|Year : 2022 | Volume
| Issue : 1 | Page : 223-224
Mirror, mirror in the orbit: Reflections from a singular orbital foreign body
Ratan Jyoti Netralaya, Orbit and Oculoplasty Service, 18-Vikas Nagar, Near Sai Baba Temple, Gwalior, Madhya Pradesh, India
|Date of Submission||07-Aug-2020|
|Date of Acceptance||28-Jun-2021|
|Date of Web Publication||07-Jan-2022|
Dr. Kamalpreet Likhari
Ratan Jyoti Netralaya, Orbit and Oculoplasty Service, 18-Vikas Nagar, Near Sai Baba Temple, Gwalior - - 474 002, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
A 23-year-old lady was working at her sewing machine when she was struck in the left eye by something, probably a piece from a hand mirror, which her children were playing with. She presented with a hard object palpable just above and behind her left upper lid. CT scan revealed a large foreign body, which was subsequently surgically removed. The need for extreme caution as well as the surgical plan and procedure for removing such brittle and hazardous objects from the orbit are discussed in this report.
Keywords: Glass, inert, intraorbital foreign body, mirror, route of entry, surgery
|How to cite this article:|
Likhari K. Mirror, mirror in the orbit: Reflections from a singular orbital foreign body. Indian J Ophthalmol Case Rep 2022;2:223-4
Intraorbital foreign bodies usually occur following acts of violence or vehicular or work-related accidents; more rarely they occur following trivial trauma. They can cause severe structural and functional damage and their removal from amidst the delicate structures in the orbit can be perilous. An unusual injury with impaction of mirror pieces and their removal is presented.A
| Case Report|| |
A 23-year-old lady was struck in her left eye by something when the hand mirror which her children were playing with fell and broke. She had short-lived sharp pain but no bleeding and something seemed lodged behind her left upper lid. She presented to us 1 day later with a large hard immobile object palpable behind her left upper eyelid, almost total mechanical ptosis and lid erythema. There was conjunctival congestion and a faint subconjunctival hemorrhage, the anterior chamber was quiet and deep, the cornea clear, and the pupil and fundus were normal. Extraocular motility seemed normal, but elevation was painful. Visual acuity was 20/20 OD and 20/40 OS; intraocular pressure was normal [Figure 1]. CT imaging revealed a horizontally oriented rectangular hyperdense shadow in the left preseptal region (approximately 22 × 6 × 4 mm), inferiorly abutting the eyeball [Figure 2]. UBM was inconclusive. Gonioscopy revealed a miniscule glass piece at the 12 o'clock limbus adjoining the iris.
|Figure 1: Top and middle rows: Left eye ptosis and subconjunctival hemorrhage at presentation. A faint impression of the foreign body is seen above the left upper lid. Bottom row: Postoperative day five picture showing near complete recovery|
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|Figure 2: Top row: Axial (left) and coronal (right) views of CT showing the hyperdense foreign body. Bottom row: Intraoperative picture showing the foreign bodies being removed from superior fornix (left) and the mirror pieces after removal (right)|
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Under general anesthesia, the area was gently palpated to estimate the extent and motility of the object. A superior forniceal approach had been planned; however, as this was presumably a large and jagged mirror shard, everting the upper lid could push it against the frontal bone with possible breakage, or inferiorly against the eyeball. Hence, exploration via the easier-appearing skin side was also contemplated though blepharotomy would presumably cause scarring/postoperative ptosis. The globe was fixed downwards with a stay suture to help in everting the eyelid and protect the cornea from any ejecting splinters/shards. The upper lid was cautiously double-everted using a Desmarres retractor and a cotton-tipped applicator; the force required for this was moderate and directed away from the globe. The entrance to a cavity was seen in the superior sulcus; slight very gentle manipulation using a cotton-bud revealed the 1.5 mm thick and razor-sharp edge of the mirror piece. It was firmly grasped with toothed forceps and its inferomedial edge teased out after extending the conjunctival wound of entry with Westcott scissors. When it was nearly delivered, a similar sliver was discernible superiorly attached at its lateral edge; it was removed separately as the two broke apart on coaxing out the first piece. Both were rectangular and measured 20 × 4 mm and 21 × nearly 2 mm, respectively [Figure 2]. The cavity was inspected as far as possible for splinters and also palpated from the skin side and flushed with saline.
A tiny superficial fragment (about 1 mm) was embedded in the sclera at 12 o'clock limbus, under a flap of conjunctiva, plugging a full thickness linear limbal tear about 2 mm across, and its removal was followed by a gush of aqueous. This wound was secured with two interrupted 10-0 nylon sutures and the anterior chamber was reformed with saline.
The forniceal wound was closed with continuous interlocking sutures using 7-0 vicryl. The patient was discharged on oral antibiotics and NSAIDs plus topical antibiotics and cycloplegics. Postoperative recovery was swift. On the last follow-up, 3 months later, there was no residual ptosis or elevation restriction [Figure 1].
| Discussion|| |
Orbital foreign bodies are uncommon, usually occur in young adult males due to industrial or vehicular accidents and can cause considerable damage to orbital vital structures.,, The preferred modality for imaging remains a CT scan with thin slices (1.0–1.5 mm), though glass embedded in muscular tissue or in close proximity to radio-dense structures like bone may not be visualized., The need for removing the foreign body depends on the nature, location, size, and shape of the object; the optimal route for removal needs to carefully decided upon and should take into account not just its size and nature but also its shape and the vital structures in its path.
This case was remarkable for several reasons. The mode of injury, as well as the entry of the large thick mirror pieces in the preseptal space without any bleeding or visible entry wound were unusual. There was no clinical indication of the small intraocular fragment. The glass was split longitudinally, so there were actually three objects to be removed instead of the one seen on CT.
| Conclusion|| |
Glass, though inert, is not harmless. Our patient had large shards lodged in her preseptal area, the sheer size of which necessitated removal; additionally, glass is known to migrate through soft tissues (12.5 cm/day); even a few millimeters could have been disastrous. The route of entry is preferred for removal especially in case of brittle objects (wood/glass). This avoids an additional wound and facilitates examining the entire path for chips and pieces. However, it may not always be the ideal route; therefore, having a predecided alternative path is good policy. Foreign body removal is one surgery where a small incision is an actual disadvantage. Hence, adequately enlarging the wound is essential, as is using both visual and tactile stimuli to locate the pieces. However, of foremost importance in foreign body removal is protecting surrounding vital structures and anticipating surprises and complications.
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.
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[Figure 1], [Figure 2]