From the Department of Ophthalmology, Kasr El Aini Hospital, Cairo University, Cairo, Egypt.
Poster presented at the American Academy of Ophthalmology annual meeting, November 8–11, 2008, Atlanta, Georgia.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Tamer I. Gawdat, MD, FRCS Ed, 59, 104 Street, El Maadi, Cairo, Egypt.
Trauma is reported to be responsible for 4% to 5% of all orbital pathologies in a busy university hospital.1 Penetrating orbitocranial injuries warrant more attention because the orbit allows easy access to the cranial cavity.2–4
In cases of orbital trauma with foreign body, the management and prognosis depend on the site and nature of the foreign body. Metallic objects, except for copper, and glass are the most inert and tolerable foreign bodies.5 Organic foreign bodies are more associated with inflammatory response, orbital cellulites (especially fungal), and abscess formation.6,7
Intraorbital foreign bodies may be found with double penetrating globe injuries due to high velocity particles (eg, missiles) where the foreign body settles in the orbit and can be detected by orbital computed tomography (CT). They are usually left undisturbed. However, many orbital foreign bodies could be overlooked due to their radiolucent nature. They could also be obscured by another clinical presentation or simply missed by the radiologist.
In this case series, we report three cases of orbital foreign bodies that were missed by the primary ophthalmologist and radiologist. They were referred to us for further treatment.
Three cases with a history of orbitofacial trauma presented to us between June 2005 and January 2007. They had unusual presentations including recurrent or chronic orbital inflammation, limited ocular motility, and orbital mass with or without proptosis. Visual acuity at presentation ranged from no light perception in one patient to 20/20 in the other two patients. Orbital and brain CT study was performed for all patients and showed the presence of blowout fracture in one patient and orbital cysts in the other two.
Two of the three patients had reported a history of trauma. The three patients were children with ages ranging from 6 to 10 years. The first and third patients had a history of recurrent orbital and periorbital inflammation with partial remission with antibiotics. The second patient presented with diplopia.
A 7-year-old child presented with red tender right upper eyelid swelling associated with proptosis of 3 weeks’ duration (Fig. 1A). There was a history of falling down the stairs 2 months earlier. Orbital inflammation responded partially to antibiotics. Examination showed a palpable tense and tender mass above the globe. It was associated with limitation of ocular motility in all directions. Ocular examination showed dilated fixed pupil with no light perception.
Figure 1. (A) A Child with Right Ptosis, Downward Globe Displacement, and Limitation of Ocular Motility. (B) Computed Tomography Shows a Cyst in the Superior Orbit. (C) A Transcrease Incision Was Used to Expose the Mass. (D) Multiple Wooden Foreign Bodies Were Retrieved.
Orbit and brain CT showed a superior orbital cyst diagnosed as an orbital abscess (Fig. 1B). Surgical evacuation was undertaken. Under general anesthesia and complete aseptic conditions, a transcrease anterior orbitotomy was done and the cyst was marsupialized (Fig. 1C). Multiple wooden foreign bodies (more than 10) of different sizes were retrieved from the operative site during cyst evacuation (Fig. 1D). The skin wound was closed using 6-0 polypropylene. Follow-up continued for 1 year with no recurrence of orbital cellulites. Proptosis was markedly improved.
A 10-year-old boy presented with a history of face trauma with a wooden stick. He suffered from diplopia on primary gaze. Examination revealed right esotropia with limitation of up and down gazes (Fig. 2A). Visual acuity was 20/20 in both eyes. Orbital CT showed a blowout fracture of the right orbit with inferior rectus and inferior oblique muscle incarceration in the floor fracture (Fig. 2B). He was scheduled for fracture repair and porous polyethylene floor implant (Medpore; Porex Surgical Products, Newnan, GA).
Figure 2. (A) A Child Presenting with Right Esotropia and Limited Elevation. (B) Computed Tomography of the Orbit Shows Orbital Floor Fracture with Inferior Rectus and Inferior Oblique Muscle Incarceration. (C) A Sinus Tract Was Detected in the Conjunctiva at the Plica Semilunaris. A Probe Was Inserted into the Tract to Show Its Position. (D) a 6-mm Wooden Foreign Body Was Retrieved.
A transconjunctival approach was used to expose the inferior orbital margin. Surprisingly, a conjunctival sinus was detected deep in the nasal fornix (Fig. 2C). A wooden foreign body that was not detected by orbital imaging was accidentally discovered and removed from this sinus (Fig. 2D). The rest of the surgery was uneventful. Follow-up continued for 14 months with marked improvement of the ocular motility.
A 6-year-old child with no definitive history of trauma presented with left ptosis and S-shaped eyelid deformity (Fig. 3A). Examination revealed a firm mass related to the superolateral orbital margin. Visual acuity was 20/20 in both eyes. Orbital CT showed an anterior orbital cyst not related to the lacrimal gland with no bone affection (Fig. 3B).
Figure 3. (A) A Left Upper Eyelid Swelling with S-Shaped Deformity. (B) Computed Tomography of the Orbit Shows a Cystic Mass that Is not Related to the Lacrimal Gland and Shows No Bone Changes. (C) a Pearly White Mass Was Detected Through a Transcrease Anterior Orbitotomy. (D) A Wooden Foreign Body Was Detected on Accidental Opening of the Cyst Wall.
The patient underwent surgical excision of the mass (Fig. 3C). A wooden foreign body appeared on accidental opening of the cyst wall (Fig. 3D). Follow-up continued for 8 months with complete resolution of the cyst and marked improvement of the ptosis.
Intraorbital foreign bodies following orbital and facial trauma could be easily missed and should be suspected in all cases until proven otherwise.6,8 Metallic foreign bodies and glass are considered inert because they usually cause minimal reaction, but organic foreign bodies are associated with inflammatory reaction and chronic sequelae such as abscess formation that may open to the skin with a sinus.9
Careful examination of the periorbital skin and conjunctiva, especially the fornices, is of utmost importance. The presence of a fistula to the skin or conjunctiva may indicate the possibility of a retained foreign body.
Diagnostic methods may aid in detecting and localizing the foreign bodies. They include plain x-ray, ultrasound, CT, and magnetic resonance imaging (MRI). They are usually helpful in cases of foreign bodies that are metallic or covered with metallic paint.10,11 However, it should be emphasized that MRI must not be requested as the initial imaging modality in the setting of trauma, because of the risk for movement of retained magnetic foreign bodies. The minimal size of foreign body to be detected by CT is approximately 0.3 mm for metal and 0.5 mm for glass. Organic foreign bodies such as wood are difficult to distinguish from the adjacent soft tissue, especially if inflammation or fibrosis is present.11 Despite the advancing technology, approximately 50% of wooden intraorbital foreign bodies remain unidentified before the time of surgery, which was true for all of the reported cases in this study.
McGuckin et al. reported an in vitro model for a wooden foreign body and studied the air/wood/tissue interfaces with MRI and CT.12 They concluded that CT is the imaging modality of choice because MRI does not differentiate dry wooden foreign bodies from air and bone fragments and CT with optimized image contrast can. Quantitative density (Housenfield units) measurements help to distinguish wood from air and bone from metal. MRI has the advantage of better delineation of intraorbital hemorrhage.12–14
Chronic or recurrent orbital inflammation following orbital trauma should always raise the suspicion of retained intraorbital foreign bodies, even if not detected by radiological orbital studies. In rural areas, falling to the ground should raise suspicion of organic foreign bodies that can be easily missed by orbital CT. It should also be noted that the presence of other orbital injuries does not exclude the possibility of retained foreign bodies.
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