Clinical features and management of intraorbital foreign bodies

Intraorbital Foreign Body- Endoscope Assisted Removal

Intraorbital wooden foreign body is uncommon in patients with orbital trauma, and if present its complete surgical removal at the earliest is of utmost importance to avoid significant complications. We report an interesting case of an intraorbital wooden foreign body that was succesfully removed using a nasal endoscope.

[Contribution of technological aids to the extraction of orbital foreign bodies]

BACKGROUND

Removal of orbital foreign bodies is a surgical challenge. The purpose of this study is to report our experience in the removal of orbital foreign bodies and to evaluate the usefulness of various technological aids in their removal.

MATERIALS AND METHODS

We conducted a single-center retrospective study at Nice University Hospital (France) from January 2017 to December 2023. All patients undergoing surgery for an orbital foreign body during the study period were included. Data recorded included the nature of the orbital foreign body, its size, location, surgical route, outcome (success, partial success, failure), and technological aids used (intraoperative navigation, intraoperative imaging scope, orbital magnet). Concurrently, we designed a dedicated orbital magnet, which was tested in the anatomy laboratory and in two of our patients.

RESULTS

Six patients, all young men, were included during the study period. Removal was successful, partially successful, or unsuccessful in one-third of cases, respectively. Failure was associated with orbital foreign bodies located in the intraconal or posterior orbital space. Preoperatively, the use of a "low-artifact" scanner allowed us to better determine the exact size and shape of the orbital foreign body. Intraoperative navigation was not accurate enough, due to the mobility of the orbital bodies within the orbital fat. In our experience, intraoperative scope imaging was more accurate. The use of a dedicated orbital magnet was successfully tested in the anatomy laboratory and allowed the removal of a small orbital foreign body in one of our patients. Intraoperative surgical videos are provided.

CONCLUSION

Vegetal orbital foreign bodies must be systematically removed. Removal of non-vegetal orbital foreign bodies should be considered on a case-by-case basis based on their size, best assessed using a "low artifact" scanner, their location, and their intrinsic ferromagnetism. Intraoperative navigation does not appear useful, while intraoperative scope imaging does. A dedicated orbital magnet might be helpful in removing ferromagnetic orbital foreign bodies. However, an orbital magnet may be ineffective in removing intraorbital bullets, since they are made primarily of an alloy of copper and lead.

Plastic orbital foreign body: the rise of plastic and its unintended consequences

Intraorbital foreign bodies (IOrFBs) are a significant cause of ocular morbidity. Although plastic IOrFBs are rare, the increasing use of plastic and polymer composites in motor vehicles will increase their prevalence. Although challenging to identify, plastic IOrFBs have unique radiographic characteristics. The authors describe a case of an 18-year-old man with a history of a motor vehicle accident and a left upper eyelid laceration. In retrospect, imaging suggested a plastic IOrFB, which was initially overlooked. A follow-up examination demonstrated persistent left upper lid ptosis with an underlying mass. Further work-up revealed a retained IOrFB, which was removed via anterior orbitotomy. Scanning electron microscopy of the material was consistent with a plastic polymer. This case demonstrates the importance of maintaining a high suspicion for IOrFBs in the correct clinical context, the need for increased awareness of plastic and polymer composite IOrFBs, and the use of diagnostic imaging for identification.

Endoscopic transnasal approach to remove an intraorbital bullet: systematic review and case report

Introduction

Intraorbital foreign bodies (IOFBs) represent a clinical challenge: surgical management can be controversial and different strategies have been proposed. When removal is recommended, depending on the location and nature of the IOFB both external and endoscopic approaches have been proposed, with significantly different surgical corridors to the orbit and different morbidities.

Methods

We performed a literature review of cases of IOFBs that received exclusive endoscopic transnasal surgical treatment to evaluate the role of this surgery in these occurrences. We also present a case of an intraorbital intraconal bullet that was successfully removed using an endoscopic transnasal approach with good outcomes in terms of ocular motility and visual acuity.

Results

A limited number of cases of IOFBs have been treated with an exclusive endoscopic transnasal approach. When in the medial compartment, this approach appears to be safe and effective. In our case, two months after surgery the patient showed complete recovery with no significant long-term sequelae.

Conclusions

When feasible, an endoscopic transnasal approach for intraorbital foreign bodies represents a valid surgical technique with optimal outcomes and satisfactory recovery.

Clinical outcomes and characterization of intraocular foreign body injuries from a Canadian centre: a 20-year retrospective study and literature review

OBJECTIVE

To analyse assessment and management patterns of intraocular foreign body (IOFB) injuries in an urban Canadian setting, providing valuable clinical insights to contextualize management.

METHODS

Single-surgeon retrospective chart review from January 2002 to January 2023 examining IOFB patient demographics, investigations, treatments, complications, and best-corrected visual acuity (BCVA).

RESULTS

This study evaluated IOFBs in 32 eyes from 31 patients (96.8% male). Sizes ranged from 1 to 12 mm; 28 (87.5%) were metallic and 15 (46.9%) were work-related injuries. For diagnosis, 19 patients (61.3%) underwent computed tomography (CT) imaging, and 8 (25.8%) received B-scans, with CT detecting IOFBs in 100% of cases and B-scan in 87.5%. At final follow-up, 17 eyes (53.1%) achieved BCVA ≥20/40, up from 7 (23.3%) initially. Presenting BCVA ≥20/200 was associated with a final BCVA ≥20/40 (P = 0.027). The IOFB was extracted in 27 eyes (84.4%), retained in 4 (12.5%), and 1 (3.1%) required enucleation. Intravitreal antibiotics were administered in 19 eyes (59.4%), resulting in one presumed case of drug toxicity. Complications were present in 30 eyes (93.8%), totalling 119 recorded overall, with 72 (60.5%) occurring within the first 24 hours. Traumatic cataracts were most common in 27 eyes (84.4%). Less-common complications included siderosis and retinal detachment with proliferative vitreoretinopathy, each occurring in one eye (3.1%). Four eyes (12.5%) developed secondary glaucoma, with 3 cases in retained or delayed extractions.

CONCLUSIONS

The IOFB characteristics and patient demographics are consistent with other regions. CT scans were the most effective investigation tool. Extended follow-up is recommended to monitor complications, particularly in retained or significantly delayed extractions.

Transsphenoidal retrieval of a needlefish beak remnants from the optic canal

KEY POINTS

Penetrating orbital trauma from marine creatures, especially needlefish, should be considered after injuries sustained in open water. Advances in endoscopic sinus surgery have enabled surgeons to remove certain orbital foreign bodies through endoscopic endonasal approaches. 3D segmentation is a valuable pre-operative tool in complex endoscopic orbital cases.

Retained wood penetrating the inferior orbital fissure removed after several months from injury: A case report and a comprehensive literature review

Background

Intraorbital wooden foreign bodies (IOWFBs) constitute a relatively rare ocular trauma. Clinically, it can be difficult to diagnose them due to their wide variety of clinical manifestations. In addition, radiologic diagnosis of IOWFBs is always uncertain and challenging since their low density and low intensity on initial images are identical to air and fat. Therefore, IOWFBs are commonly missed and may not be confirmed for days or months after the initial injury. This article endeavors to contribute to the existing literature on IOWFBs by adding a case of an unusual occurrence of retained wood penetrating the inferior orbital fissure (IOF). To date, there have been no documented instances of a similar occurrence in this particular anatomical location.

Case Description

A 58-year-old female with a history of trauma sustained by a slipping accident 10 months before her referral to our hospital. She underwent multiple surgeries and was referred to us due to persistent right eye pain, periorbital swelling, recurrent eye discharge, and inferior orbital paresthesia. The imaging revealed a retained foreign body located in the right orbital floor inferior to the inferior rectus muscle extending to the sub-temporal fossa through the IOF. The residue was successfully removed without complications.

Conclusion

A history of trauma followed by persistent symptoms should raise the suspicion of a retained foreign body, regardless of the severity of trauma or the time between trauma and clinical presentation. Appropriate and timely imaging, followed by surgical removal, remains the cornerstone of treatment with a favorable prognosis.

Ocular trauma from Lawn mower accidents: Clinical insights, visual outcomes and microbial profiles

AIMS

To characterize the clinical features of ocular trauma resulting from lawn mower, identify determinants of unfavorable final visual acuity (FVA), and assess the spectrum of microbial in posttraumatic endophthalmitis.

METHODS

This retrospective study enrolled patients who experienced ocular trauma due to lawn mower at Zhongshan Ophthalmic Center from January 2013 to August 2021. Demographics, clinical features, isolated microorganisms, risk factors influencing reduced visual acuity, treatment regimens, and utilization of eyewear were collected.

RESULTS

The study included 140 participants (140 eyes) (49.47 ± 12.03 years, 95% male). The predominant injury manifestations were penetrating globe injuries (75.7%) and intraocular foreign bodies (51.4%). Endophthalmitis occurred in 35 cases (25%) and Bacillus cereus (23.5%) was the primary pathogen, followed by Staphylococcus epidermidis (11.8%) and Streptococcus species (11.8%). Following the initial assessment, where 77.9% of patients had initial visual acuity (IVA) at grade IV (ranging from light perception to 4/200) and only 0.7% attained grade I (better than 20/40), post-treatment results revealed that 5.7% achieved FVA at grade I, with a concurrent decrease in patients with grade IV vision to 64.3%. Multivariate logistic regression revealed that injury protection (p < 0.001, OR = 0.237, 95% CI = 0.126-0.446), IVA (p = 0.001, OR = 4.102, 95% CI = 1.730-9.729), and retinal detachment (p = 0.042, OR = 8.105, 95% CI = 1.075-61.111) were significant independent risk factors impacting FVA.

CONCLUSION

Lawn mower often cause severe ocular injuries, with high-velocity metal foreign bodies that can lead to infections, most commonly caused by Bacillus cereus. Correct use of protective gear, initial vision assessment, and detecting retinal detachment are crucial for visual prognosis.

When brakes fail you: Oculocardiac reflex elicited by a retained foreign body in a penetrating orbital injury

Purpose

To report a case of oculocardiac reflex following penetrating orbital injury with entrapment of extraocular muscle secondary to a retained orbital foreign body.

Observation

A 19-year-old man with no known comorbidities presented with a foreign object in his right orbit following a motor vehicle accident. Visual acuity was 20/20 bilaterally with positive relative afferent pupillary defect for the right eye. A motorcycle brake lever was embedded in the right inferotemporal conjunctival fornix, missing his globe. He was bradycardic in the emergency department, with a pulse rate ranging between 45 and 48 beats per minute. An urgent computed tomography scan of the orbit confirmed the penetrating injury with a linear hyperdense foreign body extending from the right inferior orbit into the right maxillary sinus. This foreign body was seen abutting the right lateral rectus and the globe inferiorly. Fractures involving the inferior and medial wall of the right orbit were seen with the inferior rectus, and orbital fat herniated into the maxillary sinus.The patient underwent urgent orbit exploration with foreign body removal and orbital floor repair under general anesthesia. Immediately after removing the foreign body, his pulse rate returned to normal, within 72-80 beats per minute. Six months postoperatively, visual acuity was 20/20 for both eyes. Although he had persistent diplopia on upgaze, he refused any other interventions.

Conclusion and importance

Prompt detection of the oculocardiac reflex and removal of the inciting stimulus is vital to prevent any life-threatening events.

Trauma and chorioretinal shockwave injury from intra-orbital foreign body

High-velocity projectile trauma could lead to intra-orbital foreign body and concomitant chorioretinal shockwave injury in the absence of open-globe injury. Management depends on the types, size, and location of foreign bodies.

Medial Oblique Eyelid Split Orbitotomy

PURPOSE

The authors describe their experience with a variant of the split orbitotomy with a small medial oblique transmarginal incision for approaching a variety of lesions involving the superonasal aspect of the orbit.

METHODS

Retrospective review of medical records and clinical photographs of all patients who underwent an unilateral medial oblique incision to access various intraconal lesions abutting the superomedial quadrant of the orbit. The curvature of the medial contour of the operated and contralateral eyelids were expressed with Bézier functions and compared using the R-squared coefficient of determination (R 2 ).

RESULTS

Twenty-three patients were submitted to this surgical technique for approaching various unilateral lesions on the superonasal quadrant of the orbit. Excellent cosmesis was achieved in all eyelids, with almost imperceptible scars, and no ptosis or retraction. There was no significant difference between the postoperative medial contour of the operated and the contralateral eyelid, with R 2 ranging from 0.896 to 0.999, mean 0.971.

CONCLUSIONS

The authors' results show that the modified eyelid split approach provides a wide exposure of the superonasal quadrant of the orbit with no risk of eyelid dysfunctions or significant scars.

Toxic External Exposure Leading to Ocular Surface Injury

The surface of the eye is directly exposed to the external environment, protected only by a thin tear film, and may therefore be damaged by contact with ambient particulate matter, liquids, aerosols, or vapors. In the workplace or home, the eye is subject to accidental or incidental exposure to cleaning products and pesticides. Organic matter may enter the eye and cause infection. Ocular surface damage can trigger a range of symptoms such as itch, discharge, hyperemia, photophobia, blurred vision, and foreign body sensation. Toxin exposure can be assessed clinically in multiple ways, including via measurement of tear production, slit-lamp examination, corneal staining, and conjunctival staining. At the cellular level, environmental toxins can cause oxidative damage, apoptosis of corneal and conjunctival cells, cell senescence, and impaired motility. Outcomes range from transient and reversible with complete healing to severe and sight-compromising structural changes. Classically, evaluation of tolerance and safety was carried out using live animal testing; however, new in vitro and computer-based, in silico modes are superseding the gold standard Draize test. This review examines how environmental features such as pollutants, temperature, and seasonality affect the ocular surface. Chemical burns to the eye are considered, and approaches to protect the ocular surface are detailed.

Removal of Intraorbital Foreign Body by Transnasal Endoscopic Approach Removal of Intraorbital Foreign Body by Transnasal Endoscopic Approach

Foreign bodies in the intra-orbital area are a rare occurrence. It can be metallic or non-metallic. Intra-orbital foreign bodies can present with a variety of complications depending upon its size and location. We report a case of intra-orbital foreign body which was successfully removed by trans-nasal endoscopic approach.A 12 year old boy with an intra-orbital wooden foreign body in the medial extra-conal space was presented three days post trauma. He had normal visual acuity but there was painful restriction of eye movement. Foreign body was removed and pus drained by trans-nasal endoscopic approach. Post operatively he gradually regained his eye movements. Post operatively patient had complete recovery of eye movements. Traditionally intra-orbital foreign bodies were removed by external approach. With advancement in technology medial intra-orbital foreign bodies can be removed by trans-nasal endoscopic approaches.

Clinical analysis of 96 patients with intraorbital foreign bodies: A 10-year retrospective study

Introduction

To investigate the clinical manifestations, diagnosis, and surgical treatment of intraorbital foreign bodies (IOFBs).

Methods

Patients with IOFBs were enrolled from Wuhan Union Hospital between January 2011 and January 2021. Demographic and clinical information was extracted, including gender, age, cause and entrance of the trauma, material, size and quantity of foreign body, visual function, ocular complications, imaging findings, and surgical intervention. The patients were divided into two groups according to the timeline, group A (from January 2011 to December 2015, n = 39) and group B (from January 2016 to January 2021, n = 57).

Results

The 96 patients (81 men and 15 women) were enrolled in this series, with a median age of 39.5 (1.6–76.0) years. Work-related injuries were the cause of IOFBs in 45 individuals (46.9%). Three patients (3.3%) presented severe visual impairment, and 39 patients (42.4%) presented blindness. The majority of foreign bodies were metal (44.8%), followed by wood (26.0%). Computed tomography (CT) and magnetic resonance imaging (MRI) were performed, respectively, on 89 (92.7%) and 21 (21.9%) patients with IOFBs, in which the detection rate was 80.9% for CT and 81.0% for MRI. Among the 25 patients with intraorbital wooden foreign bodies (IOWFBs), the utilization and detection rates of MRI were 50.0% and 40.0% in group A, and 93.3% and 92.9% in group B, with significant differences in both rates between the two groups (both P &lt; 0.05). The IOWFBs detection rate in MRI was significantly higher than that in CT (78.9% vs. 45.8% overall and 92.9% vs. 53.5% in group B). The detection rates of IOFBs and IOWFBs in initial surgery were statistically different between the two groups, of which the rates were 84.6% and 40.0% in group A and 98.2% and 93.3% in group B. The reoperation rate of IOWFBs in group B (20.0%) was significantly lower than that in group A (70.0%).

Conclusion

IOFBs were mainly caused by work-related injuries and might lead to serious visual impairment. The application and detectability of MRI in IOWFBs improved in recent years, and MRI presented better detectability than CT in diagnosing IOWFBs. Thus, MRI should be recommended despite negative CT findings.

Clinical spectrum and functional outcome of firearm pellet-related eye injuries: A prospective follow-up study

PURPOSE

To determine the prognostic significance of various clinical features and surgical techniques concerning anatomical and visual outcomes in shotgun pellet-inflicted ocular trauma.

METHODS

This prospective follow-up study was done at a tertiary care institute in Kashmir, India. Six hundred sixty-four eyes of 643 patients with firearm pellet-related ocular trauma were followed up for 6 months.

RESULTS

Ocular injury involved one eye in 622 (96.7%) patients and both eyes in 21 (3.3%) patients. Open globe injury (OGI) occurred in 451 (67.9%) eyes with perforating injury being the commonest type (248 eyes, 54.9%). For perforating injuries, entry wounds in the cornea and limbus had the worst prognosis. Closed globe injury (CGI) occurred in 213 (32.1%) eyes. An anatomical success rate of 66.3% (n = 250) was achieved for 56.8% (377/664) eyes requiring an average of 2.8 (SD 0.5) surgeries per eye. OGI was associated with poor outcomes in 259 (57.4%) and CGI with good outcomes in 200 (93.9%) eyes. The visual outcome had a significant association with grade and zone of injury both in OGI and CGI, and with the type of injury in OGI (p < .0001 each). Ocular trauma score (OTS) had a significant association with the degree of vision impairment (p < .0001). WHO category 0 visual impairment was seen in 270 (40.7%) eyes, category 1 in 85 (12.8%), category 2 in 35 (5.3%), category 3 in 30 (4.5%), category 4 in 172 (25.9%), and category 5 in 72 (10.8%) eyes irrespective of type of injury at 6 months post-treatment.

CONCLUSIONS

The perforating injury was the commonest type of injury caused by shotgun pellets. The site of the entry wound in perforating injury had prognostic significance. The outcome was generally poor in OGI and good in CGI.

Eye Injuries Caused by Wooden Projectiles in Finland

INTRODUCTION

Eye injuries can cause decreased vision or even blindness, and predispose to future complications. Wood as an independent cause of eye injuries has infrequently been the focus of the studies. The aim of this study is to report the current population-based epidemiology, treatment, use of resources and outcomes of eye injuries caused by sticks, branches, and other wooden projectiles in Finland.

METHODS

The study included all patients injured by wooden projectiles with ocular or orbital traumas over a 1-y period. Patients were treated at the Helsinki University eye hospital, which covers a population of 1.5 million. The follow-up time was 3 mo.

RESULTS

Wooden projectiles caused 67 eye injuries and compromised 6% of all eye traumas during 1 y. Of the patients, males predominated (76%) and 22% were children under 17 y. Injury was most likely in spring (36%) and in males aged 51 to 67 y. The most common activity to cause injury was playing (27%), but in relation to time spent in each activity, the highest risk for eye injury was in gardening. Diagnoses were mild superficial trauma (54%), blunt ocular trauma (37%), eyelid wound (4%), orbital fracture (3%), and open globe trauma (1%). Permanent disability was estimated for 10% and a need for lifelong follow-up was estimated for 37%. Eleven patients needed major surgeries.

CONCLUSIONS

Wooden projectiles often cause serious eye injuries, permanent disability, and a need for lifelong follow-up. Caution is required to protect the eyes when playing with sticks and during gardening, forest work, and woodwork.

Personalized multidisciplinary approach of orbital apex foreign body: A case report and literature review

Foreign bodies in the intraconal space are unusual, and lodgment at the orbital apex was even more unusual. High-velocity object injuries, such as gunshots or industrial accidents, are the common causes of intraorbital foreign bodies. It is difficult for surgeons to retrieve foreign bodies from the orbital apex as it is a deep, narrow space with critical surrounding structures. The use of an image-guided navigation system improves the accuracy of transnasal endoscopic surgery and causes less damage. We present a case in which a bullet became lodged in the orbital apex and was successfully removed using transnasal endoscopic surgery with the collaboration of otolaryngologists and ophthalmologists. To summarize, orbital apex foreign bodies are harmful, and prompt removal with a personalized multidisciplinary approach is critical.

Concurrent impalement of two orbits in a child: A case report

Introduction

Orbital impalement is a serious and potentially life-threatening trauma if the brain or vessels at the base of the skull are affected. The authors report the results and aftermath of the management of a case of post-traumatic retention of an intra-orbital metallic foreign body.

Case presentation

A 5-year-old boy was struck by a motorcycle while crossing a road. His head struck the handlebars of the motorcycle with a left facial-orbital impact point. The examination revealed a foreign body penetrating the orbit at the level of the left upper eyelid with limitation of adduction. The radiological assessment confirmed the intra-orbital presence of the foreign body with probable fracture of the inner wall of the eyeball. Surgical exploration through the palpebral wound revealed an intact eyeball and an incarceration of the medial rectus muscle by a fracture of the internal wall. After delicate and meticulous removal of the foreign body, hemostasis was ensured and the wound was sutured. The evolution was satisfactory, without sequelae or visual prejudice.

Discussion

Imaging, i.e. a CT scan and a standard X-ray, is necessary to evaluate the lesions before adapting a therapeutic attitude. The choice of the approach for extraction must meet two cardinal concerns: extraction of the foreign body and minimal dissection or manipulation of the noble structures of the eye and its adnexa.

Conclusion

Intra-orbital foreign bodies are rare but potentially serious. The type of the foreign substance, its intra-orbital extension and related lesions, as well as the extraction process, all influence the prognosis.

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Orbital impalements are rare but potentially serious.

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It is exceptional to find impalement concerning the 2 orbits without ocular damage.

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It requires careful management to avoid damage to the noble structures and frequent postoperative complications.

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The type of the foreign substance, its intra-orbital extension, and related lesions, as well as the extraction process, all influence the prognosis.

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There is a need for an alternative means of exploration that can replace MRI to evaluate soft tissue lesions.

[Orbital Trauma]

Orbital trauma is a common medical emergency with potentially sight-threatening complications. Due to the confined orbital conditions, any direct injury or space-consuming lesion may cause serious tissue damage. Possible complications are orbital fractures, foreign body injuries, development of orbital compartment syndrome and traumatic optic neuropathy. Clinical signs include periorbital hematoma or emphysema, subconjunctival hemorrhage, proptosis, decreased ocular mobility, decreased vision, increased intraocular pressure and relative afferent pupillary defect. Ophthalmic status and low-dose CT-imaging provide key information regarding the therapeutic decision. Treatment options include surgical exploration, reconstruction or decompression or a conservative approach with anti-inflammatory or anti-glaucomatous medication. Rapid interdisciplinary diagnostics and therapy is critical for early detection and prevention of irreversible functional loss respectively. Considering the frequent association with life-threatening comorbidities diagnosis may be complicated.

Trauma der Orbita

Die Behandlung orbitaler Verletzungen gehört zum Alltag der medizinischen Akutversorgung. Bei 10 – 25% aller Gesichtsverletzungen ist die Orbita beteiligt. Dieser Beitrag gibt einen Überblick über die möglichen Pathologien nach Orbitatrauma sowie das primärdiagnostische Vorgehen und die therapeutischen Optionen.

The Lucky Ones: A Report of Two Cases of Intraorbital Foreign Bodies

Intraorbital foreign bodies are a common complication of eye trauma. If improperly managed, it may lead to severe complications. In this case series, the first case is an intraconal foreign body after being hit by a stone, and the second case is an intraconal foreign body from a metallic piece of a crane wheel. We discuss the role of imaging in confirming the presence of the foreign body, localizing it, and guiding when surgery is indicated. Our two cases showed differences in the management approach, as the first case had multiple issues requiring multiple procedures. However, the second case had a relatively specific pathology, management, and outcome. With adequate treatment and a bit of luck, the visual outcome can be satisfactory.

An Eye Capturing Clutch - An Orbital Foreign Body

Foreign bodies inside the orbital cavity are rare. They may lead to serious complications, depending on their nature, size and mechanism of injury. A 29-year-old male presented with a motorcycle handle embedded in his left orbit, with the vision unaffected. Active wound bleeding, increasing hematoma, a low haemoglobin level, signs of hypovolemic shock, ocular acuity and mobility were investigated. A computed tomography scan revealed a long bent metallic object lodged between the globe and floor of the left orbit with fracture of the medial orbital wall and ethmoidal hemosinus with an intact cribriform plate of the ethmoid. An interdepartmental collaborative effort of Oculoplasty, Oro-Maxillofacial and Neurosurgery were utilized in the removal of the foreign body. The patient recovered well after the surgery and a course of antibiotic therapy.

A single large round-tipped foreign body in orbit composed of both metal and plastic is an extremely rare incident and fortunately in our case, was relatively harmless despite its large size. The diagnosis and management of intraorbital foreign bodies must be tailored according to their type and a proper localisation by all possible means, blunt dissection, careful haemostasis aided with good lighting, and exposure helps in their atraumatic removal.

Perforating ocular trauma due to shotgun pellet - Clinical profile and visual outcome

Purpose:

The aim of this study was to determine visual and anatomical outcome of perforating injuries due to shotgun pellet.

Methods:

This was a prospective observational study carried out between July 2016 and Jan 2019 at a tertiary care referral center in Srinagar, Jammu and Kashmir. A total of 172 eyes with perforating injuries of 170 patients were included in the study and were followed up for 6 months with best-corrected visual acuity, slit-lamp examination for status of anterior chamber and lens, fundus examination for status of retina and media, intraocular pressure measurements, and OCT (optical coherence tomography) and FFA (fundus fluoresceine angiography) in selected cases. The relative improvement of visual acuity after treatment was interpreted by applying paired two-tailed t tests. Prognostic significance of other variables was calculated using Chi-square and Chi-square for linear trend tests, for two dependent outcome variables of good outcome and poor outcome.

Results:

WHO category 4 visual impairment was found in 66 (38.4%) eyes, whereas category 0 was found in 24 (14%) of eyes. Retina was found to be attached 99 (57.6%) of study eyes.

Conclusion:

Perforating injury is a severe form of ocular trauma with grave consequences in terms of functional and anatomical outcome.

Clinical characteristics and prognostic factors for visual outcome in 669 patients with intraocular foreign bodies

AIM

To describe the clinical characteristics and analyze prognostic factors that influence visual outcome in 669 patients with intraocular foreign bodies (IOFBs).

METHODS

Medical records of 669 patients with IOFBs from West China Hospital were reviewed. Best corrected visual acuity (BCVA) values were recorded using standard Snellen acuity chart and were converted to logarithm of the minimum angle of resolution (logMAR) scale for statistical analysis. The visual outcome was defined by the final BCVA (excellent visual outcome: final BCVA of 20/40 or better; poor visual outcome: final BCVA less than 20/200). Statistical analysis of collected data was performed using IBM SPSS Statistics version 23. A 2-tailed P value of less than 0.05 was considered statistically significant throughout the study.

RESULTS

The average age ranged from 1 to 79 years old (mean age, 34.8±12.7 SD) and the majority of patients were men (626, 93.6%). The major cause of ocular injury was hammering (383, 57.2%). Almost all the patients (97.8%) underwent surgeries (97.8%) and the average time interval between injury and surgery was 26.4±322.3d (0-7300), while 327 patients received surgeries within 24h (48.9%) and 590 patients received surgeries within seven days (88.2%) after IOFBs injury. The poor BCVA was associated with older age (P=0.013), larger IOFBs size (P<0.001), presence of complications (P<0.001) and worse presenting BCVA (P<0.001). On the contrary, younger age (P=0.005), smaller IOFBs size (P<0.001), absence of complications (P<0.001) and better presenting BCVA (P<0.001) were considered to relate to excellent BCVA.

CONCLUSION

Multiple prognostic factors may influence the final visual outcome, including age, size of IOFBs, complications and presenting BCVA. Meanwhile, further education and promotion on eye protection should be taken for the improvement on self-protection and self-health awareness.

[Orbital firearm injuries]

BACKGROUND

Injuries caused by firearms are fortunately rare in the field of ophthalmology. The treatment of an affected patient is a special challenge both ophthalmologically and emotionally.

METHODS

We report on seven consecutive cases of patients with an orbital gunshot injury who presented in a university hospital over a period of 11 years. The course of events leading to the injury with the weapon involved, the type of projectile, the injury pattern, cranial imaging, treatment and course were evaluated.

RESULTS

A total of seven cases of injuries caused by firearms could be documented and evaluated in the period 2007-2018. All seven patients were male. The average age was 44 ± 27.5 years. Of the injuries five were caused by a suicide attempt and two by an accident. Firearms were used except for one injury caused by a crossbow. There was a retained projectile in four of the cases, the bullet went through the body in two cases and one of the cases presented with a ricochet shot. The final visual acuity was unilateral amaurosis in 1 case and bilateral amaurosis in another case, 1/35 (measured at 1 m) in 1 case, while it varied between 0.2 and 0.7 in the other 4 cases. No patient died as a direct consequence of the firearm injury.

CONCLUSION

Injuries caused by firearms are relatively rare in Germany and mostly have a suicidal background. The pattern of the injury of the ocular structures is very variable. A reconstruction attempt is principally recommended. In the care of patients interdisciplinary cooperation between ophthalmologists and neurosurgeons, orofacial surgeons, ear nose and throat (ENT) surgeons and psychiatrists is necessary.

Intraocular Foreign Body: Diagnostic Protocols and Treatment Strategies in Ocular Trauma Patients

Intraocular foreign bodies (IOFBs) are critical ophthalmic emergencies that require urgent diagnosis and treatment to prevent blindness or globe loss. This study aimed to examine the various clinical presentations of IOFBs, determine the prognostic factors for final visual outcomes, establish diagnostic protocols, and update treatment strategies for patients with IOFBs. We retrospectively reviewed patients with IOFBs between 2005 and 2019. The mean age of the patients was 46.7 years, and the most common mechanism of injury was hammering (32.7%). The most common location of IOFBs was the retina and choroid (57.7%), and the IOFBs were mainly metal (76.9%). Multivariate regression analysis showed that poor final visual outcomes (<20/200) were associated with posterior segment IOFBs (odds ratio (OR) = 11.556, p = 0.033) and retinal detachment (OR = 4.781, p = 0.034). Diagnosing a retained IOFB is essential for establishing the management of patients with ocular trauma. To identify IOFBs, ocular imaging modalities, including computed tomography or ultrasonography, should be considered. Different strategies should be employed during the surgical removal of IOFBs depending on the material, location, and size of the IOFB.

Clinical Presentation and Management Strategies in Intraorbital Foreign Bodies

The authors present a retrospective, observational case study of seven patients, who presented with retained Intra-Orbital Foreign Bodies (IOrbFBs) following penetrating orbital injury at a tertiary eye hospital over a period of one year. Cases were reviewed for epidemiological features, mechanism of injury, nature of foreign body, clinical features, imaging modality, associated complications, management outcomes, and the final prognosis. The mean age of presentation was 27.43 years. Amongst the seven patients, two were children (aged <10 years). The male : female ratio was 4 : 3. Of the seven retained IOrbFBs, two were plastic, two wooden, and three metallic in nature (one gunshot injury, one ball projectile (commonly referred to as BB) injury, and one with knife). Two out of seven had no light perception at presentation. The periocular location of the foreign bodies was inferior in 4 cases and medial in 3 cases. Computed Tomography scan confirmed the diagnosis in five cases and Magnetic Resonance Imaging (MRI) was diagnostic in one. Surgical intervention was done in five cases, and two cases were managed conservatively. The authors conclude that favourable outcome can be achieved even without surgical removal in cases of inert metallic/inorganic IOrbFBs. The properties of plastic FBs can frequently render them invisible on imaging, or they may mimic chronic inflammatory conditions like tuberculosis. Long-standing wooden IOrbFBs evade identification radiologically due to prolonged hydration. The ultimate choice of intervention must be individualised, weighing the risks of retention against the risk of iatrogenic damage.

Orbital tumour or a retained foreign body? An uncommon case of missed diagnosis

We report a case who presented with decreased vision, significant hypotropia, proptosis and gross limitation of extraocular motility for one year. Suspecting an orbital tumour, we asked for a computed tomography of the orbit which revealed a mass lesion in the inferior orbit. However, incisional biopsy reported inflammatory infiltration. Diagnosing it as orbital inflammatory disease, a course of oral steroids was given for four weeks. It was only after the reduction in inflammation that a foreign body was palpable in the inferior fornix. Surgical exploration revealed a large wooden foreign body measuring 3.3 × 1 × 0.3 cm. Though intraorbital foreign bodies are not rare, ambiguous history, delayed presentation and nonspecific CT findings made this case diagnostically challenging.

Delayed orbital fibrosing inflammation from a retained crayon

A 39-year-old woman presented with sudden onset of double vision, right upper eyelid swelling and ptosis, and orbital pain. Imaging revealed an irregular mass of the upper right orbit with central non-enhancing areas. Upon inquiry, the patient recalled an intraorbital trauma with a crayon in her childhood, 35 years ago. Via translid anterior orbitotomy, remnants of a blue crayon embedded in an orbital fat mass were removed. Histopathology showed scavenger reaction of macrophages and sclerosis. Energy-dispersive X-ray spectroscopy revealed the presence of silicate particles. Repeated courses of corticosteroids were given. The patient deteriorated with reduced vision and frozen globe owing to severe orbital fibrosis of the entire orbit.

Eyelid and orbital trauma for the primary care physician

Patients who experience trauma to the eyelid or the orbit may present to their primary care providers or directly to the emergency room for evaluation of their injuries. These patients will often be in pain and may have bleeding around the eye, which can make evaluation of these patients difficult. Many traumatic injuries to the eye require quick and immediate intervention. In this article, we will review the background, anatomy, exam and management of some of the most common eye traumas including eyelid lacerations, orbital hemorrhages, intraorbital foreign bodies, and orbital fractures.

Unusual Missed Diagnosis of Foreign Body: A Case Report

Background

Penetrating intraorbital foreign body (IOFB) is usually associated with high-velocity trauma forces around the eye. IOFB injury to globe or optic nerve is considered a surgical emergency; an immediate diagnosis and management plan is generally indicated.

Methods

A case report (design). The patient was a 78-year-old male presented with diminution of vision of the right eye following a high-velocity injury. The patient was noted to have a closed globe injury with associated retinal detachment and vitreous hemorrhage. An initial orbital CT scan did not reveal any IOFB, despite and intact globe. However, repeat a CT head and orbit scan revealed an intracranial magnetic foreign body lodged in the right frontal lobe.

Conclusion

A CT scan of the brain and paranasal sinuses should be obtained along with a CT orbit in case of high-velocity orbital/ocular trauma.

Self-sealing posterior scleral perforation in airgun ocular trauma, surgical tip: a case report

Background

Intraorbital metallic foreign bodies have varied clinical presentations. Here, we report the unusual case of intraoperative evidence of spontaneously healed posterior scleral perforation in a severe ballistic trauma without previous instrumental signs of penetrating wound and complete visual restoration after surgery.

Case presentation

The patient was hit by several lead hunting pellets in the chest, abdomen, limbs, face and orbit. Computed Tomography (CT) images revealed the presence of a pellet within the orbitary cavity, close to the optic nerve, with no signs of penetrating ocular wound. While performing vitrectomy for severe vitreous hemorrhage, a point of strong adherence between a old hemorrhage and retinal surface was identified and managed conservatively, as it was attributed to trauma related-impact area. So, lead foreign body took an unusual trajectory impacting the globe and finally lodging back in the deep orbitary cavity, in absence of significant ocular injury and with visual prognosis preservation.

Conclusions

Our findings provide further information on orbital injuries from airguns, a theme of growing popularity and concern. Intraoperative recognition of hardly removable old hemorrhagic clot as self-blockage site of posterior scleral penetrating trauma, allowed for surgical stabilization and minimal solicitation of the area to avoid inadvertent perforation.

Management of Intra-orbital Wooden Foreign Bodies at a Resource-limited Setting in Sub-Saharan Africa

INTRODUCTION

Wooden intra-orbital foreign bodies (IOrbFBs) have a high risk of microbial contamination needing timely diagnosis and treatment. We describe management of three cases of wooden IOrbFB at a resource-limited setting in Liberia.

MATERIALS AND METHODS

This is a retrospective case series of three patients with IOrbFB managed at the Liberia Eye Center, Monrovia, Liberia. Demographic details, mode of injury, ocular examination findings, neuroimaging, surgical treatment, and clinical findings on post-operative follow-up visits were noted for each patient.

RESULTS

All the three patients were young, male, and were involved in traumatic incidents (fall in two cases and road traffic accident in one case). Two patients with visible wooden FB presented within 48 h of injury and one patient with occult FB presented after 2 weeks. All patients underwent orbital imaging followed by surgical exploration for the removal of FB. One patient also had coexisting orbital cellulitis, which was successfully treated medically. One of these patients had best corrected visual acuity of 20/20, and the other two had no perception of light in the affected eyes.

CONCLUSION

History of injury with a wooden material should raise a high index of suspicion for an occult IOrbFB. Timely diagnosis and treatment of wooden IOrbFB can be challenging in a resource-limited setting, but with a systematic approach they can be treated satisfactorily.

Removal of an Impaled Intraocular Hair Comb Following Self-inflicted Trauma

Ocular trauma is one of the most common and vision-threatening ophthalmic presentations with a wide spectrum of complications, such as bleeding, infection, vision loss, and enucleation. A 64-year-old-male presented to the emergency department (ED) with a self-inflicted orbital penetrating injury with a hair comb. Computed tomography showed the comb traversed the medial orbit inferior to the medial rectus but did not damage the optic nerve; there were no globe or orbital wall fractures. His ocular exam was significant for a right eye afferent pupillary defect and decreased visual acuity 20/800, consistent with optic neuropathy. Primary concerns were stabilizing and removing the foreign body without causing further damage in the setting of an uncooperative patient. The comb was removed with the aid of local and systemic analgesia using gentle traction and normal saline irrigation. The patient was admitted for systemic and topical antibiotics and showed improvement in visual acuity and resolution of his optic neuropathy. This case illustrates the importance of rapid ED assessment and management of complex penetrating ocular trauma. Examination should specifically look for signs of globe rupture and optic nerve injury. Expedited foreign body removal should be managed together with an ophthalmologist with procedural sedation and broad-spectrum antibiotics to avoid further visual and infectious complications.

Management of an Unusual Orbitocranial Penetrating Injury

Background

An intraorbital injury with a blunt penetrating intraorbital foreign body (IOFB) is an unusual cause of penetrating trauma. This type of trauma is considered a surgical emergency given the risk to vision in addition to potential intracranial injuries such as vascular injury, dural laceration, and neurologic injury. A thorough history and physical exam, along with careful radiographic and multidiscipline intervention, is crucial in providing the patient the most appropriate care. Case Presentation. A 66-year-old male presented to the emergency room (ER) after falling down the stairs and suffering an orbitocranial penetrating injury. He underwent urgent fluoroscopy-guided foreign body removal with a multidisciplinary team after a workup revealed no significant ocular or intracranial injuries. The foreign body was removed with an anterior approach without any complications.

Conclusion

In this study, we demonstrated that IOFB in proximity to orbitocranial structures requires a careful multidisciplinary team approach. An interventional radiology- (IR-) guided approach in extracting the foreign body is essential to prevent further injury. A high dose of intravenous steroid was not used due to initial suspicion of intracranial involvement. Prompt removal decreased risk of further vision loss.

Classification of orbitocranial wooden foreign body penetration injuries: what to do when they violate the intracranial space? A systematic review

INTRODUCTION

Orbitocranial wooden foreign body (OWF) penetrations are rare but challenging occurrences that may violate the intracranial space resulting in brain damage and hemorrhagic, as well as infectious, complications. Moreover, there is a specific subset of cases of OWF penetrations that are particularly challenging to treat. Although there are well-defined management guidelines for pure intraorbital localization, there is not yet a defined treatment protocol for foreign bodies reaching the intracranial space. However, their removal performed either directly or through craniotomy, is often easily attainable given the condition that all necessary precautions are accounted for.

EVIDENCE ACQUISITION

After having treated a 48-year-old man with a transorbital OWF penetration injury at our neurosurgical department, we systematically reviewed the last 15 years of literature to define and summarize the best management strategy. Multiple databases were searched for case reports and case series involving patients with intraorbital and transorbital OWF penetration injuries. For each study, we extracted data on age, sex, imaging modality, type of wood (processed vs. unprocessed), location of periorbital and intracranial entry site, treatment type ("pull and see" or "open and see"), antibiotic therapy, and complications.

EVIDENCE SYNTHESIS

We classified transorbital OWFs into two categories: transorbital with only cavernous sinus involvement and transorbital with more extensive intracranial involvement. We described what we believed was the most appropriate management conduct in each case.

CONCLUSIONS

Grounded on our experience and on the review of the literature, we suggest, based on the anatomical localization of the OWF, a classification system for OWFs which is coupled with a tailored treatment strategy for each case. These suggestions are made to provide surgeons with direction on the correct management of such rare but challenging occurrences.

Long-term ophthalmic anatomical and functional outcomes after surgical removal of intraorbital foreign bodies

PURPOSE

To analyze the anatomical and functional ophthalmic parameters after the surgical removal of various intraorbital foreign bodies.

METHODS

A retrospective analysis of medical records was performed featuring detailed history, ophthalmic examination, orbital computed tomographic scans, treatment details, and outcomes. The analyzed anatomical factors included extraocular movements, the position of the eyeball (proptosis, dystopia, and enophthalmos), and fullness of orbital sulci. The functional assessment was based on visual acuity, pupillary reactions, and diplopia. The outcomes were defined as complete, partial, and failure after a minimum follow-up of 1 year.

RESULTS

Of 32 patients, the organic and inorganic intraorbital foreign bodies were surgically removed from 18 (56.25%) and 14 (43.75%) orbits, respectively. At presentation, anatomically the extraocular movement restriction, proptosis/dystopia/enophthalmos, and orbital sulcus fullness were noted in 26 (81.25%), 24 (75%), and 15 (46.88%), respectively. Functionally, diminished visual acuity, diplopia, and pupil abnormalities were seen in 27 (84.38%), 14 (43.75%), and 8 (25%), respectively. After intraorbital foreign body removal at a mean follow-up of 14 months, the improvement of anatomical factors (same sequence) were observed in 8 (30.77%), 20 (83.33%), and 12 (80%), respectively. In functional factors (same sequence), the improvement was noted in none (0%), 13 (92.86%), and 5 (62.5%), respectively. Hence, the majority of patients (n = 20, 62.5%) achieved partial success, while 8 (25%) had complete success. Four (12.5%) had treatment failure despite similar management protocols.

CONCLUSION

The anatomical outcomes are better than the functional outcomes after surgical removal of the intraorbital foreign bodies. The visual acuity does not improve considerably after the surgical removal of intraorbital foreign bodies. Overall, the wooden intraorbital foreign bodies have poorer anatomical and functional prognosis.

Multimodal imaging features of intraocular foreign bodies

Objective: To determine the imaging approach for evaluating intraocular foreign bodies (IOFBs) by comparing the ability of different modalities [plain film x-ray, computed tomography (CT), magnetic resonsance imaging (MRI), convetional ultrasound, and ultrasound biomicroscopy] to detect and characterize IOFBs.Methods & Design: Systematic review of the literature.Results: CT is the most practical first step for evaluating patients with suspected IOFBs because it can detect a wide range of IOFB types at small limitis of detection. MRI and ultrasound are best reserved as adjunctive tests in most cases although these tests may provide important insights especially with wood, plastic, and glass IOFBs. Imaging characteristics of metal, wood, glass, plastic, stone, concrete, and graphite IOFBs are reviewed.Conclusion: Understanding the limits of detection for each IOFB type and imaging modality as well as the characteristic features of different IOFBs is of paramount importance to optimizing the management of ocular trauma patients.

Extraction of an intraorbital foreign body with the help of an ocular external electromagnet: Instruments of the past still have a place in the present

Intraorbital Foreign Bodies (IOFB) are objects, usually of metallic nature, located outside the orbit cavity, and can potentially cause serious damage to ocular and orbital structures. The case is presented of a patient with an anterior metallic IOFB that was extracted with the aid of a Livingston-Mansfield ocular external electromagnet. Despite being an instrument «of the past», we believe that the electromagnet can still be useful in certain circumstances.

Visual and Anatomic Outcomes in Perforating Ocular Injuries

Purpose

This article reports the presentation, management, and outcomes in patients suffering perforating ocular injuries.

Methods

A retrospective review was conducted at a single ophthalmology Level 1 trauma center. Patients with evidence of traumatic ocular perforation, with surgical intervention attended by a single vitreoretinal surgeon (W.F.M.), were reviewed between 2009 and 2017.

Results

Six eyes from 6 patients with perforating ocular injuries were studied. All patients were male, between ages 11 and 56 years. Perforation was the result of gunshots (3), other accidental injury (2), or surgical complication (1). Varying degrees of retinal detachments were seen in all 6 patients. Pars plana vitrectomy, with endolaser around posterior entry or exit wounds, was performed on average 21.7 ± 8.9 days from the time of injury (range, 0-58 days). In all cases with intraorbital foreign bodies, the foreign bodies were left in place. The most recent postoperative visual acuity ranged from 20/25 to counting fingers. Missile injuries tended to have poorer vision. All cases achieved full anatomic attachment at most recent follow-up. There have been no orbital complications related to retained intraorbital foreign bodies, including endophthalmitis, orbital infections, or mechanical strabismus.

Conclusion

This study demonstrates successful anatomic outcomes of 6 cases of perforating ocular injuries. Visual outcomes were variable, though missile injuries demonstrated worse prognosis, whereas several nonmissile macula-involving cases achieved quite favorable results. Although traumatic perforating injuries generally have guarded visual prognoses, favorable results may be achieved in select scenarios.

An unusual case of intra orbital foreign body; diagnosis, management, and outcome: a case report

Background

An orbitocranial injury with a penetrating Intraorbital Foreign Body (IOFB) is listed as a rare cause of penetrating trauma. Since this type of trauma is considered a surgical emergency, taking a thorough history along with careful examination to find out the mechanism and cause of the trauma is crucial towards correct diagnosis and management of the disease.

Case presentation

A 35-year-old male patient was presented to the ER with an occupational craniofacial injury because of an IOFB. The patient underwent an extra-dural orbitocranial craniotomy procedure to remove the foreign body. Interestingly, a plastic foreign body (a piece of a plastic pipe) was removed from the orbital cavity, which was suspected to be a fractured orbital bone, at first place.

Conclusion

In this study, we demonstrated that plastics could mimic bone structure in a Computerized Tomography (CT) scan leading to possible initial misdiagnosis. Hence high clinical suspicion is necessary for the correct diagnosis of such cases. However, despite the prompt intervention, our patient ended up with permanent vision loss in his injured eye.

Gun-related eye injuries: A primer

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.