|Year : 2021 | Volume
| Issue : 3 | Page : 599-601
Orbital foreign body in a child presenting with cardiogenic shock
Thangjam A Singh, Benjamin Nongrum, Prasanta K Goswami, Renjano N Okhyopvui
Department of Ophthalmology, NEIGRIHMS, Mawdiangdiang, Shillong, Meghalaya, India
|Date of Submission||29-Aug-2020|
|Date of Acceptance||27-Jan-2021|
|Date of Web Publication||02-Jul-2021|
Dr. Benjamin Nongrum
Department of Ophthalmology, Mawdiangdiang, NEIGRIHMS, Shillong, Meghalaya
Source of Support: None, Conflict of Interest: None
Orbital foreign bodies can have a variety of presentations like restriction of extraocular movement and orbital cellulitis. A child sustained injury to the right eye with a piece of wood. He had features of cellulitis but no signs of septicemia. The noncontrast computed tomography showed a hyperdense structure suggestive of a large foreign body located in the retro-orbital area upto the apex of the orbit. He presented with shock which was consistent with cardiogenic shock, probably secondary to oculocardiac reflex, as evident by the presence of bradycardia, systemic hypotension and low SpO2. On removal of the foreign body, the vitals improved.
Keywords: Adrenaline, bradycardia, cardiogenic shock, dopamine, hypotension, oculocardiac reflex, orbital foreign body
|How to cite this article:|
Singh TA, Nongrum B, Goswami PK, Okhyopvui RN. Orbital foreign body in a child presenting with cardiogenic shock. Indian J Ophthalmol Case Rep 2021;1:599-601
|How to cite this URL:|
Singh TA, Nongrum B, Goswami PK, Okhyopvui RN. Orbital foreign body in a child presenting with cardiogenic shock. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:599-601. Available from: https://www.ijoreports.in/text.asp?2021/1/3/599/320014
Orbital foreign bodies can have presentations like restriction of extraocular movement, cellulitis, diplopia and nonhealing pus discharge depending on the type, size and location of the foreign body. Foreign bodies can be metallic, nonmetallic and organic. Organic foreign bodies usually cause an intense inflammatory reaction and need to be removed urgently. A presentation of cardiogenic shock resulting from an oculocardiac reflex (OCR) is uncommon with organic foreign bodies. Metallic foreign bodies are mostly inert and may be left in situ.,,,
| Case Report|| |
An 8 year old boy was hit by a stick on the right eye [Figure 1]. The stick was part of the rein that was tied to the cow. While the boy was trying to remove the rein from the stick, the cow pulled away suddenly and part of the stick entered his eye. He presented to our hospital, which is a tertiary multispecialty center in northeast India, on the third day with altered sensorium. The noncontrast computed tomography imaging showed hyperdense structure suggestive of foreign body lodged behind the eyeball, compressing on the eyeball and extending up to the apex of the orbit measuring 30 mm × 30 mm × 8 mm [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d while the eyeball was normal. His pulse rate consistently remained below 50 beats per minute and blood pressure below 70/50 mm Hg. His blood culture was sterile, blood count showed hemoglobin of 11.7 gm/dL, Total WBC – 8.3 × 103/microL, DLC – N71 L21 M2 E6, Platelets- 530 × 103/microL, ESR – 28 mm at 1 h), CSF culture & sensitivity was sterile, CSF analysis for gram staining, protein, glucose, cells, glucose CSF: Serum ratio was normal. The reports did not correlate with features of septic shock or meningism. The patient was managed conservatively to stabilize his vitals with judicious use of IV fluids, inotropic, chronotropic, and vasopressor agents comprising of intravenous dopamine infusion at 8-15 microgram/kg/minute and adrenaline infusion at 0.1 microgram/kg/minute and empirical IV antibiotics injection of ceftriaxone 500 mg Q12 hourly, metronidazole 400 mg Q8 hourly, moxifloxacin 0.5% eye drop, and moxifloxacin 0.5% ointment. These were continued for 7 days but with no apparent benefit. We hypothesized that this could be a cardiogenic shock secondary to the pressure of the foreign body on the globe with traction on the rectus muscle that elicited the oculocardiac reflex (OCR). The condition was explained to the patient's family as was the need of removing the foreign body including all the risks involved. A large wooden foreign body measuring 32 mm × 25 mm × 8 mm was removed under general anesthesia despite the patient being in shock [Figure 3]a and [Figure 3]b. Intraoperatively itself, the heart rate normalized immediately after the foreign body was removed. Postoperatively the patient's blood pressure slowly improved and he was extubated by day 2. The pharmacologic augmentation of dopamine and adrenaline were weaned off by day 3. He was discharged on post-op day 7 with all vitals being stable and a vision of 6/60. After 1 month his vision improved to 6/9 and at 11 months, his entry wound has healed well [Figure 4]a and [Figure 4]b.
|Figure 1: An 8 year old boy with history of stick injury on the right eye. Clinical photo on the 3rd day of injury showing the entry wound and cellulitis|
Click here to view
|Figure 2: (a) CT-3D reconstruction of the orbit showing a large foreign body lodging in the upper part of the orbit retro-orbitally extending upto the apex of the orbit. (b-d). Non contrast CT sagittal, axial and coronal section soft tissue window of the orbit showing a large foreign body lodging in the superior part of the orbit extending retro-orbitally upto the apex|
Click here to view
|Figure 3: (a and b) Intraoperative pictures showing large wooden foreign body measuring 32 mm × 25 mm in length and breadth|
Click here to view
|Figure 4: (a and b) 11 months postoperative pictures showing healed wound|
Click here to view
| Discussion|| |
The oculocardiac reflex is classically described as being elicited by traction on the extraocular muscles or pressure on the globe. Stimulation of stretch receptors begins in the afferent limb of the arc via the ciliary ganglion and ophthalmic branch of the trigeminal nerve terminating in the sensory nucleus of the trigeminal nerve. The efferent limb is mediated by the motor nucleus of the vagus nerve and hence its negative effects on heart rate and cardiac output. Increased risks for the OCR include young age, hypercarbia, hypoxemia and potent narcotics. Pretreatment with intravenous anticholinergic agents such as atropine or glycopyrrolate decreases OCR as this opposes the vagal response. Deep anesthesia and retrobulbar block were found to decrease risk via blockage of the afferent limb. In rare cases, the OCR has been associated with death. In the present case, the diagnostic dilemma lay in the etiology of this patient's hypotension and bradycardia. In the setting of trauma, the differential diagnosis for hypotension and bradycardia include internal hemorrhage, cardiac tamponade, pneumo or hemothorax, cardiogenic or neurogenic shock, fat or air embolism and prolonged hypoxemia. Our patient had sustained significant ocular trauma, however radiographic imaging was negative for intracranial abnormalities. We, therefore, hypothesized that pressure from the foreign body coupled with traction on rectus muscles must have elicited the OCR. Pham CM et al. concluded that the OCR can precipitate bradycardia and hypotension in the setting of significant orbital and maxillofacial injury. Current recommendations for management of the OCR include risk factors identification and modification, careful cardiopulmonary monitoring, treatment with vagolytic agents and cessation of the inciting stimulus. In the present case, the child was constantly monitored and managed in the Paediatric Intensive Care Unit as he was in shock. Dopamine and adrenaline were used as temporary stabilizing measures until the removal of the foreign body. Anesthetists need to be cautious as the child was in shock and to use measures to minimize OCR such as atropine and retrobulbar block. Detailed counselling was therefore required to make the patient's parents understand that removal of foreign body was essential as well as the risks involved in general anesthesia. Management should include close cardiopulmonary of risk factors, prompt suspicion of OCR and removal of the inciting stimulus.
| Conclusion|| |
This case demonstrates that the OCR should be part of the differential diagnosis of bradycardia and hypotension in the setting of any orbital trauma.
The authors wished to acknowledge Dr. Himesh Barman and Dr. Prakash Deb for their intellectual contribution, Dr. Baphiralyne Wankhar for the radiological images and Dr. Sharon Uniki Lyngdoh for editing the manuscript.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Simha A, John M, Albert RR, Kuriakose T. Orbito-sinal foreign body. Indian J Ophthalmol 2010;58:530-2.
] [Full text]
Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthalmic Plast Reconstr Surg 2004;20:232-6.
Kumar GBA, Dhupar V, Akkara F, Kumar SP. Foreign body in the orbital floor: A case report. J Maxillofac Oral Surg 2015;14:832-5.
Al-Mujai A, Al-Senawi R, Ganesh A, Al-Zuhaibi S, Al-Dhuhli H. Intraorbital foreign body: Clinical presentation, radiological appearance and management. Sultan Qaboos Univ Med J 2008;8:69-74.
Arasho B, Sandu N, Spiriev T, Prabhakar H, Schaller B. Management of the trigeminocardiac reflex: Facts and own experience. Neurol India 2009;57:375-80.
] [Full text]
Pham CM, Couch SM. Oculocardiac reflex elicited by orbital floor fracture and inferior globe displacement. Am J Ophthalmol Case Rep 2017;6:4-6.
Fasina O, Ugalahi MO, Oluwaseyi OT, Bekibele CO. Unusual intraorbital foreign bodies: A report of two cases and review of literature. J Trauma 2017;6:19-22.
Sharma R, Sinha R, Menon PS. Oculocardiac reflex during orbital floor reconstruction: A case report. J Maxillofac Oral Surg 2008;7:275-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]