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BRIEF COMMUNICATION
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 105-108

Orbitocranial wooden foreign body


Department of Ophthalmology, Bharati Vidyapeeth Deemed University Medical College & Hospital, Sangli District, Maharashtra, India

Date of Submission23-May-2013
Date of Acceptance05-Dec-2013
Date of Web Publication11-Apr-2014

Correspondence Address:
Milind Suryawanshi
Arpan Bungalow, Plot No. 12, Rama Udyan, Miraj - 416 410, Sangli District, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.130542

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  Abstract 

We report a case of orbitocranial wooden foreign body, piercing through roof of orbit, frontal sinus and frontal lobe and reaching up to corpus callosum. It was, missed at the time of injury by treating surgeon and removed by us after five months. Meticulous exploration of wound and radiological imaging study of orbital injuries is mandatory at the time of injury as they complement each other in the diagnosis. Unlike metal foreign bodies that are easily diagnosed on radiological imaging, intraorbital wooden foreign bodies are often missed on cursory clinical evaluation and radiodiagnosis. This may result into significant ocular morbidity at a later date.

Keywords: Cranial, foreign body, orbital, wooden


How to cite this article:
Suryawanshi M, Desai W, Joshi A, Suryawanshi R. Orbitocranial wooden foreign body. J Clin Ophthalmol Res 2014;2:105-8

How to cite this URL:
Suryawanshi M, Desai W, Joshi A, Suryawanshi R. Orbitocranial wooden foreign body. J Clin Ophthalmol Res [serial online] 2014 [cited 2022 Jan 26];2:105-8. Available from: https://www.jcor.in/text.asp?2014/2/2/105/130542

The aim to report this case is to emphasize the importance of meticulous preliminary exploration of wound and radiological imaging study of orbital injuries since intra-orbital wooden foreign bodies are often misdiagnosed causing high ocular morbidity.


  Case Report Top


The present case report is about an 18-year-old boy, who fell from a tree and injured his left eye. He was treated for pain, redness, watering and swelling of left eye by local Ophthalmologist. For want of relief, he was referred to another ophthalmologist, who, after investigating him by doing computerized tomography (CT) scan of orbit and brain [Figure 1], removed the foreign body from left orbit under general anesthesia but patient remained symptomatic on and off.
Figure 1: (a) Coronal, (b) axial computerised tomography scan of brain showing ill-defined wooden foreign body (white arrow) in left frontal lobe

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After about 5 months, patient visited us with acute exacerbation of symptoms. Visual acuity was counting fingers at two feet. Periorbital edema involved superior part of orbit and upper lid, causing ptosis. On retracting the lids, a piece of wood protruding through upper fornix was seen, touching bulbar conjunctiva and upper half of cornea causing large corneal ulcer [Figure 2]. Retained foreign body leading to orbital cellulitis and corneal ulcer was diagnosed. On hospitalization, magnetic resonance imaging (MRI) showed a well-defined foreign body in superior orbit piercing through frontal sinus, extending superomedially into left frontal lobe and reaching corpus callosum [Figure 3]. An ill-defined signal intensity surrounding foreign body was suggestive of an early cerebral abscess. Patient had an episode of projectile vomiting. A team comprising of oculoplasty surgeon, ear, nose and throat surgeon and stand by neurosurgeon removed the foreign body, exploring superior fornix and anterior orbit under general anesthesia. Incision was made with corneal scissors at upper fornix, where foreign body was seen protruding. Taking care of not disturbing superior rectus muscle and levator palpebrae superioris muscle, foreign body was gently dissected from surrounding tissue. It was then clasped with artery forceps and pulled out gently [Figure 4]. Around 10 cc pus was drained and sent for culture. There was no leakage of cerebrospinal fluid during surgery. The wound was washed with 5% povidone iodine solution. The foreign body measured 57 mm × 12 mm [Figure 5] and was slender and sharp at an end that had pierced anterior cranial fossa. The surface of wooden piece was rough and serrated, which helped foreign body get anchored in the tissue before it got infected and started extruding. Patient was then treated with intravenous ceftazidime 1 gm (Fortum by GlaxoSmithKline), amikacin 250 mg (Amicef by Ranbaxy), metronidazole 100 ml (Metro intravenous by Baxter) and 20% mannitol 100 ml (M-20 by Baxter) and oral fluconazole 100 mg (Zocon by FDC), each twice a day for 7 days. 0.5% moxifloxacin drops (Mosi by FDC) hourly and 1% atropine drops (Bellatropin, Bell Pharma) twice a day were administered for 15 days. Post-operatively, signs of orbital cellulitis and mechanical ptosis resolved completely [Figure 6]. Pus culture showed no growth of organisms. Initially, tablet phenytoin sodium 300 mg was daily given but was replaced with divalproex sodium extended release tablet 500 mg (Dicorate ER by Sun pharma) daily, treatment to be taken for 2 years for prophylaxis of scar epilepsy. Vision improved to 6/9 and except nebular corneal opacity at superior cornea; there were no major ocular sequelae. Repeat MRI scan after 6 months showed linear scar in left frontal lobe with a small cystic encephalomalacia involving genu of corpus callosum [Figure 7].
Figure 2: (a) Left orbital cellulitis with ptosis, (b) showing foreign body protruding from upper fornix causing corneal ulcer

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Figure 3: Magnetic resonance imaging orbit and brain T2W sagittal image showing a wooden foreign body piercing through the superior fornix and roof of the orbit into the frontal lobe

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Figure 4: Removal of foreign body from upper fornix during surgery

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Figure 5: Foreign body measuring 57 mm × 12 mm with rough and serrated surface, sharply pointed at one end

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Figure 6: (a) Pre-operative picture showing left eye with complete ptosis and lid oedema, (b) post-operative photograph showing resolution of ptosis

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Figure 7: Orbit and brain T2W coronal image showing linear scar (black arrow)

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  Discussion Top


In rural part of India, wooden foreign bodies in orbit are seen in farmers and agriculture workers due to nature of their work. In radiolucent foreign bodies like wooden pieces, MRI is a useful because misinterpretation of CT images is common. CT scan is useful in diagnosing metallic foreign bodies, while MRI can prove dangerous because ferromagnetic property of foreign bodies under magnetic field of MRI may cause migration resulting in tissue damage. In our case, coronal section of CT scan at the time of injury showed fractured roof of orbit with ill-defined foreign body in the left frontal lobe. However, removal was incomplete due to poor interpretation of CT images. The downward migration of foreign body toward upper fornix caused sudden exacerbation of symptoms. MRI was a superior tool in knowing extent of intracranial penetration and assessing complications. Prompt surgical and medical treatment prevented deterioration in the patient's condition.

A retrospective case review of 23 orbital injuries was done by Shelsta et al., [1] showed that vegetative injuries were responsible for 35% of intra-orbital foreign bodies. Our patient too had injury with branch of a tree. Preliminary radiographic study was inconclusive in 13% cases in their series. John et al. [2] in their study reported a case where multiple pieces of wood were extruded from the wound over 5 years that looked trivial at the time of injury. Late migration of a foreign body was seen in our case. Gawdat and Ahmed [3] reviewed three pediatric patients, with orbitofacial trauma, who had intra-orbital wooden foreign bodies that were missed on history taking and CT scan. Misinterpretation of CT images delayed the diagnosis in our case as well. Liu [4] reviewed previously unrecognized retained orbital wooden foreign bodies to find common denominators and stated that there is no single specific diagnostic or pathognomonic finding to suggest retained wooden intra-orbital foreign body. A study done by Dunn et al. [5] reported a case of wooden foreign body at orbital apex penetrating into cranium that was missed on cursory examination. Patient's ocular examination suggested superior orbital fissure syndrome and foreign body was confirmed by radiological imaging. Since there are many such instances of missed diagnosis, we propose a simple algorithm [Figure 8] to manage orbital foreign bodies. It is quite imperative to bear a high index of suspicion during eliciting history. A proper clinical evaluation complemented by radiological imaging study is necessary in diagnosing an intra-orbital wooden foreign body. A suspicion of retention of foreign body is enough to warrant repeat diagnostic or surgical procedure.
Figure 8: Algorithm for management of orbital injuries

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  Conclusion Top


We believe that it is vital to be careful at each step of management of orbital foreign body so that misdiagnosis and consequence of ocular morbidity is minimized.

 
  References Top

1.Shelsta HN, Bilyk JR, Rubin PA, Penne RB, Carrasco JR. Wooden intraorbital foreign body injuries: Clinical characteristics and outcomes of 23 patients. Ophthal Plast Reconstr Surg 2010;26:238-44.  Back to cited text no. 1
    
2.John SS, Rehman TA, John D, Raju RS. Missed diagnosis of a wooden intra-orbital foreign body. Indian J Ophthalmol 2008;56:322-4.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Gawdat TI, Ahmed RA. Orbital foreign bodies: Expect the unexpected. J Pediatr Ophthalmol Strabismus 2010;47 Online:e1-4.  Back to cited text no. 3
    
4.Liu D. Common denominators in retained orbital wooden foreign body. Ophthal Plast Reconstr Surg 2010;26:454-8.  Back to cited text no. 4
    
5.Dunn IF, Kim DH, Rubin PA, Blinder R, Gates J, Golby AJ. Orbitocranial wooden foreign body: A pre-, intra-, and postoperative chronicle: Case report. Neurosurgery 2009;65:E383-4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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[Pubmed] | [DOI]



 

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