1. S.P. Shettar, DTCD (UK), Chest Physician, Karnataka Cancer Therapy and Research Institute Hubli, Karnataka, India
2. Anand Sajjan, Fellowship in Head and Neck Surgical Oncology, Karnataka Cancer Therapy and Research Institute Hubli, Karnataka, India
3. A.C. Deka, Medical and Radiation Oncologist, Karnataka Cancer Therapy and Research Institute Hubli, Karnataka, India
4. Shilpa Chatni, Head and Neck Surgical Oncologist, Karnataka Cancer Therapy and Research Institute Hubli, Karnataka, India
Author
Correspondence author
International Journal of Clinical Case Reports, 2015, Vol. 5, No. 23 doi: 10.5376/ijccr.2015.05.0023
Received: 20 Mar., 2015 Accepted: 21 May, 2015 Published: 18 Jun., 2015
Intra- orbital foreign bodies are more commonly seen in war injuries. Here the foreign body is normally a metallic object but when such injury occurs due to road traffic accident, the foreign body is usually organic in nature like wood. Much damage occurs to the soft tissue of the eye including globe and optic nerve but foreign body does not usually causes damage to the hard structure of eye.
Here we are presenting a case in which a patient of road traffic accident was admitted with intra orbital foreign body of organic nature. The foreign body had not caused damage to the globe of the eye, which is more common, but has fractured the supra orbital rim of the orbit.
An intra-orbital foreign body is an object that lies within the orbit but outside the ocular globe. Penetrating orbitocranial injuries are quite common in military practice, but they may occur in civilian life, where they are predominantly accidental injuries. They are usually due to a high-velocity injury, such as a gunshot or an industrial accident, but also to relatively trivial trauma. Orbital foreign bodies are more commonly observed in men than in women and in younger rather than older people. They may result in severe structural and functional damage to the eye or other orbital contents. The management and prognosis depend on the composition and location of the foreign body as well as the possible presence of secondary infection. Intraorbital foreign bodies (IOFBs) account for almost 40% of penetrating ocular injuries. 75% of the IOFBs lodge in the posterior segment. Retained intraorbital foreign bodies most commonly result from occupational activities and predominantly involve males in 3rd to 4th decade5. Most people sustain injury while hammering a metal with metal and 80% cases have metallic IOFBs. The hammer-chisel injury is the most common cause of the IOFB in adults. Other emerging causes like fire arm injuries and blast injuries road traffic accidents are becoming common.
IOFB causes damage to the eye by the following mechanisms:
• Cause mechanical trauma to the eye
• Introduce infection
• Exert toxic effect
The extent of ocular injury depends on:
• Size of the object
• Speed of impact
• Composition of the object
• Impact site
Classification
Intraorbital foreign bodies can be classified according to:
1. Anatomical zone
2. Position of IOFB
3. Nature of IOFB
1. Zones of ocular injury:
(a) Zone 1: Isolated to the cornea (including the limbus).
(b) Zone 2: From limbus to a point 5mm posterior in sclera.
(c) Zone 3: Posterior to the anterior 5mm of the sclera.
2. Position of the IOFB:
(a) IOFB located in the anterior segment
(b) In the cornea
(c) In the anterior chamber
(d) In the anterior chamber angle
(e) Intralenticular
(f) IOFB located in the posterior segment:
(g) IOFB located in the vitreous cavity
(h) IOFB floating into the vitreous after causing retinal trauma
(i) IOFB embedded in the retina/ sclera
3. Nature of IOFB
(a) Metallic e.g. copper, iron
(b) Glass
(c) Plastic
(d) Organic e.g. wood
(e) Stone
In general, injuries caused by metal and glass are well-tolerated. If these IOFBs do not cause any symptoms or signs, may be left in situ. Whereas organic matter, such as wood and vegetable matter, is poorly tolerated, and triggers an intense inflammatory reaction and needs to be removed urgently. Injuries caused by metallic objects and glass are more frequent than organic foreign bodies, probably because, despite modern imaging methods, they are often difficult to identify and locate.
Complication
IOFBs can be inert but often cause serious damage inside the eye and must be removed promptly.Possible complications of IOFB include:
1.Corneal opacity
2.Cataract
3. Intraocular hemorrhage (hyphema, vitreous hemorrhage)
4. Elevated intraocular pressure
5. Retinal breaks
6. Retinal detachment: Rhegmatogenous or tractional.
7. Proliferative vitreoretinopathy
8. Hypotony
9. Phthisis bulbi
10. Endophthalmitis: More likely to occur with:
Contaminated injury
Retained IOFB
Rupture of lens capsule
Delayed surgical repair
Siderosis (due to iron IOFB)
Chalcosis (due to copper IOFB)
Here we are presenting a case in which intraorbital foreign body has damaged the bony orbit rather than the soft tissue of the eye. In our case supraorbital rim was fractured due to the impact of forign body but vision and eye movements were soon recovered after inflammatory edema subsided.
Case History
A male patient,aged about 35 years, presented to the emergency of hospital with history of road traffic accident. Patient was on bike and was hit from behind. Due to impact, patient was thrown over to the trees nearby.
When patient reported to emergency, he had lacerations on the right face in infraorbital and nasolabial region. His right eye was swollen and shut. While examining the right eye, whole of the visible sclera was covered with small leaves of the tree. During removal of the leaves, something hard was felt. It was lying below the upper lid. This was a small piece of wood. After removal, C.T and conventional radiograph were advised. There was no brain injury detected on C.T. but part of the superior orbital rim was fractured and pushed intracranially.No CSF rhinorrhoea was present. There was associated ZMC fracture of right side as well as palatal bone fracture. Patient was advised antibiotics orally as well as antibiotic eye drops were also given. When swelling subsided, after about 15 days, visual acuity was checked as well as movement in all 9 gazes. Vision was normal and he was able to move eyes in all gazes. No sensory defecit was present in supraorbital nerve distribution area. None of the signs and symptoms were present showing supraorbital artery damage. Since this injury was associated with ZMC fracture of the same side, this was treated with open reduction and fixation under general anesthesia. Since chipped off part of supraorbital rim was not causing any symptom, it was left and no treatment of supraorbital rim fracture was done.
Patient was kept under observation for 15 days and there was no post operative complication associated either with vision or with the ZMC. There were no symptoms or sign related to presence of part of supraorbital rim in the cranial cavity (Figure 1~6).
.png)
Figure 4 Axial CT- Chipout fracture of supra orbital rim
|
.png)
Figure 5 Coronal CT- Chipout fracture of supra orbital rim
|
Discussion
All intraorbital foreign bodies cause local response in the eye. Response is much more intense if the object is organic in origin. Wood, with its porous consistency and organic nature, provides a good medium for microbial agents. Infection resulting from retained intraorbital wooden foreign bodies may lead to complications such as panophthalmitis, abscess, and fistula. Management of orbital foreign bodies should include an accurate and detailed history as well as a CT scan of the orbit, which is the imaging modality of choice for detection and localization of the foreign body. Standardized ophthalmic ultrasonography (combination of standardized A-scan and B-scan) has been suggested to be used first but with the use of CT, several authors were able to detect intraorbital wood. CT also allowed detection of associated problems such as fractures and now CT is considered modality of choice. Early examination by ophthalmologist should be done in cases of intraorbital foreign body. Treatment should not be delayed in patients with organic intaorbital foreign body.
In our case, foreign body was present below the upper eyelid and so removed immediately. Since there was associated ZMC fracture, it’s treatment was delayed till we got clearance from ophthalmology department. ZMC was treated using ORIF. ‘L’ shaped 2mm miniplate was used for fixation, at buttress area.
Conclusion
Detection of intraorbital wooden foreign bodies may be difficult, especially in cases of apparently minor trauma. The severity of injury in penetrating trauma to the orbit is often underestimated by physical examination. Plain film radiography is not useful in detecting intraorbital wooden foreign bodies. In conclusion, Management of orbital foreign bodies should include an accurate and detailed history as well as a CT scan of the orbit. The final outcome and prognosis depend greatly upon early diagnosis, followed by surgical exploration and extraction when indicated. Foreign body injuries in the orbital region can be treated with a combination of clinical suspicion, basic knowledge and diagnostic tests and call for surgical skill and experience to decrease the risk of iatrogenic injury in relation to the inherent risk of retaining an organic intraorbital foreign body.
Abdullah Al-Mujaini, Rana Al-Senawi, et al., 2008, Intraorbital foreign body: Clinical presentation, Radiological Appearance and Management, Sultan Quaboos University Medical Journal, 8:69-74
Antonio Moretti, Melissa Laus, et al., 2012, Peri-orbital foreign body: A case report, Journal of medical case report, 6:91
Mustafa Iobal, 2002, Retained intraocular Foreign body, Pak J.Opthalmol., 26:3
Sharon P. Bord, Judith Linden, 2008, Trauma to the globe and orbit, Emerg. Med. Clin. N. Am., 26(2008): 97-123
.png)
.png)
.png)
.png)
.png)
.png)
