Peri-orbital foreign body: a case report
Journal of Medical Case Reports
Peri-orbital foreign body: a case report
Antonio Moretti 0
Melissa Laus 0
Domenico Crescenzi 0
Adelchi Croce 0
0 ENT Department, University “G D'Annunzio” of Chieti-Pescara, Hospital “SS Annunziata” , Via dei Vestini, I-66100 Chieti , Italy
Introduction: Foreign bodies inside the orbital cavity are rare. They can cause more or less serious complications, depending on their nature and size. Case presentation: We report a case of a work-related accident involving a peri-orbital foreign body. The patient was a 50-year-old Caucasian man whose face was injured on the right side while he was working with an agricultural machine. On admission, he was fully conscious and did not have any neurological deficits. He had no loss of vision or ocular motility, but had a laceration of the lateral side of his right upper eyelid. A computed tomographic scan revealed a 6-cm-long bended metal object lodged in the lateral bulbar space of the right orbit. The patient recovered well after surgery and a course of antibiotic therapy. Conclusion: The original aspects of this case are the singularity of the foreign body and its relative harmlessness in spite of its large size.
peri-orbital foreign body; case report; diagnostic imaging; surgery
Penetrating orbitocranial injuries are quite common in
military practice, but they very rarely 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 [1,2]. 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
An intra-orbital foreign body is an object that lies
within the orbit but outside the ocular globe. These
objects can be classified according to their composition
as (1) metallic, such as steel; (2) non-metallic, which
may be inorganic, such as glass; and (3) organic, such as
wood or vegetable matter. In general, injuries caused by
metal and glass are well-tolerated and, if they do not
have any symptoms or signs, may be left in situ, whereas
organic matter, such as wood and vegetable matter, is
poorly tolerated, 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.
Surgery is planned on the basis of the size and nature
of the foreign body (organic objects are usually poorly
tolerated), the location (anterior or posterior orbit) and
the presence of other injuries or foreign body-related
complications (such as optic nerve compression,
infections and extraocular muscle involvement) . Foreign
body injuries in the orbital region can be approached
with a combination of clinical suspicion, basic
knowledge and diagnostic tests. The skill and experience of
the surgeon are fundamental to decreasing the risk of
iatrogenic injuries [5,6].
A 50-year-old Caucasian man who had sustained an
injury to the right side of his face while working with an
agricultural machine presented to our hospital. He had
a completely negative medical history and was not
taking any drugs. Cranial X-rays were supplemented by a
computed tomographic (CT) scan without contrast
enhancement but with multiplanar reconstructions. The
CT scan showed a linear metallic foreign body in the
soft tissues of the right parietal region (6 cm long,
0.6 cm wide). Anteriorly, this object crossed the lateral
wall of the right orbit, determining bone fracture, and
small bone and metal fragments and air bubbles could
be seen. Posteriorly, the object was localized in the soft
tissues over the zygomatic arch. There were no
significant alterations in the brain parenchyma. The
ventricular system was in place and regular in shape and size
The patient’s physical examination revealed eyelid
hematoma; sub-conjunctival hemorrhage; transparent
horny, normal papilla; absent fascicular reflex; and
retinal hemorrhages in the superior-temporal septal
quadrant. The patient received analgesic medication and
prophylactic antibiotics. He then underwent surgery
while under general anesthesia. The foreign body was
easily extracted through the external injury, located
lateral to the outer part of the upper right eyelid. It was
metallic, smooth and twisted and measured 6 cm ×
0.6 cm (Figure 2). It was extracted from the lateral wall
of the orbit, which appeared fractured. We overlapped
this fracture with a plate of TUTOPATCH (Med&Care,
Gdynia, Poland) for external reinforcement. The injury
was sutured in layers and medicated (Figure 3). The
patient was discharged with antibiotic therapy, a
corticosteroid in decreasing doses and eye drops with the
same drugs. One week later, when the patient returned
to our department for removal of the stitches, his eyelid
bruising had completely resolved.
We report this case for several reasons. First, the
patient’s condition was unusual because of the type of
accident and the proximity of the foreign body to one of
the “noble” organs of our body (the eyeball). The clinical
examination of patients with an impacted object in the
face should be carried out systematically . Active
wound bleeding, increasing hematoma, a low
hemoglobin level, signs of hypovolemic shock (indications of an
associated vascular injury), ocular acuity and mobility
(frequently associated with ocular trauma) upon
admission should be investigated [8-10].
Our patient was examined by an ophthalmologist, who
performed right-eye biomicroscopy (BOD), and
examined right-eye tone (TOD), right-eye visual acuity
(VOD) and right-eye fundus (FOD). The BOD showed
eyelid hematoma, subconjunctival hemorrhage and
transparent cornea; the TOD was 18 mm in breadth;
the VOD was 7 of 10 natural; and the FOD showed
retinal hemorrhages in the upper temporal limits in the
papilla and absence of reflection of foveolae. Plain
radiography is usually the first additional examination to be
requested, owing to its low cost and easy access. It may
be useful in identifying and locating intra-orbital foreign
bodies, with detection rates of 69% to 90% for metallic
foreign bodies and 71% to 77% for glass; however, the
detection rate for organic material, such as wood, is low
(0% to 15%) [11,12]. If foreign bodies are small and/or
Figure 1 Cranial X-rays and some axial sections of the computed tomographic scan.
Figure 2 Intra-operative images of the foreign body.
of weak density, magnetic resonance imaging (MRI)
should be carried out .
The second point of interest is that reverse penetration
of the foreign body is very important in terms of surgical
removal. The history of an orbital or penetrating eyelid
injury should always raise suspicion of an embedded
intraorbital foreign body, particularly in the case of a
high-velocity injury. Clinically, the presentation varies, with the
patient being asymptomatic or having visual disturbances
(decreased vision, double-vision), pain or swelling. The
nature of the injury and the foreign object can be
ascertained by taking a detailed history. Assessment through
radiological images assists in the proper localization of the
foreign body, estimation of its consistency and size and
evaluation of the response of surrounding orbital tissue.
CT scanning has been recommended as the imaging
modality of choice in this situation. Despite their being highly
sensitive and specific for detection of foreign bodies,
however, CT scans may produce false-negative findings,
particularly if the size of the foreign body is less than 0.5 mm
and especially in the case of wooden objects. In our
present case report, the foreign body was located outside the
lateral wall of the right orbit and was demarcated clearly
by CT scans of the orbit.
Third, priority should be given to the selection of the
most logical treatment strategy. The best management
of retained metallic intra-orbital foreign bodies remains
controversial [14,15]. A retained metallic intra-orbital
foreign body may cause a variety of signs, symptoms
and clinical findings on the basis of its size, location
and composition . Loss of vision is usually due to
the initial trauma and is generally not influenced by
surgical intervention . Anteriorly located foreign
bodies can easily be removed, whereas foreign bodies
located more posteriorly without any clinical features
should be left where they are, as their removal may
result in serious complications . In our patient,
because the neurological and radiological investigations
showed no vascular injury, we decided to extract the
foreign body surgically.
Figure 3 Patient after surgery.
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. 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.
Written informed consent was obtained from the patient
for publication of this case report and any
accompanying images. A copy of the written consent is available
for review by the Editor-in-Chief of this journal.
AM and AC were the doctors to whom the patient presented. AM and AC
discussed the treatment procedure which followed. AM performed surgery
on the patient. AM, AC and DC conducted the patient’s post-operative
follow-up. All authors contributed to writing the manuscript. All authors read
and approved the final manuscript.
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