2594
Views & Citations1594
Likes & Shares
Intraorbital
foreign bodies are a common complication of ocular trauma. The reaction to a
retained foreign body varies depending on the chemical composition, sterility
and location of the foreign body. They can be classified according to their
composition into a) metallic such as steel; b) non-metallic, such as glass; c)
organic such as wood or vegetable matter. In general, metallic foreign bodies
and glass are well tolerated and if not causing any symptoms or signs, may be
left alone, while organic matter like wood and vegetable matters are poorly
tolerated, elicits an intense inflammatory reaction and need to be removed urgently
[1,2].
The presence of an
intra-orbital mass with a discharging sinus should evoke suspicion of a
retained organic foreign body [2]. Retained wooden foreign bodies in the orbit
may remain quiescent for a long time without causing symptoms or signs, before
presenting with delayed onset of complications such as orbital cellulitis,
abscess, granuloma and chronic draining sinus [3,4]. They
may also present to the Ophthalmologists with spontaneous extrusion and patient
may carry in their hands giving history of some trauma months back. The
symptoms include swelling of the lids, ptosis, loss of movements and loss of
vision [5]. The signs include lid edema and sinus with purulent discharge [6]. Patients
can present as esotropia, orbital abscess, optic atrophy, mass in medial
canthus [7], proptosis after few weeks of injury. Patients who present late
have discharging sinus [8] or orbital cellulitis as the chief presentation [9].
The associated wound may be small and self-sealing. If there is recurrence of
symptoms, especially if there is a discharging sinus and granuloma, the
possibility of retained foreign body should be considered [10].
Plain x-ray is of no use in diagnosing an
intra-orbital wooden foreign body since wood is not seen due to its radiolucent
property. B-scan ultrasonography has a very limited role because it does not
visualize orbital apex with reliability [11]. CT scan is the standard diagnostic
test, because it demonstrates most intra-orbital foreign bodies and is safe in
the presence of metallic foreign bodies; however MRI is better at demonstrating
wooden foreign bodies. The properties of wood are dissimilar enough from those
of the soft tissue to allow differentiation [12]. It is recommended that MRI
should be performed after a negative CT scan if there is a high degree of
suspicion of wooden intra-orbital foreign body [8].
Early surgical removal of organic intra-orbital
foreign bodies is recommended as they serve as a nidus of infection [4].
However, a review of literature reveals cases of spontaneous extrusion of
organic intra-orbital foreign bodies also.
Banarjee et al. [10] reported spontaneous
extrusion of wooden foreign body after 6 months of injury in a 23 year old male
who presented with swelling in the left upper lid and purulent discharge for
two months after sustaining 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. Systemic antibiotic and anti-inflammatory were
started; the very next day morning after admission, spontaneous partial
extrusion of a stick was seen through the sinus. The stick was removed
completely with the help of an artery forceps. The extracted stick measured 3.8
cm. The CT scan and ultrasonography did not show any residual foreign body in
the orbit [13].
Early expulsion of entire foreign body is
very rare. Only one case has been reported with spontaneous extrusion of wooden
foreign body in just three weeks of time. In a case report by Mehta et al.
[14], a 6 year old male child reported to the emergency room with trauma to
right eye with a wooden stick, accompanied by sudden painful diminution of
vision, drooping of right upper lid, redness and watering. At presentation, his
visual acuity in right eye was accurate PR. Right eye upper lid edema was
present with complete ptosis and axial proptosis of 3 mm. Extra ocular muscle
movements was limited in all gazes. Conjunctival congestion and chemosis was
present. The pupil was fixed and mid-dilated with normal anterior chamber
depth, iris and lens. The fundus showed normal optic disc and diffuse retinal
edema. A sinus with purulent discharge through it was present on inferolateral
aspect of the right lower lid. The pus was sent for culture and sensitivity.
The culture was sterile after 48 h. Left eye was normal. A provisional
diagnosis of orbital cellulitis with retained orbital foreign body was made and
patient was started on intravenous antibiotics. The proptosis, ptosis and
chemosis improved markedly. However the limitation of extra ocular movement and
discharging sinus persisted. A computed tomography (CT) scan revealed a hyper
dense intra-orbital foreign body of 5.6 × 3.4 mm with minimal surrounding fluid
in the intraconal space of the right orbit. A hypodense tract was also noted
along inferolateral aspect of right orbit, the findings of which were confirmed
by the MRI scan. Orbital exploration was done through trans-conjunctival
approach from inferior fornix one week later. No foreign body was detected even
after a thorough exploration. Three weeks later, patient presented with
spontaneous extrusion of a wooden foreign body of approximately 4 × 5 mm. The
sinus below the eyelid was closed and replaced by a scar. The vision in right
eye had improved to 6/12. A repeat MRI head and orbit done after four weeks
showed normal study with no foreign body and no sinus tract. In this case, the
foreign body was missed despite thorough exploration of both intraconal and
extraconal spaces of orbit probably because it was lodged deeper into the floor
of orbit and encased within the soft tissue of orbit. Whole of the wooden
foreign body then spontaneously extruded through the same sinus tract without
any intervention and the sinus closed on its own.
Thus, we emphasize that a high index of
suspicion is required to prompt early diagnosis of retained organic foreign
bodies because of the diagnostic dilemma presented by the virtue of a small and
frequent self-sealing wound, tendency of organic foreign body to break during
removal and misdetection by standard diagnostic tests like the computed
tomography scan, adding to the diagnostic dilemma. Thus it is prudent to obtain
a history of trauma in patients presenting with an intra-orbital mass with or
without discharging sinus regardless of the interval between the trauma and
clinical presentation to prompt early management. However, a possibility of
spontaneous extrusion should be borne in mind while dealing with such cases to
prevent misdiagnosis and mismanagement.
1.
Al-Mujaini
A, Al-Senawi R, Ganesh A, Al-Zuhaibi S, Al-Dhuhli H (2008) Intraorbital foreign
body: Clinical presentation, radiological appearance and management. Sultan
Qaboos Univ Med J 8: 69-74.
2.
Ho VH,
Wilson MW, Fleming JC, Haik BG (2004) Retained intraorbital metallic foreign
bodies. Ophthalmic Plast Reconstr Surg 20: 232-236.
3.
Goldberg
MF, Paton D (1980) Principle and practice of ophthalmology. WB Saunders.
4.
Fulcher
TP, McNab AA, Sullivan TJ (2002) Clinical features and management of
intraorbital foreign bodies. Ophthalmology 109: 494-500.
5.
Kumar
D, Saxena S, Goel U (1995) Retained wooden foreign bodies in the orbit: A case
report. Indian J Ophthalmol 43: 195-196.
6.
Agarwal
PK, Kumar H, Srinivasa PK (1993) Unusual orbital foreign bodies. Indian J
Ophthalmol 41: 125-127.
7.
Lee
JA, Lee HY (2002) A case of retained wooden foreign body in orbit. Korean J
Ophthalmol 16: 114-118.
8.
John
SS, Rehman TA, John D, Raju RS (2008) Missed diagnosis of a wooden intra
orbital foreign body. Indian J Ophthalmol 56: 322-324.
9.
Lakshmanan
A, Bala S, Belfer KF (2008) Intra orbital organic foreign body - A diagnostic
challenge. Orbit 27: 131-133.
10.
Banerjee
A, Das A, Agarwal PK, Banerjee AR (2003) Late spontaneous extrusion of a wooden
foreign body. Indian J Ophthalmol 51: 83-84.
11.
Lagalla
R, Manfre L, Carona A, Bencivinni F, Duranti C, et al. (2000) Plain film, CT
and MRI sensibility in the evaluation of intra orbital foreign bodies in an in vitro model of the orbit in pig eyes.
Eur Radiol 10: 1338-1341.
12.
Green
BF, Kraft SP, Carter KD, Buncic JR, Nerad JA, et al. (1990) Intraorbital wood:
Detection by magnetic resonance imaging. Ophthalmology 97: 608-611.
13.
Blake
EM (1931) Spontaneous extrusion of intra ocular foreign bodies. Am J Ophthalmol
14: 1009-1013.
14.
Mehta
A, Abrol S, Singh P, Gupta A, Gupta V (2015) Spontaneous extrusion of intra
orbital foreign body. DJO 26: 111-114.
QUICK LINKS
- SUBMIT MANUSCRIPT
- RECOMMEND THE JOURNAL
-
SUBSCRIBE FOR ALERTS
RELATED JOURNALS
- Journal of Spine Diseases
- Journal of Clinical Trials and Research (ISSN:2637-7373)
- Journal of Renal Transplantation Science (ISSN:2640-0847)
- International Journal of Clinical Case Studies and Reports (ISSN:2641-5771)
- Journal of Cell Signaling & Damage-Associated Molecular Patterns
- International Journal of AIDS (ISSN: 2644-3023)
- International Journal of Anaesthesia and Research (ISSN:2641-399X)