Retained intraorbital metallic foreign bodies

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.

Recurrent Periorbital Edema Associated With Retained Foreign Body After Filler Injection

A 34-year-old man presented with recurrent bilateral periorbital swelling and pain for 16 years after receiving facial fillers of an unknown substance in a hotel room from a stranger claiming to work in a medical office. Exam demonstrated a firm, mildly tender nodule along the right upper cheek. Imaging revealed a tubular hyperdensity in the right premaxillary soft tissues. Lower eyelid and upper cheek dissection resulted in retrieval of a tubular metallic foreign body consistent with a needle. Histopathology of surrounding tissue demonstrated iron deposition with granulomatous inflammation. Periocular fillers are a common aesthetic procedure. Although generally well-tolerated, complications include inflammatory reactions, infection, necrosis, and vision loss. This case highlights retention of a metallic foreign body, a complication of filler injection that has not been previously reported, emphasizing the importance of careful injection technique by licensed professionals and imaging and surgical exploration if a foreign body is suspected.

Severe Ocular Trauma and the Race Against Time in its Management: A Case Series

Ocular injury is one of the most important causes of vision loss. We present a case series of different ocular trauma cases with rare presentations which presented a great challenge to emergency management. The management of ocular injuries is a fight against time, with not only the vision but also at times present with the life of patients at risk. These thus require timely diagnosis. The first case involves a sharp penetrating injury with a metallic foreign body in the orbit. The second case is of a retained intraorbital foreign body secondary to a gunshot injury. The third case is of traumatic globe luxation secondary to a blunt injury. Lastly, the fourth case is of an animal bite with a lacerated wound. All the patients in the reported cases presented to the casualty of the Government Medical College, Haldwani. We believe this case series will add to the literature and help ophthalmologists gain experience dealing with such cases.

The Demographic and Social Characteristics of Patients with Ocular Foreign Bodies in a Greek Tertiary Hospital

Purpose

Patients and Methods

Results

Conclusion

Management of unusual missed diagnosis of a Intra-orbital wooden foreign body: A case report and review of literature

Introduction

Although intra-orbital foreign bodies (IOrFBs) are commonly seen in daily ophthalmology practice, rarely, they can have very unusual clinical presentations, especially nonmetallic FBs.

Presentation of case

A 33-year-old male presented with sudden onset right lower lid swelling and tearing. He was initially tolerating the symptoms, however, it got progressively worse, so he came two weeks after the initiation of symptoms. His eye vitals were within normal limit, including the visual acuity of 6/6 OU. Additionally, slit lamp and fundus examinations were benign. Concern was for infectious etiology with unclear source. After a lengthy conversation, he recalled falling on the ground with face down about 16 months ago. However, he stated that he had remained asymptomatic and never went for treatment after the incident. Non-contrast CT of head and orbit showed hyperdense tract in medial aspect of right eye adjacent to the globe, piercing across the bilateral ethmoidal sinuses. Thus, a diagnosis of retained IOrbFB was made. He underwent surgery where a 5cm rotten wood was extracted. Post-surgical course was uncomplicated. Not all penetrating intra-orbital foreign bodies present immediately after the incident. In our case the patient remained asymptomatic for 16 months.

Conclusion

Therefore, when dealing with an ocular infection of unclear source, clinicians should ask about distant histories of ocular or facial injuries to assess intraocular foreign bodies.

•

Recognizing retained orbital foreign bodies secondary to trauma can be a challenge.

•

Organic IOrbFB following a penetrating injury can remain asymptomatic for a significant period, resulting in delayed diagnosis and treatment.

•

When dealing with an ocular infection of unclear source, clinicians should ask about distant histories of ocular or facial injuries to assess intraocular foreign bodies.

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.

Jael's syndrome: Case report and literature review

Introduction and importance

Jael's syndrome, an intentional injury caused by a knife in the face or skull is a rare encounter in clinical and forensic practice, rarely involving an impacted knife. Clinical and radiographic diagnosis is essential to identify severity of injury and location of the retained knife. To the best of our knowledge, this is the first reported novel case of Jael's syndrome in Tanzania.

Case presentation

We present the case of a 31-year old man admitted at Muhimbili National Hospital following an impacted knife. The stab wound extended to the medial wall of left orbit and ended just before the optic foramen associated with vitreous hemorrhage and the retained knife caused superoposterior displacement of the globe. Multidisciplinary management was instituted including prompt evaluation, imaging and surgical removal of the knife under general anesthesia.

Clinical discussion

Plain skull X-ray revealed an extensive retained blade and computerized tomography (CT) showed the tip of the blade adjacent to the right styloid process with no neurovascular compromise. Initial concern was the left eye that was reported to be viable by ophthalmologists. Incredibly, the patient had no initial sequelae from such an extensive injury and had unremarkable recovery with no complications apart from the wound to left inferior rectus muscle that was conservatively managed. Simple withdrawal of the retained knife was successful.

Conclusion

Craniofacial retained knives are rare. Thorough prompt initial evaluation and intervention is vital since improper management can be devastating.

•

Impacted knife at the craniofacial region is a very rare encounter.

•

Clinical and radiographic diagnosis is essential to identify extent of damage to critical structures.

•

Complications such as diplopia, intracranial hemorrhage and acute cerebrospinal fluid leakage have been reported.

•

Multidisciplinary management has to be instituted when retained foreign bodies are encountered.

•

Simple surgical removal along the path of insertion of retained foreign body seems safe and effective.

[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.

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.

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.

Removal of intraconal bullet through endoscopic transnasal surgery with image-guided navigation system 8 months after injury: a case report

Background

Lodgment of a bullet within the orbit is uncommon. The decision to remove these objects poses a challenge to surgeons due to a high risk of complications. Currently, endoscopic transnasal surgery with navigator assistance facilitates the localization of foreign bodies allowing their safe removal with minimal surrounding tissue damage or optic nerve injury.

Case presentation

We describe a case of a 26-year-old Thai woman with a chronic intraorbital foreign body located within her medial intraconal space. The chronic intraorbital foreign body was successfully removed by endoscopic transnasal surgery, combined with assistance from a navigation system, 8 months after injury without any damage to her eye or disturbance in vision.

Conclusion

Intraconal foreign bodies, such as bullets, are a chronic problem and should be observed in the long term; prompt surgical removal should be performed if indicated.

Traumatic chorioretinitis sclopetaria: Risk factors, management, and prognosis

Purpose

To describe new cases of sclopetaria and evaluate the risk factors, management, and visual prognosis of all reported cases in the literature.

Observations

We performed a retrospective, observational case series. This study included six cases (median age 23, interquartile range 33) of sclopetaria. Additionally, literature searches were conducted in the PubMed and Cochrane Library databases to uncover risk factors associated with all published cases of sclopetaria. Main outcome measure was best corrected visual acuity (BCVA) worse than 20/20. Sixty-seven cases (71 eyes) of sclopetaria have been reported, of which 59 cases (61 eyes) met inclusion criteria in this study. Most were young (median age 19.5 years) men (51/59, 88.1%). Thirty-seven eyes were observed while 24 underwent immediate surgery including six pars plana vitrectomies and three scleral buckles. Compared to initial presentation, BCVA improved in 31/48 (64.6%) eyes, remained stable in 12/48 eyes (25.0%), and worsened in 5/48 eyes (10.4%). Ten patients (16.4%) achieved a final BCVA of 20/20 with median follow up time of seven months. In a multivariate model, location of sclopetaria in the macula, temporal retina, or immediate orbital foreign body removal predicted poor final BCVA with an area under receiver operating characteristic curve of 0.767.

Conclusions and importance

Traumatic chorioretinitis sclopetaria is rare, but reports have increased dramatically over the past two decades. While pars plana vitrectomy may be required for the management of retinal detachments and non-clearing vitreous hemorrhage, close observation is appropriate in most cases. Visual prognosis is poor with most patients attaining 20/200 vision or worse.

Quality of CT Imaging of Periocular Metallic Foreign Bodies Using Artifact Reduction Software

PURPOSE

CT is the standard of care for assessment of ocular and orbital trauma; however, artifacts from metallic foreign bodies can limit the utility of CT. The authors hypothesize that implementation of metal artifact reduction techniques can improve image quality and diagnostic confidence for a diverse group of interpreters.

METHODS

A case series of ten subjects with retained periocular metallic foreign bodies imaged with CT were identified retrospectively from a large urban trauma center. Postacquisition images were processed with an iterative-based metal streak artifact reduction software. The severity of the metal streak artifact was assessed by clinicians including radiologists (4), ophthalmologists (4), and oculoplastic specialists (3) using a numeric scale to grade images on seven clinically relevant criteria. Each image was also analyzed to measure the size of the artifact and degree of streaking.

RESULTS

Overall confidence in diagnosis and severity of metallic streak was improved with metallic artifact reduction (p < 0.001, Wilcoxon signed-rank test). Similarly, confidence in assessing specific features-including extra-ocular muscle, optic nerve, globe rupture, orbital fracture and identification of foreign bodies-was improved after metallic artifact reduction (p < 0.001, Wilcoxon signed-rank test). The standard deviation of pixel intensity for a path surrounding the foreign body as well as the area of the streak artifact decreased in the metallic artifact reduction-processed images (p < 0.001, paired t test).

CONCLUSIONS

Metal artifact reduction in CT has potential benefits in improving image quality and reader confidence for periocular trauma cases in real-world settings.

Self-insertion of foreign bodies into the orbit and periocular tissue

We describe six patients with 12 separate episodes of self-inflicted periocular foreign body injuries, which presented to our institution recently. All patients were male, relatively young (mean 28.5 years old), incarcerated, and had significant underlying psychiatric conditions. The subjects had inserted staples (6), paperclips (2), or other small metallic wire segments (4) into the periocular region. Most cases (9/12) involved concurrent self-inflicted injury to other body parts. Ten cases involved foreign bodies inserted through the palpebral conjunctiva into the upper eyelid, while two cases involved insertion into the orbit. Identification and surgical retrieval of foreign bodies was successful in most cases (9/11) but was not attempted in one case. Self-inflicted periocular injuries, while rare, are challenging cases for which the ophthalmologist should be prepared. A multidisciplinary approach, including psychiatric assessment and treatment, is important for optimal care.

Delayed diagnosis of an intraorbital wooden foreign body

A 35-year-old male patient was presented with pain on his right upper eyelid. A piece of wood injured his orbital and supraorbital regions while working at a furniture factory 10 days prior to our hospital admission. It was learned that the patient was discharged following the primary would closure procedure. Subsequent to the craniofacial computed tomography, primary wound closure was performed in the emergency room of previous hospital. In our clinic, a skin suturing on the nasal side of the right eyebrow was inspected and a foreign body (FB) was palpated on the superonasal contiguity of the patients' right globe. A hyperdense FB measuring 30 × 10 × 5 mm in size with smooth margins on superonasal contour of the globe was detected. Superonasal orbitotomy was performed and the FB was completely removed. Finally, visual acuity was 20/20 and a mild residual ptosis was observed.

Long-Term Retention of an Intraorbital Metallic Foreign Body Adjacent to the Optic Nerve

We report the case of an asymptomatic 47 year-old male patient who suffered a penetrating wound from a metallic foreign body that became embedded adjacent to the optic nerve for over thirty years, as well as the associated examination, imaging, and fundus photography. Intraorbital metallic foreign bodies can be well tolerated and may not require surgical intervention despite proximity to important structures.

Systemic Allergic Response in the Setting of a Metallic Intraorbital Foreign Body With Intraoperative Magnet-Assisted Retrieval

A 12-year-old boy with a past medical history of nickel allergy was referred to our service after sustaining an air rifle injury with a retained BB in his left inferior orbit. On examination, he had a palpable orbital mass and systemic urticaria. Plain films demonstrated a spherical metallic foreign body adjacent to the left inferior orbital rim. Given his worsening systemic reaction despite oral antihistamine therapy, decision was made to remove the foreign body. In the operating room, the Allergan Magna Finder-a prepackaged, sterile device normally used for retrieval of a port used in tissue expansion surgery-was placed over the inferior conjunctiva of the lower eyelid. With the magnet holding gentle anterior traction on the foreign body, it was easily dissected and removed. The patient tolerated the procedure well, and had rapid resolution of his systemic allergic response following removal of the BB.

An unusual case of protruding retro-orbital metallic foreign body

A 34-year-old female presented with firecracker injury with curved metallic foreign body embedded in the left orbit and protruding out through the upper eyelid. The report highlights notable aspects in diagnosis, decision-making, and successful removal of this unusual case of retro-orbital foreign body.

Traumatic Intraconal Foreign Body: Report of an Injury Corrected With Combined Surgical and Endoscopic Treatment

BACKGROUND

Management of penetrating ocular splinter injuries is very controversial. Penetrating wounds of the orbit represent a complex therapeutic problem that requires a multidisciplinary approach. Endoscopic approaches to the orbit are currently performed through the lamina papyracea to access the medial part, or through large orbitotomies to access the lateral part.

OBJECTIVE

To describe a novel combined approach to the lateral part of the orbit.

METHODS

Clinical and surgical findings of intraorbital foreign body removal are presented. A minimal supraorbital osteotomy was performed, combined with endoscopic intraorbital dissection.

RESULTS

The foreign body was removed, no postoperative complications were reported, and visual acuity increased from 2/10 preoperatively, to 8/10 one month after surgery.

CONCLUSION

The present technique can be considered a safe and novel surgical approach to access the retrobulbar space and to treat the pathology of this anatomic region.

[Management of suicidal orbital gunshot wounds to the temple]

BACKGROUND

Orbital gunshot wounds are rarely found after suicide. A gunshot fired at point blank range into the temple has devastating effects on all intraorbital and neighboring structures.

CASE REPORTS

This article reports on two cases of gunshot wounds to the lateral orbit in attempted suicides with different weapons from 2012 and 2013 and treated at the Ruhr University Eye Hospital in Bochum. In both cases treatment was carried out in cooperation with the department of oral and maxillofacial surgery, Ruhr University Hospital, Bochum. In the first case a 7.65 mm gun was used. The patient presented with a double penetration of both orbits with total destruction of both globes and a reconstruction was not possible. The second patient presented with multiple shots to the head from a small caliber gun (5.6 mm) where one bullet entered the right orbit behind the globe. The bullet could be localized using computed tomography (CT) and surgically removed with preservation of the globe and with a postoperative visual acuity of 20/60.

CONCLUSION

The preservation of visual function after orbital gunshot wounds depends on both the projectile channel and the characteristics of the gun and bullet. Close collaboration in surgical management between ophthalmologists, maxillofacial surgeons and neurosurgeons in specialized centers is necessary because patients often present with multiple trauma and prompt interdisciplinary treatment is needed.

The Spectrum of Pediatric Orbital BB Gun Injuries: A Case Series

Three cases of pediatric BB orbital injury are reported demonstrating varying outcomes. Pediatric orbital BB injuries have a wide spectrum of clinical outcomes depending on the ocular structures involved. Improved safety education of patients and parents is necessary to reduce the burden of these vision-threatening injuries.

Pediatric eye injuries due to nonpowder guns in the United States, 2002-2012

PURPOSE

To identify epidemiologic trends in nonpowder gun-related pediatric eye injuries and to determine factors associated with severe injury requiring hospital admission.

METHODS

US emergency department data on pediatric eye injuries between 2002 and 2012 were reviewed using the National Electronic Injury Surveillance System. Literature review was conducted to determine trends in visual outcomes after treatment and use of eye protection.

RESULTS

In 2012 roughly 3,161 children were treated in US emergency departments for nonpowder gun-related eye injuries. Since 2010 rates of severe nonpowder gun pediatric eye injury have increased by over 500% (P = 0.039). Specifically, while rates of hospital admission due to paintball gun eye injury have dropped precipitously (P = 0.0077), rates of admissions for air gun eye injuries have increased by over 600% since 2010 (P = 0.033). Children sustaining eye injury due to air guns are more likely to be diagnosed and admitted with foreign body or ocular puncture injury. Roughly 28% of documented cases of airsoft or BB gun-related injury had visual acuity worse than 20/50 after initial treatment. Over 98% of injuries occurred without eye protection.

CONCLUSIONS

Air guns are rising in popularity and now account for the majority of pediatric eye injuries requiring hospital admissions. These eye injuries occur without ocular protection and may lead to permanent eye injury. Increasing regulations for eye protection, sales, and usage of air guns are needed to prevent serious pediatric eye injuries.

Retinal detachment associated with traumatic chorioretinal rupture

Traumatic chorioretinal rupture, also known as sclopetaria, is a full-thickness break of the choroid and retina caused by a high-velocity projectile striking or passing adjacent to, but not penetrating, the globe. Previous reports have emphasized that retinal detachment seldom occurs, and observation alone has been the recommended management strategy. However, the authors present herein a series of consecutive patients with retinal detachment associated with sclopetaria and provide a literature review of the topic. They recommend that patients with traumatic chorioretinal rupture be monitored closely for the development of retinal detachment during the first few weeks after the injury.

Localization and Retrieval of an Eyelid Metallic Foreign Body With an Oscillating Magnet and High-Resolution Ultrasonography

A patient was found to have a metallic foreign body in the left anterior orbit on CT imaging, but the foreign body was not evident on clinical examination. On high-resolution ultrasonography, an object was identified in the left upper eyelid; however, the typical shadow with metallic foreign bodies was not seen. A high-power oscillating magnet was then applied to the eyelid, which revealed a subcutaneous metallic foreign body in the left upper eyelid. When used in conjunction, the high-resolution ultrasound and oscillating magnet successfully localized and facilitated retrieval of the metallic foreign body from the left upper eyelid.

Clinical observation on removal of small foreign bodies touching the optic nerve in the deep orbital region: a case series

PURPOSE

Five patients presented to our institution with deep intraorbital foreign bodies adjacent to the optic nerve. We removed all foreign bodies by lateral orbitotomy to evaluate the treatment and the benefits of their extraction.

METHODS

The clinical outcomes of the five patients were retrospectively analyzed.

RESULTS

Radiology in all five patients revealed small foreign bodies touching the optic nerve in the deep orbital region. All patients also suffered from significant secondary psychological disturbances, these including anxiety and altered sleep patterns. They had become preoccupied with a strong desire to remove the intraorbital foreign bodies [IFB]. In this cohort, two had no light perception before surgery, another two had light perception, and one had hand motion perception as well as vitreous hemorrhage that had been plugged with silicone oil in other hospital. All foreign bodies were removed via lateral orbitotomy. Visual acuity improved after the operation in only three cases. However, the psychological well-being of all five patients improved.

CONCLUSIONS

Consideration should be given to removal of intraorbital foreign bodies adjacent to the optic nerve, even where a significant degree of vision has already been lost. Furthermore some patients can achieved vision improvement and such surgery can frequently address the significant psychological disturbance that can be associated with such orbital foreign bodies.

An intraorbital metallic foreign body

A 30-year-old male presented with diplopia for 20 days post occupational accident involving left side of his nose, while he was working with a nail gun. He was fully conscious and did not have any neurological deficits. Patient narrated the mechanism of injury and was sure that the nail fell down after hitting the left side of his nose. He had normal vision, but extra ocular movements were restricted and painful. Computed tomography (CT) scan revealed a curved metal object lodged in the posterior aspect of the left orbit extending diagonally from medial wall to the anterior-superior aspect of the orbital roof. The object was removed via a small surgical approach, inflicting least possible surgical trauma. Post surgery, the patient recovered with complete resolution of diplopia. The original aspects of this case are the lack of signs of a foreign body entry and its relative harmlessness in spite of its large size.

Imaging in orbital trauma

Orbital trauma is one of the most common reasons for ophthalmology specialty consultation in the emergency department setting. We survey the literature from 1990 to present to describe the role of computed tomography (CT), magnetic resonance imaging (MRI) and their associated angiography in some of the most commonly encountered orbital trauma conditions. CT orbit can often detect certain types of foreign bodies, lens dislocation, ruptured globe, choroidal or retinal detachments, or cavernous sinus thrombosis and thus complement a bedside ophthalmic exam that can sometimes be limited in the setting of trauma. CT remains the workhorse for acute orbital trauma owing to its rapidity and ability to delineate bony abnormalities; however MRI remains an important modality in special circumstances such as soft tissue assessment or with organic foreign bodies.

Retained periorbital and intracranial air-gun pellets causing sclopetaria and visual loss

Three healthy males presented on separate occasions to the emergency room at the King Khaled Eye Specialist Hospital (KKESH) after sustaining trauma by air-gun pellets. Clinical examination indicated sclopetaria in all the cases. The foreign bodies (air-gun pellets) were imbedded in different locations (subconjunctival, intraorbital, and intracranial). All cases resulted in a profound and permanent visual loss. The management of this traumatic injury is discussed and concurs with the published literature.

Gunshot wound to the eye and orbit: a descriptive case series and literature review

BACKGROUND

The objective of this study is to report ocular and orbital findings in a series of six patients (8 eyes) with gunshot wounds and to review the literature on the pathophysiology, management, and outcome of such patients.

METHODS

Retrospective case series and review of the literature. Main outcome measures were ocular and orbital injury, surgical intervention, and presenting and final visual acuity.

RESULTS

Six male patients (mean age, 32 years) were enrolled. Three patients with globe concussion and low presenting visual acuity were treated by observation. Two patients (25%) underwent primary enucleation or evisceration. Retinal detachment developed in one patient who had a globe perforation, and he underwent vitrectomy and lensectomy with silicone oil injection. Visual acuity remained unchanged in all but one patient who underwent retinal detachment surgery. Final visual acuity was poor in all patients, with five eyes ending in no perception of light. Four patients had orbital fractures, two of whom underwent orbital reconstruction. One of these patients also underwent drainage of orbital abscess, eyelid surgery, and a dacryocystorhinostomy. The mean follow-up time was 26 months.

CONCLUSIONS

Gunshot wounds to the eye and orbit cause severe open and closed ocular injuries with guarded outcome and poor visual acuity. When feasible, initial wound closure may preserve the globe and allow further surgical rehabilitation. Primary evisceration may be required in cases of a severely ruptured globe. Orbital surgery may be needed in cases of infection, orbital wall disruption with disfigurement, or late enophthalmos.

Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons

PURPOSE

The incidence of gunshot wounds from civilian firearms is increasing. Despite this fact, guidelines on indications for bullet removal are scarce. In this analysis, we combine an overview of the available literature in these rare entities with our experiences in our own clinical practices.

METHODS

We conducted a systematic literature search of computerized bibliographic databases (Medline, EMBASE, and the Cochrane Central Register). The local experience of the authors was reviewed in light of the available literature.

RESULTS

145 full-text articles were suitable for further evaluation. Only six retrospective studies were available, and no prospective study could be retrieved. Most of the articles were case reports. In the South African co-author's own clinical practice, approximately 800 patients are treated per year with gunshot wounds.

CONCLUSIONS

In summary, there are only a few clear indications for bullet removal. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.

An extraordinary orbital foreign body

The authors report a unique case of a broken motorbike handle that presented as a bilateral orbital foreign body. A 30-year-old male sustained an injury to the right side of his face when he skidded from his motorbike while riding. He had bilateral sudden loss of vision and presented to emergency services with bilateral proptosis, motility restriction, and a right lower eyelid laceration. CT scan revealed a 7-cm-long motorbike handle lodged in the retrobulbar space of both orbits, close to the cribriform plate. Left lateral orbitotomy was performed to remove the foreign body; the right eye regained normal vision and function. The unique features of this case include the nature of the foreign body, its bilateral location, its proximity to the optic nerve and cribriform plate, and the challenges in its removal. The clinical presentation and management is presented, along with the surgical video.

Changes in management strategies after spontaneous migration of a retained intraorbital metallic foreign body

PURPOSE

Because of the controversial biologic tolerance and management, retained intraorbital metallic foreign body (RIMFb) poses a formidable challenge to surgeons. Besides location of the foreign body, indications for surgical management include neurologic injury, mechanical restriction of the eye movement, and development of local infection or draining fistula. The authors describe an unusual case of spontaneous migration of a RIMFb.

METHODS

A 26-year-old man had a gunshot injury on the left orbit. The patient was initially managed conservatively because of the posterior position of the bullet fragment. Thereafter, because of the clinical impairments and anterior migration of projectile, surgical treatment was considered.

RESULTS

Spontaneous anterior migration has led to mechanical disturbances and inflammatory complications that comprise explicit surgical indications for removal. The patient underwent surgery with complete relief of symptoms. We suppose that extrinsic ocular muscles might play a role in shifting large RIMFb over time, leading to change in the management strategies.

CONCLUSIONS

Spontaneous migration of RIMFb is a rare clinical situation that can lead to pain, local deformity, as well as changes in the management strategies of the affected patients even in the late phase of follow-up.

Clinical presentation and outcome of chorioretinitis sclopetaria: a case series study

PURPOSE

To report the clinical presentation, treatment approach and natural course of a series of chorioretinitis sclopetaria patients.

METHODS

Thirteen consecutive patients with clinical diagnosis of chorioretinitis sclopetaria were included in a case series study during 2000-2006. All patients underwent clinical examination, including the best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, funduscopy and fundus photography. Three-port standard vitrectomy was performed in two patients due to dense vitreous haemorrhage and suspected retinal detachment in both cases. All patients were followed up at week 4, months 2 and 6 and then every 6 months.

RESULTS

The mean age of the patients was 16+/-6 (range: 5-27) years and 11 patients (84.6%) were male. The mean follow-up period was 37+/-18 (range: 17-82) months. Baseline best-corrected visual acuity ranged from no light perception (NLP) to 20/1600, and final visual acuity range was from NLP to 20/1200. Only one patient developed acute retinal detachment, and the retina remained attached in others through follow-up.

CONCLUSION

In spite of severe retinal and choroidal injuries in chorioretinitis sclopetaria, retinal detachment does not usually occur, probably due to spontaneous retinopexy and scar formation. Whilst dealing with chorioretinitis sclopetaria, it is important to make an accurate diagnosis to prevent unwarranted surgical intervention.

[An unusual foreign body in the orbit]

INTRODUCTION

Foreign bodies in the orbit are rare. They can generate more or less serious complications depending on their nature and size. We report an exceptional case of a bulky foreign body in the orbit (the tip of a pen), which did not lead to any complication.

OBSERVATION

A 13-year-old child presented with a right orbital trauma caused by a pen. He consulted 3 months later when a small palpebral swelling appeared. The CT scan showed the presence of a foreign body on the orbital floor. Wound debridement allowed extracting the tip of a pen measuring 3.5cm without any complication. There were no postoperative complications.

DISCUSSION

The originality of this observation is two-fold; the singularity of the foreign body and its total harmlessness in spite of its large size. However, orbital trauma and a secondary orbital syndrome must lead to emergency imaging.

Intraoperative fluoroscopy-guided removal of orbital foreign bodies

PURPOSE

To describe the use of intraoperative fluoroscopy as an aid in the removal of radio-opaque orbital foreign bodies.

METHODS

A retrospective interventional case series of 12 patients with orbital foreign bodies that required removal for various indications. All patients underwent orbitotomy and removal of the foreign bodies with the aid of real-time intraoperative fluoroscopic localization.

RESULTS

The orbital foreign body was successfully removed without complication in all 12 patients. One patient with ethmoid sinusitis preoperatively had resolution of the infection after surgery. Two patients with extraocular motility deficits preoperatively experienced significant improvement in motility after surgery. Three patients who required MRI studies for unrelated conditions were able to undergo scanning postoperatively without complications. Two patients were combat casualties treated by US medical personnel during Operation Iraqi Freedom. There were no cases of visual or ocular morbidity directly attributable to foreign body removal.

CONCLUSION

Intraoperative fluoroscopy is a valuable tool that can aid in the removal of radio-opaque orbital foreign bodies.