Download surgery 179 intraorbital foreign body

Rev. Med. Chir. Soc. Med. Nat., Iaşi – 2015 – vol. 119, no. 1
SURGERY
CASE REPORTS
INTRAORBITAL FOREIGN BODY
Dana Mihaela Turliuc 1,2, V. V. Costan1*, A. I. Cucu2, Claudia Florida Costea 3
University of Medicine and Pharmacy”Grigore T. Popa”- Iasi
Faculty of Medicine
1. Department of Surgery
Clinical Emergency Hospital „Prof. Dr. N. Oblu” Iasi
2. Neurosurgery Unit II
3. Ophthalmology Unit
*Corresponding author. E-mail: [email protected]
INTRAORBITAL FOREIGN BODY (Abstract): Penetrating orbitocranial injuries caused by
intraorbital foreign body are a rare cause of morbidity being most common among young
people. The term intraorbital foreign body refers to a foreign body that occurs within the o rbit but outside the ocular globe. We report the case of a 12-year-old male child who sustained a right cranial facial trauma due to accidental fall on a piece of wood, which penetra ted intraorbitally. Native cranial magnetic resonance imaging (MRI -1.5 T) revealed the presence of an intraorbital foreign body, 6 cm long and 1.5 cm wide, near the orbital apex. In our
patient, early surgical extraction of the foreign body had a decisive role on his full reco very.In this case, although a large foreign body penetrated the entire length of the orbit, it did
not cause damage to any intraorbital structure. Vision and right ocular globe function had an
excellent prognosis. Keywords: INTRAORBITAL FOREIGN BODY, ORBITAL TRAUMA, VISUAL ACUITY.
CASE REPORT
We report the case of a 12-year-old
male child who sustained a right craniofacial trauma due to an accidental fall while
playing with another child on a stake set
firmly in the ground. During the impact, a
wooden fragment 6 cm long and 1.5 cm
wide penetrated intraorbitally the anterior
right maxillary sinus wall and then the right
orbital floor up to the orbit apex.
On local examination, the external end
of the foreign body was seen just below the
right lower orbital rim. The right eye was
painful and showed significant palpebral
edema and erythema (fig. 1).
Fig. 1. The patient photography at the first
examination: a wooden foreign body, below the right lower orbital rim.
The ophthalmologic examination revealed preservation of visual acuity of the
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right eye (V.A.R.E.=1) and no pathologic
changes on slit-lamp biomicroscopic and
ophthalmoscopic examination.
Native cranial computed tomography
(CT) scan showed a right intraorbital hypodensity with a trajectory parallel to the
interior wall of the orbit, medial to the right
internal muscle up to the orbit apex, involving the scleral wall and a temporal
aerial bulla.
Native cranial MRI (1.5 T) revealed the
presence of an intraorbital foreign body
which did not cause damage to the intraorbital vascular and nerve structures (fig. 2,
3, 4).
The child was admitted and the administration of antibiotics (clindamycin and
metronidazole) was initiated.
Fig. 4. Coronal T1 MRI, intraorbital foreign body (arrow).
Surgery was performed 24 h after the
accident and consisted in the removal of
the foreign body (wooden fragment) by
enlarging the entry point (fig. 5, 6).
Fig. 2. Sagittal T1 MRI, intraorbital foreign
body (arrow).
Fig. 5. Wooden foreign body
extracted from the orbit.
Fig. 3. Axial T1 MRI, intraorbital
foreign body (arrow).
Fig. 6. The post operative results.
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Intraorbital foreign body
The postoperative course was favorable,
the patient being discharged 5 days after
surgery.
Upon discharge, the patient showed diplopia, with left eye (L.E.) fixer and right
eye (R.E.) sursumvergent +13°.
One month after discharge, diplopia remitted and visual acuity of the right eye
remained 1.
DISCUSSION
Penetrating orbitocranial injuries caused
by an intraorbital foreign body are a rare
cause of morbidity and they occur mostly
in children and adolescents.
Penetrating orbitocranial injuries are
more common in people involved in military services, but they may also occur in
civil life, where they usually take the form
of accidents. The occurrence mechanism
relies on high velocity forces like work
accidents, injuries caused by weapons or
even simple injuries (household accidents,
play accidents). Accidents caused by intraorbital foreign bodies are more common in
men than in women and young people, as
compared to senior citizens.
Depending on the material, intraorbital
foreign bodies may be classified into: inorganic metallic (iron, aluminum, steel, etc.),
nonmetallic (plastic, glass, rock, etc.) and
organic (wood, plants, thorns, etc).
The orbit is a cranial cavity where the
eye and eyeball adnexa are located. Although the orbit is described as a pyramid,
its walls are not exactly straight. The walls,
tip and basis are curvilinear and they are
pierced by foramens and fissures. An anatomical characteristic of the orbit is that
structures are arranged in groups of seven:
seven bones (frontal, ethmoid, lacrimal,
sphenoid, zygomatic, palatine and maxillary), seven intraorbital muscles and seven
nerves, respectively (1).
Foreign bodies located in the anterior 2/3
of the orbit may be approached extracranially, whereas those located in the apical
area, especially in the medial section of the
optic nerve, require a transcranial approach.
Orbital injuries extending beyond the upper
orbital fissure require a combined and complex surgical approach due to their closeness
to the cavernous sinus.
The presence of the periorbita allows
the classification of orbital injuries into
intradural (deep in the periorbita) and extradural (when they are located between the
periorbita and osseous orbit). In its turn,
the muscular cone divides the orbit into
two areas, the intraconal and the extraconal
one. Whereas intraconal injuries are always
intradural, extraconal injuries may be intraor extradural. The intraconal area may also
be divided in relation with the optic nerve
into a medial, central and lateral area (2)
(Figure 7).
The transcranial approach is preferred
when the injuries are located at the top of
the orbit and/or of the optic foramen. A
direct approach through the lateral wall of
the orbit requires lateral orbital margin and
wall osteotomy and it is preferred when the
foreign bodies are located in the upper,
temporal or lower compartment and in the
lateral side of the apex (3).
There are 2 basic types of surgical orbital approaches: transorbital, preferred by
ophthalmologists, and extraorbital, preferred by neurosurgeons.
These are the primary transorbital approaches (3, 4):
-anterior orbitotomy without osteotomy:
-superior-incision through the eyelid,
supra-orbital or sub-frontal incision,
-inferior-transconjunctival
incision,
subciliary incision or incision through the
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lower eyelid,
-anterior orbitotomy with osteotomy of
the upper orbital edge (for larger foreign
bodies),
-lateral orbitotomy,
-medial orbitotomy,
-combination between lateral and medial orbitotomy.
Fig. 7. Topographic classification of intraorbital lesions.
Extraorbital approaches are possible
through a frontotemporal approach with or
without orbital osteotomy and through a
lower orbital approach. Extraorbital approaches may also be supported by endoscopic methods (4).
The approach path is set after the imaging assessment of the intraorbital injury,
which reveals both the foreign body and its
relations with the neighboring anatomical
structures.
Eye Ultrasonography (US)
Although ophthalmic ultrasonography
plays a well-determined role (5), as it provides real-time information about the eye
and the orbit (especially about the intraocular structures), it may also be used during
the surgical procedure. Here are some of
the disadvantages of eye ultrasonography
performed in case of injury caused by an
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intraorbital foreign body: foreign body
migration (due to the probe moving
around) and lack of information related to
orbit fractures.
Computed Tomography (CT)
Unlike eye ultrasonography, computed
tomography is available in most hospitals,
does not require direct contact with the
orbit, eyeball or foreign body, is superior to
US in determining the size and shape of the
foreign body, allows easier orbital fracture
diagnosis, and is faster and cheaper than
the MRI.
CT scanning should ideally observe the
standard orbit examination protocol, according to which both the axial and coronal
sections should be 1.0-1.5 mm. Nevertheless, foreign bodies smaller than 0.5 mm
and plastic foreign bodies may be overlooked, whereas organic (wood) bodies
Intraorbital foreign body
may have false negative results. Due to the
air-containing wood cellulose matrix, the
wood foreign body may be taken for pneumoorbita (6). Another disadvantage would
be that orbit CT cannot be done in the operating room, the intraorbital structures are
not viewed as by an eye US, and artifacts
from metallic foreign bodies may occur.
CT scan is recommended for: intraorbital
foreign bodies, eye ball ruptures/dilacerations and orbit fractures (7).
Magnetic resonance imaging (MRI)
MRI exploration is indicated when a
ferromagnetic foreign body or a foreign
body of mixed organic-inorganic composition is excluded. Some of the advantages of
examination by MRI are: axial, coronal and
sagittal images and patient repositioning is
not required (as in coronal CT sections),
provides higher quality images of soft tissues compared to CT. The disadvantages of
MRI exploration are: motion artifacts, long
time of image acquisition and nonspecificity for orbit fractures. The MRI
characteristic aspect of dry or moist wood
is the hypo dense signal related to intraorbital fat. T1 sections are more useful than
T2 as they provide a better contrast between wood and intraorbital fat. Should
there by the least suspicion of vessel injury,
CT or MRI angiography are recommended
to assess vascular integrity (3).
TREATMENT
The prevention of endophthalmitis is the
main objective of early surgery, although
recent studies found no difference between
the surgery performed within the first 48
hours and surgery performed after this time
interval. In all patients diagnosed with an
intraorbital foreign body, antibiotic therapy
must be initiated, due to the higher inci-
dence of secondary orbital infections (5).
The surgical approach is selected based
on the nature of the foreign body, its location (anterior or posterior orbit) and complications (infections, injury or compression of the optical nerve, injury to the extraocular nerves or intraorbital vessels).
Asymptomatic metallic (mostly the small
ones) and inert foreign bodies located within the posterior orbit may be left in situ and
kept under control.
On the other hand, organic foreign bodies (wood or other vegetable matter) cause
an intense inflammatory reaction and are
not tolerated. Organic wooden foreign
bodies determine a fast infection in the
orbit due to its spongy texture and organic
nature, which is a good environment for
microbial agents (8). They may cause panophthalmia, intraorbital abscess or fistula,
reason why their extraction is a surgical
emergency (9).
A surgical challenge may be the
transorbital penetrating intracranial injury.
In this circumstance, only a multidisciplinary team may conduct a safe and successful surgery. In such cases, the upper orbital
fissure and the optical channel may be
gateways to the intracranial space, mostly
to the cavernous sinus and the internal
carotid artery (cavernous, clinoid and ophthalmic segment).
CONCLUSIONS
The patient presented to hospital immediately after the accident, which made possible the immediate initiation of antibiotic
and antimycotic therapy, a possible endophthalmitis being thus prevented. The
diagnosis was penetrating craniofacial
trauma with a wooden intraorbital foreign
body, the damage to the ocular globe supported by initial physical examination be-
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ing refuted by radio-imaging investigations.
Surgical treatment is indicated in case
of foreign bodies of large sizes, with cutting edges, in the presence of signs of inflammation or infection, intraorbital abscess or contrast medium uptake in the
foreign body, palpable orbital mass, restricted motility, proptosis, chemosis, compression of the optical nerve, fistula, suspicion of a wooden, copper or vegetable
foreign body (7).
The intraorbital foreign body as a result
of a penetrating trauma is a therapeutic
emergency, and the removal of an organic
foreign body is a surgical emergency. The
first recommended imaging method of
diagnosis is computed tomography. The
diagnosis and early surgical treatment influence the course and prognosis of patient’s vision.
This case is peculiar because, although
a large foreign body passed through the
entire length of the orbit and important
anatomic structures, it did not cause damage to any intraorbital structure. Vision and
right ocular globe function had an excellent
prognosis.
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