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 Table of Contents  
CASE REPORT
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 176-178

The chronicles of missing metallic intraorbital foreign body: A case series


Department of Ophthalmology, Regional Institute of Ophthalmology, PGIMS, Rohtak, Haryana, India

Date of Submission01-May-2022
Date of Acceptance26-Aug-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Neeru Yadav
MS, Ophthalmology, Junior Resident, Regional Institute of Ophthalmology, PGIMS, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1074_22

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  Abstract 


Intraorbital foreign bodies should be thoroughly looked for and removed judiciously and timely in order to avoid sight-threatening complications. In this series of cases, three patients presented with various types of intraorbital foreign bodies secondary to trauma or iatrogenic causes. After confirmation of diagnosis using appropriate radiological investigations, the foreign bodies were retrieved with the help of suitable surgical techniques. Timely intervention prevented infection and other inflammatory processes such as siderosis and other serious complications like airway obstruction and chemical injury. Meticulous examination supported by radiological investigations is the mainstay of management in cases of orbital trauma.

Keywords: Iatrogenic, intraorbital foreign body, trauma


How to cite this article:
Sharma V, Narula A, Chugh JP, Yadav N, Jain G. The chronicles of missing metallic intraorbital foreign body: A case series. Indian J Ophthalmol Case Rep 2023;3:176-8

How to cite this URL:
Sharma V, Narula A, Chugh JP, Yadav N, Jain G. The chronicles of missing metallic intraorbital foreign body: A case series. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:176-8. Available from: https://www.ijoreports.in/text.asp?2023/3/1/176/368121



Intraorbital foreign bodies occur with a frequency of one in six orbital injuries.[1],[2] Any foreign body that occurs within the orbit but outside the globe is labeled as an intraorbital foreign body. It usually follows a high force injury like gunshot or industrial accident, but relatively trivial trauma may lead to intraorbital foreign bodies as well.[3]

The objects can be metallic, nonmetallic, or organic matter. Surgical retrieval of foreign body is usually contraindicated, and the focus should be on protecting the oculomotor muscles, eyeball, and optic nerve function.[4] In general, injuries caused by metal and glass are well tolerated and may be left in situ, whereas organic matter triggers an intense inflammatory reaction and needs to be removed urgently.[5]

This report discusses three cases with varying types of intraorbital foreign bodies, which presented a clinical dilemma. Removal of each was warranted due to differing causes.


  Case Reports Top


Case 1: The wandering bullet

A 45-year-old male presented to the emergency with history of accidental firearm injury with his own rifle. Entry wound was present on his right temple with no exit wound. An assessment by the neurosurgeon ruled out intracranial injury. Ocular examination revealed extensive lid edema and ecchymosis and a full chamber hyphema. Eye was soft, indicating globe rupture. However, no scleral wound could be seen on thorough slit-lamp examination. B-scan ultrasonography confirmed vitreous hemorrhage and posterior globe rupture. Radiological investigation (computed tomography [CT] scan of the head) was done and the bullet was found in lateral wall of the right orbit [Figure 1]a.
Figure 1: (a) CT scan of the skull showing the bullet at the lateral wall of right orbit (star) with vitreous hemorrhage (bold arrow) and hyphema (arrow). (b) Bullet visible at the medial canthus in a lateral view X-ray of the skull (white arrow). (c and d) Exploration was done, and the bullet was retrieved from the medial canthus. CT = computed tomography

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Exploration of the temporal wound was done, but no bullet was found. After 3 days of observation and treatment, as the lid edema subsided, a stony hard swelling was noted in the medial canthus at the right upper lid. Repeat X-ray revealed a metallic foreign body at the site of the swelling [Figure 1]b. As the foreign body was very superficial and easily accessible, the bullet was retrieved [Figure 1]c and [Figure 1]d.

Impression: The bullet had probably traveled from the lateral aspect of orbit to the medial subcutaneous plane due to laxity of tissues in the region and natural absence of any firm attachments of muscles or fascia with the orbital bones.

Case 2: The lost bone punch

A 28-year-old female presented to the ophthalmology outpatient department complaining of epiphora and purulent discharge from the right eye for the last 1 year. Regurgitation test was positive. A diagnosis of chronic dacryocystitis right eye was made. Patient was taken up for dacryocystorhinostomy. The surgery was accomplished uneventfully. However, after completion of surgery, the operating staff informed about the missing tip of a bone punch used in the procedure. To rule out the worst case scenario, X-rays were ordered, which revealed a metallic foreign body at the site of the new ostium [Figure 2]a and [Figure 2]b. There was a risk of the foreign body entering the airways through the nasal cavity. The surgical incision was reopened, and the foreign body was retrieved using a magnet [Figure 2]c and [Figure 2]d. The wound was closed; patient was asymptomatic thereafter.
Figure 2: (a and b) x-ray anteroposterior and lateral views of the right orbit showing a piece of bone punch (white arrow) lying close to the site of the ostium. (c and d): Exploration done for retrieval of the foreign body, and retrieval of foreign body with a magnet

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Impression: The tip of the bone punch broke in the orbital space while punching the last chips of the bone when the ostium was almost complete. Therefore, the broken tip was missed at the time of closure of the surgical incision.

Case 3: The cutting capacitor

A 6-year-old child sustained a skin laceration on the right upper lid due to a fall while playing. The laceration measured 1 cm in length and was located just below the eyebrow in the right eye upper lid. A suspicious-looking piece of wire was peeking through the laceration [Figure 3]b. Attempt at removal of the wire met with resistance as if something was stuck inside. An X-ray showed a metallic foreign body measuring about 1 cm in length at the site of the laceration [Figure 3]a and [Figure 3]c. On gentle questioning, the child gave a history of holding some electrical device in his hand when he fell down. As it could be batteries which might leak chemicals causing severe burns to the lids, removal of the foreign body was urgently needed.
Figure 3: (a and c) X-ray right orbit AP and lateral views showing metallic foreign body (white arrows). (b) Lid laceration with one end of wire (black arrow) peeking from the wound. (d and e) Foreign body being removed from the site of laceration, and the capacitor after removal from the wound

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Exploration was done and an electrical device called capacitor was found [Figure 3]d and [Figure 3]e. The laceration was stitched. Repeat X-ray was done to ensure complete removal.

Impression: The child was most probably holding the capacitor attached to the wire when he fell down, and the capacitor caused the laceration getting embedded in the lid in the process.


  Discussion Top


Orbital bony frame and lids can protect the globe only if orbital structures can contain the impact force.[6] Most eye injuries involve the penetration of a foreign body and exhibit minimal surface damage.[4] The severity of injury is, therefore, underestimated by physical examination. Variable clinical presentation ranging from no symptoms to even loss of eye may be seen.[1],[4]

The choice of imaging modality chiefly depends on the nature of suspected foreign body. Although CT is considered the gold standard, it can be replaced by magnetic resonance imaging (MRI) when suspecting organic foreign bodies. However, in case of suspected metallic foreign bodies, MRI must be avoided.[7] X-rays were sufficient in two of our cases as the foreign bodies were metallic and lying quite anteriorly. In case 2, margins of the new ostium were used as a landmark for localization of the foreign body, whereas in case 3, X-ray was needed only for confirmation of presence of the foreign body. The attached wire and the wound acted as the guide for extraction of the foreign body.


  Conclusion Top


In our compilation, all the cases had a history of orbital trauma varying from high-velocity gunshot injury to trivial fall. In the first case, the foreign body was lying quite anteriorly and was easily removed. High degree of suspicion helped in discovering the foreign body in the iatrogenic case. Surgical removal was warranted in the third case as electronic devices contain chemicals which may cause serious chemical burns.

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.
Al-Mujaini 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.  Back to cited text no. 1
    
2.
Jabang JN, Dampha L, Sanyang B, Robert CA, Ceesay B. Management of a large intraorbital wooden foreign body: Case report. Surg Neurol Int 2020;11:158.  Back to cited text no. 2
    
3.
Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494-500.  Back to cited text no. 3
    
4.
Ananth Kumar GB, Dhupar V, Akkara F, Praveen Kumar S. Foreign body in the orbital floor: A case report. J Maxillofac Oral Surg 2015;14:832-5.  Back to cited text no. 4
    
5.
Moretti A, Laus M, Crescenzi D, Croce A. Peri-orbital foreign body: A case report. J Med Case Rep 2012;6:91.  Back to cited text no. 5
    
6.
Owji N, Razeghinejad MR, Nowroozzadeh MH. A missed intraorbital wooden foreign body presented as soft tissue mass. Iran J Ophthalmol 2011;23:65-8.  Back to cited text no. 6
    
7.
Ho VT, McGuckin JF Jr, Smergel EM. Intraorbital wooden foreign body: CT and MR appearance. AJNR Am J Neuroradiol 1996;17:134-6.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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