Penetrating Orbital Injuries: A Review

Transorbital penetrating intracranial injury involving bilateral frontal lobes with evisceration of right eye: A case report

Key Clinical Message

Timely diagnosis, multidisciplinary surgical intervention, and appropriate imaging are crucial in managing transorbital-penetrating intracranial injuries (TOPIs), minimizing morbidity, and optimizing patient outcomes.

Abstract

Transorbital-penetrating intracranial injuries (TOPIs) are rare occurrences with potential for severe neurological complications and high mortality rates. Prompt diagnosis and management are essential to mitigate adverse outcomes. Understanding injury patterns and employing appropriate imaging modalities are crucial for effective surgical planning and patient care. We present a case of a 22-year-old male mechanic who sustained a TOPI involving bilateral frontal lobes with evisceration of the right eye following a workplace accident with a metal cutter. Upon arrival at the emergency department, the patient exhibited vision loss in the right eye, proptosis, and a dilated pupil. Imaging studies revealed the trajectory of a metal arrow through the right orbital roof, necessitating surgical intervention. A multidisciplinary team performed bifrontal craniectomy with duroplasty to remove the foreign body and address associated injuries. Postoperatively, the patient received broad-spectrum antibiotics and anticonvulsants, leading to full recovery and discharge on postoperative day 10. TOPIs present unique challenges due to their rarity and potential for devastating consequences. Our case highlights the importance of timely diagnosis, meticulous surgical planning, and multidisciplinary collaboration in achieving favorable outcomes. Radiological imaging plays a crucial role in guiding treatment decisions and optimizing patient care. This report underscores the significance of early surgical intervention, antimicrobial therapy, and prophylactic measures in reducing morbidity and mortality associated with TOPIs.

[Diagnostics and treatment of organic intraorbital foreign bodies]

BACKGROUND

Orbital injuries with organic foreign bodies are a clinical challenge as they can cause a variety of complications and sometimes lead to irreversible visual impairment.

MATERIAL AND METHODS

We report five consecutive cases of patients with organic orbital foreign bodies who presented between 2012 and 2022. Documented parameters include age, gender, time of injury, mechanism of injury, best-corrected visual acuity (BCVA), presence of pain, restriction of motility, performed imaging, location and type of foreign body, treatment and complications.

RESULTS

The mean patient age was 61.8 ± 32.3 years and the gender ratio was 4:1 (female:male). In 4 cases the injury had been reported on average 4.6 days (0/14 days min/max) previously. Best corrected visual acuity at first presentation was 0.5 ± 0.2 decimal and after a mean follow-up of 12.7 months (0.5/38 months min/max) at last presentation 0.67 ± 0.3 decimal (p = 0.2). The reason for initial presentation was pain (n = 3) and/or double vision (n = 2). All patients underwent computer tomography (CT). The diagnosis was confirmed in two cases by means of CT. In all five cases the foreign body material could be completely surgically removed, while one patient needed repeated surgery due to retained foreign body material. The organic foreign body material included wood (4) and wax (1). In two cases, a foreign body-induced infection was successfully treated with systemic antibiotics. There were no other complications.

CONCLUSION

In orbital trauma a thorough wound exploration must be performed, especially if the mechanism of injury is uncertain and residual foreign bodies or a perforation injury cannot be excluded. The imaging of choice is CT, which may have to be performed again in the postoperative course.

Presentation and Management of a Complex Orbital Apex Syndrome From Penetrating Mechanical Spring Hook: A Case Report

Our case report demonstrates the management of a unique penetrating orbital injury. The intraorbital foreign body was an approximately 22 cm long metal dishwasher spring hook lodged into the left orbital apex. An ophthalmological check-up a couple of weeks following the removal surgery discerned the patient had an unprecedented case of orbital apex syndrome. We present this unique case so physicians, medical students, and other emergency and medical professionals can learn about the diagnostic, surgical, and multidisciplinary management necessary to achieve a favorable clinical outcome.

Endoscopy-assisted extraction of orbital and nasal foreign body

Penetrating orbital injury with a foreign body is a complex problem that requires an interdisciplinary therapeutic approach. Conventionally, an external approach using either transconjuntival or transseptal entry is used by an ophthalmologist. However, there is a risk of damage to the optic nerve and orbital tissue using only the traditional approach. This study concerns a 36-year-old male who has an intra-orbital foreign body (OrbFB). Timely three-dimensional reconstruction computed tomography scan demonstrated an 8-cm-long intra-OrbFB adjacent to the optic nerve penetrating to the contralateral nasal cavity. Endoscopic inspection confirmed a chopstick fragment. Assisted by transnasal endoscopy, the chopstick penetrating from the orbit to the nasal cavity was smoothly removed. Nasal endoscopy is useful for an ophthalmologist in removing foreign body in the orbit.

Transorbital-penetrating intracranial injury due to a homemade metal arrow: A case report

A transorbital-penetrating intracranial injury (TOPI) is an unusual traumatic brain injury. This rare injury has the potential to result in serious and fatal brain damage with a high mortality rate and requires prompt multidisciplinary surgical intervention. Here, we describe an interesting case in which a patient who presented with accidental penetrating injuries of the brain was found to have a transorbital-penetrating intracranial injury (TOPI). We chose an anterior approach to the foreign body above the entrance wound for removal in a retrograde manner with fluoroscopic guidance. The patient remained well with no complications and was discharged on postoperative day 10. Reasonable diagnostic imaging, surgical planning, and careful post-surgery management can increase patients successful outcomes.

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A transorbital-penetrating intracranial injury (TOPI) is an uncommon traumatic brain injury.

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TOPIs have the potential to result in serious brain damage with a high mortality rate.

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An interesting case of accidental TOPI that was treated successfully with fluoroscopic guidance is presented.