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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 557-559

A rare case of orbital injury with a keychain in a toddler


Department of Ophthalmology, Government Medical College and Hospital, Chandigarh, India

Date of Submission12-Dec-2021
Date of Acceptance29-Jan-2022
Date of Web Publication13-Apr-2022

Correspondence Address:
Sudesh K Arya
Department of Ophthalmology, Government Medical College and Hospital, Sector-32, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3091_21

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  Abstract 


Orbital injuries caused by foreign bodies are common among children and young adults and may cause ocular morbidity. We report a rare case of an 18-month-old child who sustained an injury with a large metallic keychain in the right medial orbital wall and bridge of the nose following a fall. Timely radiological imaging with X-ray and CT orbit helped in localization and planned removal of the metallic keychain in the most atraumatic way. Early surgical removal with a multidisciplinary approach played a pivotal role in preventing infection, salvaging vision, and anatomical integrity, leading to holistic recovery of the child.

Keywords: Bridge of nose, foreign body, metallic keychain, orbit, orbital wall


How to cite this article:
Jha UP, Arya SK, Dhillon HK, Bariya S. A rare case of orbital injury with a keychain in a toddler. Indian J Ophthalmol Case Rep 2022;2:557-9

How to cite this URL:
Jha UP, Arya SK, Dhillon HK, Bariya S. A rare case of orbital injury with a keychain in a toddler. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 24];2:557-9. Available from: https://www.ijoreports.in/text.asp?2022/2/2/557/342990



Eye injuries are often associated with orbital foreign bodies (FBs), which may be metallic (magnetic or non-magnetic) or even non-metallic.[1] FBs, whether metallic or organic, if not removed promptly, may lead to infections and deleterious complications such as orbital cellulitis, orbital abscess, fistula, and optic neuropathy.[2] Prompt detection and accurate localization of orbital FBs are important to enable the surgeon to plan an atraumatic method of removing them.[3] We report a rare case of a toddler presenting with a large metallic keychain FB in the right medial orbital wall and bridge of the nose following a fall.


  Case Report Top


An 18-month-old, apparently healthy male child, presented to Ophthalmology Emergency with complaints of pain and profuse bleeding around the right eye after sustaining a fall from the bed 3 h back. On examination, there was an impacted keychain ring in the medial wall of the orbit and bridge of the nose [Figure 1]a. The right globe was found to be intact. Left-eye examination was unremarkable. Because the keychain was rubbing against the globe and eyelids on movement, it was secured with a tape to minimize further damage to the eye and to prevent deeper impaction [Figure 1]b. An urgent X-ray orbit (lateral view) was done, which revealed the ring of keychain to be impacted in soft issues [Figure 2]c. This was confirmed on non-contrast computed tomography (NCCT) of the orbit where there was no involvement of bone or any sinuses [Figure 2]a and [Figure 2]b. The child tested negative for COVID-19 via reverse transcription polymerase chain rection (RT-PCR) test. An otorhinolaryngology consultation was done, and the child was planned for emergency removal of FB under general anesthesia on the same day. Intravenous amoxycillin and clavulanate (30 mg/kg/day) and metronidazole (7.5 mg/kg/day) were started preoperatively and were continued for 5 days.
Figure 1: (a) Clinical picture at presentation with impacted keyring. (b) Clinical picture after securing the keys to minimize the trauma to adjacent tissue. (c) Intraoperative picture showing the impacted keychain along with retraction of soft tissues prior to removal. (d) Suturing of gaping defect post removal of keychain with Vicryl 8-0 sutures. (e) Intact keychain with ring after surgical removal. (f) Postoperative clinical picture at 4 weeks showing healed scar over the nasal bridge

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Figure 2: (a) Non-contrast computed tomography (NCCT) coronal view showing impacted keyring not involving bony structure or sinus. (b) NCCT lateral view showing impacted keyring not involving bony structure or sinus. (c) Plain radiograph lateral view showing the metallic keychain and ring impacted in the soft tissue

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Intraoperatively, care was taken to protect the globe while removing the FB by covering the lids with a gauze piece. The keychain was slightly rotated and freed from the underlying soft tissue and pulled outwards to remove it while inflicting the least possible surgical trauma [Figure 1]c and [Figure 1]e. A thorough wash with normal saline was done after removal of keychain. A careful inspection by the otorhinolaryngology surgeon confirmed no damage to any vessels or nerves. Double layered suturing with Vicryl 8-0 was done to approximate the gaping wound [Figure 1]d.

Four weeks after the surgery, the sutured area healed completely with a mild scar [Figure 1]f. The anterior segment and fundus examination were normal, and extraocular movements were full and free in all gazes.


  Discussion Top


Contusions and FBs in the eye are common eye injuries and males account for most of them. Home is the most frequent place of injury in the pre-school age group, while outdoors and street activities are common in older children (age group over the age of 13 years). It has been reported that closed-globe injuries are more common than open-globe injuries.[4],[5] Orbital fractures in children are reported to be the third most common type of fracture, and those of the medial wall and orbital floor are the most common.[6] Retained sino-orbital FBs following orbital wall fractures have been reported.[7] In the present case too, the child was an 18-month-old male with orbital wall FB who was left unsupervised at home.

Diagnostic imaging should be performed in all patients with suspicion of a FB. Conventional X-ray films help in the visualization of radiopaque FBs such as metal filings or gunshot pellets. However, NCCT is the investigation of choice as it precisely defines the location of the FB, its topographic relationships, and any associated intracranial injuries.[7],[8] Intraorbital FBs penetrating the area of the upper eyelid are more likely to damage the structures of the anterior cranial fossa than cases of penetrating trauma to the lower eyelid.[7] In our case, there was no involvement of sinuses or any evidence of fracture of orbital wall.

Literature reports recommend immediate or early surgical removal of all FBs.[2],[9] Our case was taken up for planned emergency removal the same day and thus had good anatomical and functional outcomes.


  Conclusion Top


This case highlights the importance of meticulous history taking, timely radiological investigations, and early surgical intervention to reduce ocular morbidity, complications, and the risk of infections. We also recommend supervision of children to prevent such mishaps. A multidisciplinary approach by an ophthalmologist, an otorhinolaryngologist, a facio-maxillary surgeon, and a neurosurgeon may often be required.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li J, Zhou LP, Jin J, Yuan HF. Clinical diagnosis and treatment of intraorbital wooden foreign bodies. Chin J Traumatol 2016;19:322-5.  Back to cited text no. 1
    
2.
Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494-500.  Back to cited text no. 2
    
3.
Mohotlhoane GP, Mabongo M. Unusual intraorbital foreign body impactions, a case report. S Afr Dent J 2019;74:32-4.  Back to cited text no. 3
    
4.
Al-Mahdi HS, Bener A, Hashim SP. Clinical pattern of pediatric ocular trauma in fast developing country. Int EmergNurs 2011;19:186-91.  Back to cited text no. 4
    
5.
Puodžiuvienė E, Jokūbauskienė G, Vieversytė M, Asselineau K. A five-year retrospective study of the epidemiological characteristics and visual outcomes of pediatric ocular trauma. BMC Ophthalmol 2018;18:10.  Back to cited text no. 5
    
6.
Alcalá-Galiano A, Arribas-García IJ, Martín-Pérez MA, Romance A, Montalvo-Moreno JJ, Juncos JM. Pediatric fractures: Children are not just small adults. Radiographics 2008;28:441-61.  Back to cited text no. 6
    
7.
Natung T, Shullai W, Lynser D, Tripathy T. A challenging case of a large intraorbital foreign body perforating the nasal septum in a child. Indian J Ophthalmol 2018;66:1511-3.  Back to cited text no. 7
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8.
Yamashita K, Noguchi T, Mihara F, Yoshiura T, Togao O, Yoshikawa H, et al. An intraorbital wooden foreign body: Description of a case and a variety of CT appearances. Emerg Radiol 2007;14:41-3.  Back to cited text no. 8
    
9.
Dujovny M, Osgood C, Maron J, Janetta P. Penetrating intracranial foreign bodies in children. A report of two cases. Trauma 1975;15:981-6.  Back to cited text no. 9
    


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