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Year : 1992  |  Volume : 40  |  Issue : 3  |  Page : 94-95

An unusual orbito-cranial foreign body

Neuroophthalmic section, SCB Medical College Hospital, Cuttack-753 007, Orissa, India

Correspondence Address:
Madhumati Misra
Department of Ophthalmology, SCB Medical College, Cuttack - 753007 (ORISSA).
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Source of Support: None, Conflict of Interest: None

PMID: 1302235

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The rarity of orbito-cranial gun shot injury in both war and civilian practice has been reported. In a large series of 351 missile head injuries in the Vietnam war, orbital penetration was noted in 0.6% cases only. Review of literature shows that orbital injury was ipsilateral to the cerebral injury in most reported cases. We have previously reported a rare case of left parieto-occipital lobe injury due to gun shot wound of the contralateral (right) orbit. The case reported here sustained a bullet injury to the left frontal bone but the missile was located below the contralateral (right) optic canal. The rarity of the case prompted this report.

How to cite this article:
Misra M, Khan G M, Mohanty AB, Rath S. An unusual orbito-cranial foreign body. Indian J Ophthalmol 1992;40:94-5

How to cite this URL:
Misra M, Khan G M, Mohanty AB, Rath S. An unusual orbito-cranial foreign body. Indian J Ophthalmol [serial online] 1992 [cited 2023 Nov 28];40:94-5. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1992/40/3/94/24390

  Case report Top

BS, a male 2aged 30 years was admitted to the neurosurgery unit after sustaining an accidental gun shot injury over the left forehead. At admission, the patient was disoriented, bleeding through the right nostril and had no focal neurological deficit. The entry wound over the left frontal forehead, 2" lateral to the midline was bleeding with exposure of the underlying fractured skull bone. Both the eye balls sustained no injury, had full range of movements, equally reactive pupil and normal optic fundi. Vision could not be assessed at admission due to altered sensorium, however, finger counting in either eye could be elicited.

Lateral X-ray skull showed the bullet entry through the left frontal bone. The bullet was lodged below the right optic canal. The pituitary fossa and sphenoidal sinus were clear. Immediate surgical intervention was done. The depressed fracture over the left frontal bone was elevated and bone pieces were removed. The dural tear over the left orbital roof was repaired. The bullet was located below the right optic canal away from the right optic nerve and was left in situ. The patient was observed carefully under antibiotic cover in the post operative period, on the 10th post operative day, both eyes had 6/6 vision and normal optic fundi. The patient is asymptomatic till the day of last report. Check X-ray showed the bullet in the previous position.

  Discussion Top

Orbito-cranial gunshot injury is rare in civilian practices. Calvert reported four patients with orbito-cranial gunshot wounds, the missile penetrated through the ipsilateral greater wing of sphenoid and lodged in the cerebral lobes on the same side [4]. We have previously en­countered a case of left parieto-occipital injury due to gunshot injury of the contralateral (right) orbit [1]. In the present case, the missile traversed to right orbital apex from the contralateral (left) frontal bone. The optic nerves escaped direct injury evidenced from normal optic fundi and preserved vision in both eyes.

Following radiological localisation of the bullet below the right optic canal, attempt at its surgical removal was made. After debridement of the left frontal scalp wound, resection of the bone fragments and devitalised brain tissue was done. The missile was located below the right optic canal and the right optic nerve was seen free. Attempt to remove the missile at the stage was not done for the fear of inflicting further functional damage to the right optic nerve and neighbourhood structures.

Similar guidelines for surgical management of missiles has been outlined in literature. According to previous authors, it a metallic fragment is easily accessible without inflicting further functional damage, attempt should be made to remove it. In different situations and in asymptomatic patients, the bullet could be left in situ and the patient should be carefully monitored for a prolonged period [1],[3],[5].The brain tolerates metallic foreign bodies well and the incidence of delayed abscess is 10-15% on ly [6],[7]. Sterile abscesses may develop due to chemical decomposition or liquefaction of the brain tissue.

Changes in position of the missile in subsequent check X-rays is suggestive of development of brain abscess or intraventricular or subdural migration [1],[7]. Delayed removal is indicated if such complications or epilepsy develop [1],[7]. Intraventricular metallic frag­ments should be removed early as free migration can occlude the foramina producing obstructive hydrocephalus [8].

  References Top

Misra M. Rath S. Acharya B N - Ind. Jr. Ophthalmol 1985. 33-105  Back to cited text no. 1
Mammon M.A. - 1971 Jr. Neurosurgery 1971. 34-91   Back to cited text no. 2
Hagan R.E. - Jr Neurosurgery 1971 34-132  Back to cited text no. 3
Calvert CA. Brit. Jr. Surgery. 1947. 34-119  Back to cited text no. 4
Dinakar I and Deshpande R.P. Neurology India 1976. 24-162   Back to cited text no. 5
Campbell E.H. Jr. Annal Surgery 1945 122-375  Back to cited text no. 6
Martin J and Campbell E.H. Jr. - Jr Neurosurgery 1946 3-58  Back to cited text no. 7
Eurlow J.T., Bender M.B. and - Jr. Neuro surgery, 1947.4. 380.  Back to cited text no. 8


  [Figure - 1]

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