drugs. The postoperative course was uneventful and visual acuity and ocular movements were within normal limits.
The common causes of the discharging sinus in the upper lid near the orbital margin are tuberculosis, fungal or bacterial osteomyelitis and the retained intraorbital foreign bodies ,. This case presented with the history of extrusion of small foreign bodies (arhar sticks). The radiological investigations like X-rays and sophisticated tools like C.T. scan and ultrasonography failed to reveal the presence of a foreign body . A foreign body was suspected because of continuous discharge and exploratory anterior orbitotomy was done which revealed multiple foreign bodies in the orbit. It is well known that the wooden foreign bodies cause granulomatous reaction and infection to give rise to discharging sinus and osteomyelitis. Normally, orbital exploration is not done for foreign bodies not exciting a granulomatous reaction, like lead - pellet, glass - pieces etc. which are the common foreign bodies found in the orbit after accidents. One has to carefully weigh the pros and cons of exploration of the orbital foreign bodies especially in relation to good visual acuity and ocular movements in the given case, so as to prevent damage to visual acuity and the ocular movements causing diplopia . In this case the successful removal of the foreign bodies was done without any damage to visual acuity and ocular movements. The proptosis however remained due to excessive granulomatous tissue present in the orbit.
Curretage and cauterization with carbolic acid and subsequent lavage with saline and antibiotic solution is a must in every case before wound closure is done. Excision of the necrotic and friable walls and the track of the sinus should be done for better healing of the wound. The shortening of the skin giving rise to ectropion is dealt with at a later date, by split-thickness-skin grafting for the upper lid to retain the suppleness of the upper lid skin and to facilitate the normal movements of the upper lid.
Smith, B.C. Ophthalmic plastic and reconstructive surgery. Vol. 1, page 523. The C. V. Mosby Company, St. Louis, 1987.
Brock, L. and Tannenbaum, H.L. Retention of wooden foreign bodies in the orbit. Can. J. Oghthalmol. 15:70,1980.
Ferguson, E.C. III. Deep, wooden foreign bodies of the orbit: A report of two cases. Trans. Am. Acad. Ophthalmol. Otolaryngol. 74:778,1970.
Macrea, J.A. Diagnosis and management of a wooden orbital foreign body. Brit. J. Ophthalmol. 64:848,1979.
Mandelcom, M.S. and Brown, M. Computed axial tomography localization of intraorbital foreign body. Can.]. Ophthalmol. 13:213, 1978.
Wesley, R.E. Management of wooden foreign bodies in the orbit. South Med. J. 75:924,1982.
[Figure - 1], [Figure - 2], [Figure - 3]