CLINICAL STUDY
An Undetected Intraorbital Foreign Body After a “Trivial” Facial Injury Nagarajan Swathi, MS, DNB,* and Jayavelu Umadevi, DO*† Abstract: Intraorbital foreign objects are common after high-velocity injuries and can result in disastrous consequences. A “trivial” facial injury may sometimes obscure the presence of an intraorbital foreign object. Difficulties in the approach to the intraconal space and possible surgical morbidity to the optic nerve make management especially challenging. We are reporting a case wherein an intraconal foreign body was missed during the initial examination of a maxillofacial injury and was subsequently successfully extracted by an endoscopic approach. Key Words: Intraorbital foreign object, penetrating injury, intraconal space, orbital endoscopy, orbital compartment syndrome (J Craniofac Surg 2014;25: 1782–1783)
O
rbital injuries are often seen after maxillofacial trauma. In particular, the intraorbital foreign body (IOFB) is usually associated with high-velocity injuries and industrial accidents.1 Rarely, a so-called “trivial” maxillofacial injury may lull the maxillofacial surgeon into a sense of false security with regards to orbital injuries with a potential for serious consequences. A high index of suspicion is essential to avoid potential pitfalls and ensure a prompt and proper management.
CLINICAL REPORT A 25-year-old man reported to the Department of Ophthalmology with complaint of pain and a decrease in vision in his right eye (RE). A blacksmith by profession, he had apparently injured the right side of his face while hammering an iron piece 4 days ago. He had reported to the emergency medical services immediately and was evaluated by a resident maxillofacial surgeon. Mild periorbital edema was recorded, and there seemed to be no clinical evidence of a facial bone fracture. The patient was prescribed anti-inflammatory medications and discharged. He subsequently began to experience a gradual increase in pain and a rapid decrease in visual acuity of the RE on the second day. He was urgently referred for an ophthalmic evaluation by the maxillofacial team. On examination, the patient seemed distressed. Visual acuity in the RE was perception of light with inaccurate projection, whereas in the left eye, the visual acuity was 6/6 by Snellen chart. Furthermore,
From the *Department of Ophthalmology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India; and †Refractive Surgery, Vasan Eye Care Hospitals, Chrompet, Chennai, India. Received August 5, 2013. Accepted for publication February 10, 2014. Address correspondence and reprint requests to Nagarajan Swathi, MS, DNB, 74, 4th Cross, Thanthai Periyar Nagar, Pondicherry 605005, India; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000905
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the RE was proptosed (3 mm) and resistant to retropulsion. Orthoptic evaluation revealed exotropia in primary gaze. Extraocular movements were severely restricted with almost nil adduction (Figs. 1A–D). The globe itself was intact, but slit lamp biomicroscopy revealed a 5-mm curvilinear entry wound in the right upper lid close to the inner canthus and a diffuse subconjunctival hemorrhage whose posterior extent could not be traced. Pupil was 3 mm with grade 3 relative afferent papillary defect. Intraocular pressure of RE as measured by Perkin tonometer was 26 mm Hg. Clinical examination of the left eye was unremarkable. A provisional diagnosis of retrobulbar hemorrhage/edema was made, and the patient was started on intravenous osmotic diuretic and systemic steroids. After this medical intervention, proptosis of the RE reduced, and vision improved to 6/36. A plain radiograph surprisingly showed a radio opaque structure close to the apex of right orbit. Computed tomography (CT) of the orbits showed a 6 8-mm radio opaque object in the intraconal space (RE), which was impinging on the optic nerve (Figs. 2A, B). Scatter artifacts indicated that the object was of a metallic nature. A field examination confirmed the presence of an inferior altitudinal defect of the RE. On the second day, the foreign body (splinter metal) was removed by the otolaryngology team via a transnasal transethmoid endoscopic approach under general anesthesia. The postoperative period was uneventful, and the patient was discharged on the seventh postoperative day with orthophoric primary gaze and best corrected visual acuity of 6/24, N10 in RE (Figs. 3A, B). He was advised to have regular follow-up. On the third month, the inferior altitudinal field defect had also improved significantly (Figs. 4A, B). The patient showed no further deterioration since last seen.
DISCUSSION The IOFB is a term that refers to any foreign material within the bony orbit but outside the globe.2 The clinical presentation may range from a complete absence of symptoms to varying degrees of disturbances in vision along with periorbital pain, edema, and ecchymosis. The IOFBs are often associated with severe maxillofacial and cranial injuries, and the effect of such objects depends on its size, location, and composition. As an ophthalmic evaluation is mandatory with such severe injuries, these IOFBs are almost always detected during the initial phases permitting prompt management. Sometimes, the supposedly trivial nature and mechanism of injury
FIGURE 1. A–D, Restricted extraocular movements.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Intraorbital Foreign Body
FIGURE 2. A and B, CT images of orbit with IOFB. FIGURE 4. Field defect: preoperative (A) and postoperative (B).
may mask the presence of an IOFB and escape the attention of the examining surgeon.3 Although plain radiographs may be of value in detecting metallic IOFBs, a CT is often the first choice investigation due to its sensitivity in detecting IOFBs of a nonmetallic nature.4 Furthermore, patients with serious injuries routinely undergo CT scans of the brain. Magnetic resonance imaging of the orbits may be advised to obtain more accurate information of the surrounding soft tissue but can result in blindness if performed before ruling out the presence of metallic foreign body. A surgeon with a high index of suspicion may be prone to ordering a CT scan even for minor facial injuries around the orbits. This may not be feasible from an economic viewpoint in a developing country with stretched resources. Warning the patient to look out for early signs of visual disturbances is often the more practical option to manage patients in a busy emergency medical room. There has been some controversy with the semantics of orbital injuries after maxillofacial trauma with authors using the terms “retrobulbar hemmorhage” and “retrobulbar edema.” Whereas the former may require urgent surgical intervention, the latter is more prone to be managed medically. The term “orbital compartment syndrome” is now believed to be the more accurate term to describe the ongoing pathophysiology.5 Not all cases of tense proptosis after trauma are due to retrobulbar hemmorhage and could be secondary to edema of retrobulbar tissues, resulting in compartment phenomenon.6 This patient had normal vision immediately after the injury with subsequent loss. This is suggestive for the onset of orbital compartment syndrome causing traumatic optic neuropathy, not the transaction of the optic nerve. The decision to remove an IOFB may depend on a variety of factors such as the patient’s general condition, position and nature of the object, the degree of morbidity, and associated symptoms.7 The conventional transconjuctival/transcaruncular open surgical approach to the intraconal space is fraught with a risk of further injury to the optic nerve and intraocular muscles. This is more so especially in this case where the IOFB is at a more posterior location and almost impossible to approach without significant collateral damage. The transethmoidal approach is known to provide excellent access to the medial and inferior aspects of the optic canal and is commonly used by neurosurgeons for decompression of the optic canal.8,9 The use of the transnasal/transethmoidal endoscopic approach for removal of IOFBs has been described in only a few cases with obvious
FIGURE 3. Primary gaze: preoperative (A) and postoperative (B).
advantages of minimal morbidity and an early return to normal function.10,11 Here, the medial location of the IOFB permitted a quick access by the endoscopic approach with minimal damage to the optic nerve or intraocular muscle. The clinical course in this case underscores the importance of a detailed history and thorough examination as the severity of the penetrating orbital injury was grossly underestimated in the initial evaluation of the facial injury. The patient’s employment and mode of injury should have red-flagged the patient needing a mandatory ophthalmic examination. Oral and maxillofacial surgeons who handle the management of facial injuries must be encouraged to request mandatory ophthalmic examinations in all patients with upper and middle third facial fractures irrespective of the “severity” of the injury.12 As ophthalmologists are not traditionally trained in the use of endoscopic approaches, collaboration with otolaryngologists and neurosurgeons is essential to improve the overall prognosis of patients with IOFBs.
REFERENCES 1. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494–500 2. Al-Mujaini A, Al-Senawi R, Ganesh A, et al. Intraorbital foreign body: clinical presentation, radiological appearance and management. Sultan Qaboos Univ Med J 2008;8:69–74 3. Detorakis ET, Symvoulakis EK, Dvakonaki E, et al. Unexpected finding in ocular surface trauma: a large intraorbital foreign body (bullet). Acta Medica 2012;55:100–103 4. Pinto A, Brunese L, Daniele S, et al. Role of computed tomography in the assessment of intraorbital foreign bodies. Semin Ultrasound CT MR 2012;33:392–395 5. Lima V, Burt B, Leibovitch I, et al. Orbital component syndrome: the ophthalmic surgical emergency. Surv Ophthalmol 2009;54:441–449 6. Perry M. Acute proptosis in trauma. Retrobulbar hemmorhage or orbital compartment syndrome—does it really matter. J Oral Maxillofac Surg 2008;66:1913–1920 7. Mukherjee B, Goel S, Subramanian M. An unusual case of intraorbital foreign body and its management. Indian J Ophthalmol 2011;59:58–60 8. Maniscalco JE, Habal MB. Microanatomy of the optic canal. J Neurosurg 1978;48:402–406 9. Akdemir G, Tekdemir I, Altin L. Transethmoidal approach to the optic canal: surgical and radiological microanatomy. Surg Neurol 2004;62:268–274 10. Lysoń T, Sieskiewicz A, Rogowski M, et al. Transnasal endoscopic removal of intraorbital wooden foreign body. J Neurol Surg A Cent Eur Neurosurg 2013;74:e100–e103 11. Napora KJ, Obuchowska I, Łyson T, et al. Modern neurosurgical techniques to remove intraorbital foreign bodies—report of two cases. Klin Oczna 2009;111:240–245 12. Roccia F, Boffano P, Guglielini V, et al. Role of maxillofacial surgeon in the management of severe ocular injuries after maxillofacial fracture. J Emerg Trauma Shock 2011;4:188–193
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1783
An Undetected Intraorbital Foreign Body After a “Trivial” Facial Injury Nagarajan Swathi, MS, DNB,* and Jayavelu Umadevi, DO*† Abstract: Intraorbital foreign objects are common after high-velocity injuries and can result in disastrous consequences. A “trivial” facial injury may sometimes obscure the presence of an intraorbital foreign object. Difficulties in the approach to the intraconal space and possible surgical morbidity to the optic nerve make management especially challenging. We are reporting a case wherein an intraconal foreign body was missed during the initial examination of a maxillofacial injury and was subsequently successfully extracted by an endoscopic approach. Key Words: Intraorbital foreign object, penetrating injury, intraconal space, orbital endoscopy, orbital compartment syndrome (J Craniofac Surg 2014;25: 1782–1783)
O
rbital injuries are often seen after maxillofacial trauma. In particular, the intraorbital foreign body (IOFB) is usually associated with high-velocity injuries and industrial accidents.1 Rarely, a so-called “trivial” maxillofacial injury may lull the maxillofacial surgeon into a sense of false security with regards to orbital injuries with a potential for serious consequences. A high index of suspicion is essential to avoid potential pitfalls and ensure a prompt and proper management.
CLINICAL REPORT A 25-year-old man reported to the Department of Ophthalmology with complaint of pain and a decrease in vision in his right eye (RE). A blacksmith by profession, he had apparently injured the right side of his face while hammering an iron piece 4 days ago. He had reported to the emergency medical services immediately and was evaluated by a resident maxillofacial surgeon. Mild periorbital edema was recorded, and there seemed to be no clinical evidence of a facial bone fracture. The patient was prescribed anti-inflammatory medications and discharged. He subsequently began to experience a gradual increase in pain and a rapid decrease in visual acuity of the RE on the second day. He was urgently referred for an ophthalmic evaluation by the maxillofacial team. On examination, the patient seemed distressed. Visual acuity in the RE was perception of light with inaccurate projection, whereas in the left eye, the visual acuity was 6/6 by Snellen chart. Furthermore,
From the *Department of Ophthalmology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India; and †Refractive Surgery, Vasan Eye Care Hospitals, Chrompet, Chennai, India. Received August 5, 2013. Accepted for publication February 10, 2014. Address correspondence and reprint requests to Nagarajan Swathi, MS, DNB, 74, 4th Cross, Thanthai Periyar Nagar, Pondicherry 605005, India; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000905
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the RE was proptosed (3 mm) and resistant to retropulsion. Orthoptic evaluation revealed exotropia in primary gaze. Extraocular movements were severely restricted with almost nil adduction (Figs. 1A–D). The globe itself was intact, but slit lamp biomicroscopy revealed a 5-mm curvilinear entry wound in the right upper lid close to the inner canthus and a diffuse subconjunctival hemorrhage whose posterior extent could not be traced. Pupil was 3 mm with grade 3 relative afferent papillary defect. Intraocular pressure of RE as measured by Perkin tonometer was 26 mm Hg. Clinical examination of the left eye was unremarkable. A provisional diagnosis of retrobulbar hemorrhage/edema was made, and the patient was started on intravenous osmotic diuretic and systemic steroids. After this medical intervention, proptosis of the RE reduced, and vision improved to 6/36. A plain radiograph surprisingly showed a radio opaque structure close to the apex of right orbit. Computed tomography (CT) of the orbits showed a 6 8-mm radio opaque object in the intraconal space (RE), which was impinging on the optic nerve (Figs. 2A, B). Scatter artifacts indicated that the object was of a metallic nature. A field examination confirmed the presence of an inferior altitudinal defect of the RE. On the second day, the foreign body (splinter metal) was removed by the otolaryngology team via a transnasal transethmoid endoscopic approach under general anesthesia. The postoperative period was uneventful, and the patient was discharged on the seventh postoperative day with orthophoric primary gaze and best corrected visual acuity of 6/24, N10 in RE (Figs. 3A, B). He was advised to have regular follow-up. On the third month, the inferior altitudinal field defect had also improved significantly (Figs. 4A, B). The patient showed no further deterioration since last seen.
DISCUSSION The IOFB is a term that refers to any foreign material within the bony orbit but outside the globe.2 The clinical presentation may range from a complete absence of symptoms to varying degrees of disturbances in vision along with periorbital pain, edema, and ecchymosis. The IOFBs are often associated with severe maxillofacial and cranial injuries, and the effect of such objects depends on its size, location, and composition. As an ophthalmic evaluation is mandatory with such severe injuries, these IOFBs are almost always detected during the initial phases permitting prompt management. Sometimes, the supposedly trivial nature and mechanism of injury
FIGURE 1. A–D, Restricted extraocular movements.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Intraorbital Foreign Body
FIGURE 2. A and B, CT images of orbit with IOFB. FIGURE 4. Field defect: preoperative (A) and postoperative (B).
may mask the presence of an IOFB and escape the attention of the examining surgeon.3 Although plain radiographs may be of value in detecting metallic IOFBs, a CT is often the first choice investigation due to its sensitivity in detecting IOFBs of a nonmetallic nature.4 Furthermore, patients with serious injuries routinely undergo CT scans of the brain. Magnetic resonance imaging of the orbits may be advised to obtain more accurate information of the surrounding soft tissue but can result in blindness if performed before ruling out the presence of metallic foreign body. A surgeon with a high index of suspicion may be prone to ordering a CT scan even for minor facial injuries around the orbits. This may not be feasible from an economic viewpoint in a developing country with stretched resources. Warning the patient to look out for early signs of visual disturbances is often the more practical option to manage patients in a busy emergency medical room. There has been some controversy with the semantics of orbital injuries after maxillofacial trauma with authors using the terms “retrobulbar hemmorhage” and “retrobulbar edema.” Whereas the former may require urgent surgical intervention, the latter is more prone to be managed medically. The term “orbital compartment syndrome” is now believed to be the more accurate term to describe the ongoing pathophysiology.5 Not all cases of tense proptosis after trauma are due to retrobulbar hemmorhage and could be secondary to edema of retrobulbar tissues, resulting in compartment phenomenon.6 This patient had normal vision immediately after the injury with subsequent loss. This is suggestive for the onset of orbital compartment syndrome causing traumatic optic neuropathy, not the transaction of the optic nerve. The decision to remove an IOFB may depend on a variety of factors such as the patient’s general condition, position and nature of the object, the degree of morbidity, and associated symptoms.7 The conventional transconjuctival/transcaruncular open surgical approach to the intraconal space is fraught with a risk of further injury to the optic nerve and intraocular muscles. This is more so especially in this case where the IOFB is at a more posterior location and almost impossible to approach without significant collateral damage. The transethmoidal approach is known to provide excellent access to the medial and inferior aspects of the optic canal and is commonly used by neurosurgeons for decompression of the optic canal.8,9 The use of the transnasal/transethmoidal endoscopic approach for removal of IOFBs has been described in only a few cases with obvious
FIGURE 3. Primary gaze: preoperative (A) and postoperative (B).
advantages of minimal morbidity and an early return to normal function.10,11 Here, the medial location of the IOFB permitted a quick access by the endoscopic approach with minimal damage to the optic nerve or intraocular muscle. The clinical course in this case underscores the importance of a detailed history and thorough examination as the severity of the penetrating orbital injury was grossly underestimated in the initial evaluation of the facial injury. The patient’s employment and mode of injury should have red-flagged the patient needing a mandatory ophthalmic examination. Oral and maxillofacial surgeons who handle the management of facial injuries must be encouraged to request mandatory ophthalmic examinations in all patients with upper and middle third facial fractures irrespective of the “severity” of the injury.12 As ophthalmologists are not traditionally trained in the use of endoscopic approaches, collaboration with otolaryngologists and neurosurgeons is essential to improve the overall prognosis of patients with IOFBs.
REFERENCES 1. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494–500 2. Al-Mujaini A, Al-Senawi R, Ganesh A, et al. Intraorbital foreign body: clinical presentation, radiological appearance and management. Sultan Qaboos Univ Med J 2008;8:69–74 3. Detorakis ET, Symvoulakis EK, Dvakonaki E, et al. Unexpected finding in ocular surface trauma: a large intraorbital foreign body (bullet). Acta Medica 2012;55:100–103 4. Pinto A, Brunese L, Daniele S, et al. Role of computed tomography in the assessment of intraorbital foreign bodies. Semin Ultrasound CT MR 2012;33:392–395 5. Lima V, Burt B, Leibovitch I, et al. Orbital component syndrome: the ophthalmic surgical emergency. Surv Ophthalmol 2009;54:441–449 6. Perry M. Acute proptosis in trauma. Retrobulbar hemmorhage or orbital compartment syndrome—does it really matter. J Oral Maxillofac Surg 2008;66:1913–1920 7. Mukherjee B, Goel S, Subramanian M. An unusual case of intraorbital foreign body and its management. Indian J Ophthalmol 2011;59:58–60 8. Maniscalco JE, Habal MB. Microanatomy of the optic canal. J Neurosurg 1978;48:402–406 9. Akdemir G, Tekdemir I, Altin L. Transethmoidal approach to the optic canal: surgical and radiological microanatomy. Surg Neurol 2004;62:268–274 10. Lysoń T, Sieskiewicz A, Rogowski M, et al. Transnasal endoscopic removal of intraorbital wooden foreign body. J Neurol Surg A Cent Eur Neurosurg 2013;74:e100–e103 11. Napora KJ, Obuchowska I, Łyson T, et al. Modern neurosurgical techniques to remove intraorbital foreign bodies—report of two cases. Klin Oczna 2009;111:240–245 12. Roccia F, Boffano P, Guglielini V, et al. Role of maxillofacial surgeon in the management of severe ocular injuries after maxillofacial fracture. J Emerg Trauma Shock 2011;4:188–193
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1783
