Clinical Image
Complications of retained intraorbital wooden foreign body Bijnya B. Panda, Usha R. Kim Department of Orbit, Aravind Eye Hospital, Madurai, India
Introduction Wooden foreign bodies can remain entrapped in the orbit for long time and lead to complications like orbital cellulitis, abscess formation, chronic discharging sinus, noninfectious inflammation, and fibrosis.[1‑5] They can migrate intracranially leading to chronic brain abscess or undergo spontaneous extrusion. They may rarely lead to gaze evoked amaurosis.[1] This clinical image describes a case of retained wooden foreign body in the orbit and ethmoidal sinus, which was removed after a period of 9 months in spite of repeated orbital explorations.
extrusion of small pieces of wood from the site. Magnetic resonance imaging (MRI) showed hyperdense attenuation along the medial orbital wall suspected to be a retained foreign body [Figure 3] in the ethmoidal sinus and took expert opinion from an otorhinolaryngologist. Multiple wooden foreign bodies of varying sizes covered with granulomatous tissue were retrieved from the ethmoid sinus [Figure 4] through nasal endoscopy route. Postoperatively, he was treated with oral antibiotics and analgesics following which proptosis subsided but there was residual restrictive strabismus [Figure 5] due to dense fibrosis and no light perception due to long standing compressive optic neuropathy.
Case Report A 22‑year‑old male presented to us with recent history of trauma with a sharp stick to his left eye. On examination there was eccentric proptosis, discharging sinus at medial canthus, lid edema, chemosis, relative afferent pupillary defect (RAPD), restricted extraocular movements in all gazes [Figure 1], intraocular pressure within normal limits and no light perception due to compressive optic neuropathy. Computed tomography (CT) scan showed a retained foreign body along medial orbital wall, medial rectus muscle and surrounding reactionary granuloma, blow out fracture of orbital roof, medial wall, and floor [Figure 2]. Pus culture and sensitivity was positive for Enterobacter cloacae sensitive to amikacin, fluoroquinolones for which we started him on intravenous amikacin and oral levofloxacin. Medial orbital wall exploration was done four times but failed to retrieve any wooden foreign body except excision of granulation tissue. He again presented to us after 6 months with a discharging sinus, pain, watering, and left nasal blockage and gave history of spontaneous
Figure 1: External photograph at presentation showing left eye eccentric proptosis and discharging sinus at medial canthus
Access this article online Quick Response Code: Website: www.ojoonline.org DOI: 10.4103/0974-620X.127929
Figure 2: Computed tomography orbit coronal scan showing a retained foreign body along medial orbital wall and the medial rectus muscle and surrounding reactionary granuloma, blow out fracture of orbital roof, medial wall, and floor
Copyright: 2014 Panda BB and Kim UR. This is an open‑access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Correspondence: Dr. Bijnya B. Panda, Department of Orbit, Aravind Eye Hospital, Madurai, India. E‑mail: [email protected]
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Oman Journal of Ophthalmology, Vol. 7, No. 1, 2014
Panda and Kim: Complications of retained intraorbital wooden foreign body
Figure 4: Multiple wooden foreign bodies of different sizes retrieved by transnasal endoscopic removal
Figure 3: Magnetic resonance imaging orbits axial scan showing hyperdense linear structure along medial quadrant of left orbit measuring 2.17 × 0.59 cm with coexistent ethmoidal and maxillary sinusitis
otolaryngologist well trained in transnasal endoscopy where the foreign body cannot be retrieved on orbital exploration. The cause for difficulty in retrieving the foreign body in our case was that it was entrapped within the ethmoidal sinus with extensive surrounding granulomatous tissue.
References
Figure 5: External photograph (after endoscopic removal of foreign body) showing left eye in exotropia due to restrictive strabismus
We have reported this case to make our fellow readers aware of the grave prognosis of retained wooden foreign bodies if not dealt aggressively. We insist that MRI should be the first imaging modality of choice where patients give history of penetrating trauma with wooden objects. Endoscopic exploration of the wound should be done with interdisciplinary input from an
Oman Journal of Ophthalmology, Vol. 7, No. 1, 2014
1. McNab AA, Satchi K. Orbital foreign bodies and penetrating orbital injuries. In: Black EH, Nesi FA, Calvano CJ, Gladstone GJ, Levine MR, editors. Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery. 3rd ed. New York: Springer; 2012. p. 297‑307. 2. Shinder R, Gutman J, Gunasekera CD, Connor M, Nakra T. Occult orbital organic foreign body. Ophthal Plast Reconstr Surg 2011;27:463‑4. 3. Lee JA, Lee HY. A case of retained wooden foreign body in orbit. Korean J Ophthalmol 2002;16:114‑8. 4. Kumar D, Saxena S, Goel U. Retained wooden foreign bodies in the orbit: A case report. Indian J Ophthalmol 1995;43:195‑6. 5. John SS, Rehman TA, John D, Raju RS. Missed diagnosis of a wooden intra‑orbital foreign body. Indian J Ophthalmol 2008;56:322‑4. Cite this article as: Panda BB, Kim UR. Complications of retained intraorbital wooden foreign body. Oman J Ophthalmol 2014;7:38-9. Source of Support: Nil, Conflict of Interest: None declared.
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Copyright of Oman Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Complications of retained intraorbital wooden foreign body Bijnya B. Panda, Usha R. Kim Department of Orbit, Aravind Eye Hospital, Madurai, India
Introduction Wooden foreign bodies can remain entrapped in the orbit for long time and lead to complications like orbital cellulitis, abscess formation, chronic discharging sinus, noninfectious inflammation, and fibrosis.[1‑5] They can migrate intracranially leading to chronic brain abscess or undergo spontaneous extrusion. They may rarely lead to gaze evoked amaurosis.[1] This clinical image describes a case of retained wooden foreign body in the orbit and ethmoidal sinus, which was removed after a period of 9 months in spite of repeated orbital explorations.
extrusion of small pieces of wood from the site. Magnetic resonance imaging (MRI) showed hyperdense attenuation along the medial orbital wall suspected to be a retained foreign body [Figure 3] in the ethmoidal sinus and took expert opinion from an otorhinolaryngologist. Multiple wooden foreign bodies of varying sizes covered with granulomatous tissue were retrieved from the ethmoid sinus [Figure 4] through nasal endoscopy route. Postoperatively, he was treated with oral antibiotics and analgesics following which proptosis subsided but there was residual restrictive strabismus [Figure 5] due to dense fibrosis and no light perception due to long standing compressive optic neuropathy.
Case Report A 22‑year‑old male presented to us with recent history of trauma with a sharp stick to his left eye. On examination there was eccentric proptosis, discharging sinus at medial canthus, lid edema, chemosis, relative afferent pupillary defect (RAPD), restricted extraocular movements in all gazes [Figure 1], intraocular pressure within normal limits and no light perception due to compressive optic neuropathy. Computed tomography (CT) scan showed a retained foreign body along medial orbital wall, medial rectus muscle and surrounding reactionary granuloma, blow out fracture of orbital roof, medial wall, and floor [Figure 2]. Pus culture and sensitivity was positive for Enterobacter cloacae sensitive to amikacin, fluoroquinolones for which we started him on intravenous amikacin and oral levofloxacin. Medial orbital wall exploration was done four times but failed to retrieve any wooden foreign body except excision of granulation tissue. He again presented to us after 6 months with a discharging sinus, pain, watering, and left nasal blockage and gave history of spontaneous
Figure 1: External photograph at presentation showing left eye eccentric proptosis and discharging sinus at medial canthus
Access this article online Quick Response Code: Website: www.ojoonline.org DOI: 10.4103/0974-620X.127929
Figure 2: Computed tomography orbit coronal scan showing a retained foreign body along medial orbital wall and the medial rectus muscle and surrounding reactionary granuloma, blow out fracture of orbital roof, medial wall, and floor
Copyright: 2014 Panda BB and Kim UR. This is an open‑access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Correspondence: Dr. Bijnya B. Panda, Department of Orbit, Aravind Eye Hospital, Madurai, India. E‑mail: [email protected]
38
Oman Journal of Ophthalmology, Vol. 7, No. 1, 2014
Panda and Kim: Complications of retained intraorbital wooden foreign body
Figure 4: Multiple wooden foreign bodies of different sizes retrieved by transnasal endoscopic removal
Figure 3: Magnetic resonance imaging orbits axial scan showing hyperdense linear structure along medial quadrant of left orbit measuring 2.17 × 0.59 cm with coexistent ethmoidal and maxillary sinusitis
otolaryngologist well trained in transnasal endoscopy where the foreign body cannot be retrieved on orbital exploration. The cause for difficulty in retrieving the foreign body in our case was that it was entrapped within the ethmoidal sinus with extensive surrounding granulomatous tissue.
References
Figure 5: External photograph (after endoscopic removal of foreign body) showing left eye in exotropia due to restrictive strabismus
We have reported this case to make our fellow readers aware of the grave prognosis of retained wooden foreign bodies if not dealt aggressively. We insist that MRI should be the first imaging modality of choice where patients give history of penetrating trauma with wooden objects. Endoscopic exploration of the wound should be done with interdisciplinary input from an
Oman Journal of Ophthalmology, Vol. 7, No. 1, 2014
1. McNab AA, Satchi K. Orbital foreign bodies and penetrating orbital injuries. In: Black EH, Nesi FA, Calvano CJ, Gladstone GJ, Levine MR, editors. Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery. 3rd ed. New York: Springer; 2012. p. 297‑307. 2. Shinder R, Gutman J, Gunasekera CD, Connor M, Nakra T. Occult orbital organic foreign body. Ophthal Plast Reconstr Surg 2011;27:463‑4. 3. Lee JA, Lee HY. A case of retained wooden foreign body in orbit. Korean J Ophthalmol 2002;16:114‑8. 4. Kumar D, Saxena S, Goel U. Retained wooden foreign bodies in the orbit: A case report. Indian J Ophthalmol 1995;43:195‑6. 5. John SS, Rehman TA, John D, Raju RS. Missed diagnosis of a wooden intra‑orbital foreign body. Indian J Ophthalmol 2008;56:322‑4. Cite this article as: Panda BB, Kim UR. Complications of retained intraorbital wooden foreign body. Oman J Ophthalmol 2014;7:38-9. Source of Support: Nil, Conflict of Interest: None declared.
39
Copyright of Oman Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
