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Retained orbital wooden foreign body
Retained Orbital Wooden Foreign Body A Surgical Technique and Rationale Don Liu, MD, FACS,1,2 Essam Al Shail, MBBS, KFUF3 Objective: To emphasize the potential complications of a retained orbital wooden foreign body (WFB) and the rationale of a surgical technique. Design: Two interventional case reports. Participants: Two patients sustained an orbital WFB injury. Both patients had ocular complications despite repeated attempts to remove the suspected residues. Intervention: Computed tomography and magnetic resonance imaging of both patients at different intervals revealed evidence of orbital foreign body migration toward the cranium. A surgical technique combing transcranial and orbital approaches was used to remove the residues. Main Outcome Measures: Preoperative and postoperative vision, proptosis, ocular motility, and various ocular symptoms and signs. Results: In both patients, no postoperative complications were seen, and all preoperative symptoms and signs were resolved at 9- and 19-month follow-ups, respectively. Conclusions: A retained orbital WFB can cause early or late complications and is known to have the potential to migrate intracranially. In selected patients, a team approach may be the best technique to ensure complete removal. Ophthalmology 2002;109:393–399 © 2002 by the American Academy of Ophthalmology. An orbital wooden foreign body (WFB) can cause serious complications if left undetected.1–13 A latent period before complications are manifested due to a retained orbital WFB may range from a few hours to many months.3–13 It is often difficult to detect an orbital WFB, for none of the imaging modalities is 100% sensitive or specific.2,14 –22 In addition to taking a good history and performing a meticulous examination, a high index of suspicion is usually needed to make the proper diagnosis. It is frustrating to both the patient and the ophthalmologist when recurring signs and symptoms or a late complication develop despite repeated attempts at complete removal. We report our experience with two such cases and present a surgical technique and its rationale.
Case Report Patient 1 A 19-year-old male was struck in the left lower eyelid by a tree branch in mid-April 1998, with a large piece protruding from the Originally received: November 6, 2000. Accepted: June 1, 2001. Manuscript no. 200761. 1 Oculoplastics/Orbit Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. 2 Ophthalmology Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. 3 Neurosurgery Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. The authors have no financial interest in any of the equipment, instruments, drugs or laboratory facilities mentioned in this article. Correspondence and reprint requests to Don Liu, MD, FACS, Mason Eye Institute, University of Missouri, 1 Hospital Drive, Room EC149, Columbia, MO 65212. © 2002 by the American Academy of Ophthalmology Published by Elsevier Science Inc.
right orbit. Reportedly, an ophthalmologist removed this wooden foreign body completely and irrigated the wound thoroughly before wound closure. In the next few days, the same ophthalmologist performed additional “lid surgery” related to the WFB injury before referring the patient to a regional hospital. At the regional hospital, the patient presented with 20/20 vision in both eyes and a large draining right lower lid abscess. Computed tomography, performed at the end of April 1998, revealed “thickening of [the] right lateral rectus muscle with a small hyper-dense area, which could correspond to a hematoma or residual foreign body.” More specifically, there was no comment of an orbital roof fracture or possible retained foreign body made by the radiologist. An ophthalmologist at the regional hospital drained the lid abscess and prescribed systemic antibiotics for the patient. The culture from the abscess was sterile. The patient returned 10 days later with recurrence of lid abscess and draining fistula. At that time, the patient had normal vision and motility and was referred to a tertiary eye care center. Computed tomography performed in May at this tertiary eye care center revealed that the density previously described had now migrated toward the orbital apex. An orbital roof fracture near the orbital apex was also noted at that time. In May 1998, two oculoplastic surgeons at the tertiary eye care center proceeded with an exploration and drainage via the right lower lid fistula track. Reportedly at this time, approximately 20 pieces of wooden fragments were removed, with the largest one measuring 15 ⫻ 6 mm. The patient was discharged in satisfactory condition. However, the patient returned to the same center in early August 1998 with a history of more spontaneously extruding wood fragments from the fistula. He was readmitted for further management. A magnetic resonance image obtained in August 1998 demonstrated a mass, likely a granuloma containing a foreign body, located along the lateral orbital wall near the apex. The same two ophthalmologists performed exploration and drainage using the same approach via the same fistula as before. Three more pieces of wood were removed, with the largest one measuring 15 ⫻ 6 ⫻ 3 mm. The patient was given systemic antibiotics. The patient reISSN 0161-6420/02/$–see front matter PII S0161-6420(01)00928-9
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Ophthalmology Volume 109, Number 2, February 2002 ported an annoying diplopia on the first postoperative day. Follow-up examination in mid-September 1998 showed vision in the right eye to be 20/30 with a dilated right pupil. He also had 3 mm of right proptosis, restriction in both horizontal and vertical gazes, and a right lower lid retraction. Subsequently, in early 1999, a magnetic resonance image obtained at another institution suggested the mass had further migrated towards the apex and by that time had involved the “frontal basal area” with “focal signs of meningitis” (Fig 1).2 A standard orbital B-scan confirmed the presence of an orbital mass at the apex. Based on these findings, the patient was referred to another institution where a neurosurgical service was available. However, the service was not offered initially because of his lack of neurologic deficits. In February 1999, one author (DL) became involved, immediately admitted the patient to his care, and used a combined approach to remove the residual foreign bodies (see Surgical Technique for description). Intraoperative cultures later showed Haemophilus parainfluenzae, coagulase negative Staphylococcus and alpha hemolytic Streptococcus. Cultures of anaerobes, acid fast bacilli, and fungus were negative. One author (DL) requested identification of the wood, but the laboratory was unable to provide this service due to its limited capability. There was no postoperative complication whatsoever. The patient was followed-up regularly and was last seen in September 2000 for a 19-month follow-up. He maintained 20/20 vision in the right eye and had a dilated right pupil. He enjoyed full motility and single binocular vision. There was no proptosis, no draining fistula, and no more extruding wooden fragments. His right lower lid was in good position.
Patient 2
Surgical Technique
Discussion
A coronal flap was created, and the cranium was opened. The brain was retracted to expose the orbital apex. An intracranial mass was clinically evident. It appeared to be a pseudoencapsulated granuloma. The mass was carefully dissected from the surrounding normal tissues and was removed in piece-meal fashion. Several large pieces of wooden fragments, visible to the naked eye, were removed. The largest of these measured approximately 5 ⫻ 2 mm. With the removal of the intracranial portion of this mass, the orbital roof could then be removed in a controlled manner. The mass was easily identified and followed into the orbit. As much as is allowed by this approach and good exposure, the orbital portion of the mass was removed. At this point, more than 30 small pieces of wooden fragments were counted, not including those too tiny or those deeply embedded in the tissue. Next, an incision was made in the right lower eyelid using the existing scar. The fistula tract was followed gently from the skin opening to the surgical opening at the orbital apex. A small, soft catheter was next inserted in the orbital apex from the cranium above. While irrigating with antibiotics solution through the catheter, gentle repeated curettage was applied to the soft tissue of the fistula track both in circular and in to-and-fro manners. This was done so gently that no bleeding and no abrupt movement of the globe was observed. At the same time, the curettage was performed with enough force to remove suspected WFBs embedded in the fistula track. Indeed, an occasional gritty sensation or minor resistance was felt. Using this technique, we observed many fine particles in the irrigation fluid coming out of the skin wound. Only when no more particles were seen, no gritty sensation was felt, and a few drops of blood became visible in the irrigation fluid, did closure begin. The lid retraction was repaired with a Z-plasty.
A variety of orbital foreign bodies have been reported. These include glass, stone, metal, wood, graphite, button, faucet handle, fish jaw, iron hat peg, chopstick, pencil, large wooden plank, pocket knife, meat hook, and pitchfork.1,2,23–26 In general, a penetrating foreign body orbitocranial injury may be categorized either as a low-velocity or high-velocity injury, with most of them in the former category. Young men appear to have a propensity to these injuries, and children tended to get injured by falling onto a pencil.1– 4 In the preantibiotics era, the mortality rate was as high as 25%, and the morbidity rate 76%.2,3 In the 1970s, before the advent of modern computed tomography or magnetic resonance imaging technique, intracranial WFB was not initially suspected in 74% of cases.1– 4,7 Although there has been no large series to clearly document a decrease in the mortality and morbidity rates, it seems reasonable to assume such a trend exists. The reasons include the advent of antibiotics, heightened awareness on the part of the general public and physicians, improved diagnostic imaging techniques, and refined surgical instruments and techniques. Intracranial foreign body injury is managed by the neurosurgeons. Hence, its diagnosis, management, and potential complications are not discussed here. Because each orbital foreign body injury is different, and the diagnosis and management of a patient in the acute stage is beyond the scope of this article, our discussion will be limited to only missed or retained orbital WFBs. Ophthalmologists are usually the first to see patients with
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A 20-year-old male was assaulted in the left eye with a wooden stick in mid-1999. His vision was 20/20 in the right eye and 20/200 in the left eye. Reportedly, an ophthalmologist removed the foreign body completely and explored and irrigated the wound before closure. A few weeks later, the patient went to a local hospital with a draining fistula. At that time, his vision was 20/20 in the right eye and counting fingers in the left eye. Apparently a computed tomography revealed an orbital lesion and more exploration, drainage, and fistula repair were performed. Toward the end of 1999, he presented to the emergency room of the same tertiary center. At that time, his vision was 20/20 in the right eye and hand motion in the left eye. Hertel measurement with a base of 110 showed 22 mm in the right eye and 26 mm in the left eye. There was a large left exotropia with limited ocular motility in all gazes. There was a 2-mm left ptosis with a levator function of 13 mm. The right eye was normal. The patient was then referred to the authors. Computed tomography and magnetic resonance imaging at that time showed a complex intraorbital and intracranial lesion protruding nearly 1 cm into the left subfrontal region. The patient was taken to the operating room in January 2000. Using the same surgical technique and noting essentially the same intraoperative findings, we removed the retained foreign bodies and granulation tissue without difficulty (Fig 2). There were no postoperative complications. His vision remained 20/20 in the right eye and counting fingers in the left. He regained full motility of the left eye. There was no clinical evidence of proptosis or ptosis. There was no recurrence of draining fistula or extruding wooden fragments. He was last seen in September 2000, a 9-month follow-up without any recurrences or new complaints.
Liu and Al Shail 䡠 Retained Orbital Wooden Foreign Body
Figure 1. A, Computed tomographic scan of the patient’s orbit and brain, taken in April 1998. The coronal view demonstrated that the lesion involved mainly the lateral aspect of the right orbit. B, Axial view of the patient’s orbit and brain, taken in April 1998. C, Computed tomographic scan obtained in May 1998. Coronal cut of the patient’s orbit showed a roof fracture near the apex. No foreign body could be identified. D, Magnetic resonance image (MRI), obtained in August 1998, showed involvement of the orbital apex and cranium. E, Axial view of the MRI from August 1998. F, Magnetic resonance imaging scan in January 1999 showed migration of the foreign body-granuloma complex toward the cranium. G, Axial view of the MRI obtained in January 1999.
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Ophthalmology Volume 109, Number 2, February 2002 a penetrating orbital WFB injury, and are also usually participants in surgical intervention, whether it is in the acute or secondary stage. Therefore, their diagnostic skills, surgical armamentarium, and awareness of the potential complications of a missed or retained orbital WFB are crucial to the proper care of these patients. There are many case reports and imaging technique studies of orbital WFB injuries. These case reports mainly emphasize the potential devastating effects of an orbital WFB. All of these reports also emphasize the importance of recognizing the latent period (the time between the initial injury and when a serious complication was apparent). Such a latent period could vary from hours to many months.3–13 The imaging technique studies chiefly stressed the usefulness and limitations of various imaging techniques.14 –20 Suffice to say, no imaging modality to date, whether computed tomography, magnetic resonance imaging, or standardized orbital B-scan, can detect an orbital WFB with 100% sensitivity. Hence, in addition to relying on the best imaging technology, a thorough history and meticulous examination coupled with a high index of suspicion remain critical factors in making the correct diagnosis of orbital WFBs. There are several reasons why an orbital WFB results in serious complications. Its relatively soft and organic nature coupled with porosity makes it easy to fragment and to harbor various microorganisms.3,7,10 Unless it is relatively large or it contains otherwise radiopaque materials, it is difficult to detect.14,17,20 Consequently, it is essential to make the proper diagnosis and effect timely surgical intervention when an orbital WFB is suspected. A team approach is often used in an acute situation. When a patient presents with an acute injury due to a large orbitocranial foreign body, a team approach involving neurosurgeons and ophthalmologists under emergency conditions is obviously required. For example, Doucet et al25 reported a large wooden plank in the right orbit with clear computed tomographic evidence of cranium penetration. Michon and Miller26 reported their joint efforts with neurosurgeons in removing a large steel rod impinging on the brain stem of a child. Vander and Nelson27 also worked with neurosurgeons to remove a large nail impinging on the cavernous sinus. Albert et al4 reported an emergency right front temporal craniotomy performed by neurosurgeons 12 hours after they had admitted a patient with a pencil lodged in the right orbit. Mutlukan et al5 had a patient who underwent an emergency right frontal craniotomy along with right optic canal decompression 6 hours after admission. A team approach involving a neurosurgeon is occasionally used in a secondary manner, mainly when late neurologic complications become evident. Kazarian et al6 described an 8-year-old boy who presented with a small puncture wound in the right upper eyelid. Six weeks later, the patient was admitted for proptosis of the right eye with drainage from the puncture wound, headache, vomiting, and nuchal rigidity. The diagnosis of a right temporal lobe abscess was made and a temporal craniotomy was performed by a neurosurgeon. An ophthalmologist and an otolaryngolosist also participated in the exploration and drainage of the fistula. A few weeks later, the patient’s
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condition deteriorated and a different team performed another exploration. Once the orbit had been unroofed, a WFB was extracted from the superior orbital fissure. Despite successful removal of the WFB at that time, the patient had permanent ocular complications and neurologic deficits. In 1964, Bard and Jarrett7 reported a series of nine patients with various penetrating orbital injuries. These patients underwent cranial and/or orbital exploration at different times for various reasons. As the patient series was collected from the late 1950s to the early 1960s (i.e., before the advent of modern imaging technology), most of the patients did not do very well and many had ocular and neurologic complications. Other authors in those early days also reported missed orbital WFBs with serious complications and often after repeated explorations.8,28,29 Therefore, it is extremely important for ophthalmologists to recognize the serious consequences of a missed or retained orbital WFB and the rationale of a timely and effective surgical intervention. Furthermore, it should be recognized that when an orbital WFB is initially missed, the diagnosis and subsequent management can become even more challenging. Our two cases presented herein were unique and instructive in several aspects. Both patients had undergone repeated exploration and drainage by ophthalmologists at major centers. Despite best efforts, the ocular problems for both patients recurred and, in fact, became worse. Although both patients were free of acute or serious intracranial complications at the time of our initial examination, this did not diminish our sense of urgency of the problems. In fact, this only served to heighten our preparedness. Our discussion now centers on two major points: (1) the retention and subsequent migration of the WFBs, and (2) our surgical technique and rationale. It is known that a retained orbital WFB may migrate or extrude spontaneously.1–3,30 In the two cases reported herein, however, there are strong suggestions that other mechanisms, including iatrogenic ones, could play a role in the observed orbital WFB retention and migration. Understandably, it is very difficult to completely remove a piece of wood, particularly a tree branch, from living tissue. The wood “catches” the tissue and tends to disintegrate as force is applied to it during an attempted removal. Usually large orbital WFBs can be extracted under direct visualization. Copious irrigation is generally used to remove the smaller foreign body particles and fragments, whether directly visualized or suspected. Given this, it is likely that when a patient’s problem persists, ophthalmologists tend to become more aggressive. In other words, a more extensive exploration with more irrigation will follow. In both of our patients, the observed subsequent migration of the retained orbital WFB (and the granuloma that surrounds it), usually perceived as a natural course may have an additional mechanism.1–3,30 It is possible that that course may have been exacerbated if not directly caused by the subsequent and repeated, albeit well-intentioned attempts to remove the WFB using the same skin wound approach and copious irrigation. At first glance, it appears logical to utilize the existing skin wound and to explore the fistula track. It may very well
Liu and Al Shail 䡠 Retained Orbital Wooden Foreign Body
Figure 2. A, Computed tomographic scan from January 2000. Coronal view demonstrated the intracranial position of the foreign body granuloma. B, Axial view. C, Magnetic resonance imaging scan from January 2000. The intracranial location of the foreign body is clearly demonstrated. D, Part of the wooden fragments that were surgically removed.
be the technique used initially by most surgeons. However, we would like to stress that it is not the best technique to use repeatedly when a patient continually returns with complications. Emphatically, this approach offers only a very limited exposure of the anterior orbit and permits no direct visualization whatsoever of any deep orbital anatomy. It should be avoided when the pathology is known to be located deep at the orbital apex. In fact, it is very likely that the remaining orbital WFB was further disintegrated and pushed deeper into the surrounding tissues due to such blind surgical manipulations. Additional irrigation with hydraulic pressure directed inward, from the skin wound toward the deep end of the orbit, may further facilitate the deeper migration of these remnants. Careful review of the computed tomography obtained for patient 1 in May 1998 revealed a small orbital roof fracture near the apex (Fig 1). This breach of anatomic integrity made the subsequent intracranial migration of the WFB and granuloma complex possible, whether natural or iatrogenic. Although it was not possible for anyone to state with certainty if any WFB was present at the fracture site, the following argument highlights the crux of the problem. If one assumes that there was no WFB present initially at the fracture site, then the iatrogenic mechanism for the intracranial migration of the WFB is a valid concern. The subsequent clinical course of this patient appeared to render
good support of this hypothesis. However, if one assumed that some WFBs (detectable or not) were, indeed, initially present at the fracture site, then the clinician has to rely on a well-conceived and well-planned combined approach from the very beginning. A blind surgical manipulation has no place in the management of these patients at all, let alone repeating it. An orbital roof fracture with a possible retained WFB was evident in patient 2 at the time we obtained a computed tomography in January 2000 (Fig 2). This fracture, if it was initially present, also allowed the subsequent intracranial migration of the WFB and granuloma complex. We were unable to obtain any detailed information or previous scans from the previous physicians. It would be hard to imagine that the radiologist could miss such a large fracture or retained WFB, if indeed it were initially present. Accordingly, the management of this patient (and patient 1) by the other ophthalmologists did not demonstrate their concerns of a possible intracranial WFB. Therefore, an iatrogenic mechanism for the intracranial migration of the WFB remained a strong consideration. It must be emphasized again that maintaining a high index of suspicion and correlating clinical findings with imaging studies are the most helpful guide in managing these patients. The ophthalmologist should provide a de-
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Ophthalmology Volume 109, Number 2, February 2002 tailed history and the clinical findings when reviewing the imaging study with the radiologist. Emphatically, it is not prudent for any clinician to make a decision based solely on the negative findings of an imaging study. Although it is realized that no surgical technique is 100% effective, our combined surgical approach took various considerations into account. We began with the retraction of the brain to locate the intracranial portion of the WFB granuloma complex. Once the intracranial portion of this complex was removed and the orbital apex was exposed from above, there was direct visualization of everything thereof. As much as possible, this WFB granuloma complex was removed from the deep orbit under direct visualization. Subsequent removal of the WFB granuloma complex was achieved with a two-prong approach and we felt this was the critical maneuver. The circular plus to-and-fro curettage within the fistula, with simultaneous irrigation from deep orbit out to the skin wound, helped bring out fragments and particles embedded in the tissues. This maneuver continued until the fluid coming out became clear. Of critical importance too was the direction of irrigation fluid flow. If irrigation was performed in the usual skin-to-orbital-apex manner, it was possible that our patients’ problems might have persisted or worsened as these particles could easily have been dispersed intracranially. Constantly watching the globe to make sure there was no abrupt movement or change in pupil size was also important to avoid complications.31 Using this combined approach, both of our patients did very well at follow-up (one patient at 9 months and one at 19 months). There were no complications whatsoever, and all of their preoperative symptoms were resolved. In summary, an initial good history-taking, keen clinical observation and high index of suspicion, coupled with modern imaging techniques, are necessary to make a correct diagnosis of a retained orbital WFB. A retained orbital WFB is known to have the potential to migrate or extrude spontaneously. Ophthalmologists must do their best to prevent such migration deeper into the orbit or the cranium during their attempt to explore the orbit and extract the WFB. When one surgical technique repeatedly fails to achieve the expected results, a surgeon must use other viable alternatives or an early referral. Our technique seems to have been effective in these two patients. As each patient is unique, modification of this surgical technique is expected, although the basic principles remain the same.
References 1. Duke-Elder S, MacFaul PA. Retained foreign bodies. In Duke-Elder S, ed. System of Ophthalmology, Vol. 14, pt 1. St. Louis: C.V. Mosby, 1972:655– 69. 2. Linberg JV. Management of orbital trauma. Duanes Clinical Ophthalmology, Vol. 87. Philadelphia: JB Lippincott, 1994; 11–5. 3. Miller CF II, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95–103. 4. Albert DM, Burns WP, Scheie HG. Severe orbitocranial foreign-body injury. Am J Ophthalmol 1965;60:1109 –11.
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5. Mutlukan E, Fleck BW, Cullen JF, Whittle IR. Case of penetrating orbitocranial injury caused by wood. Br J Ophthalmol 1991;75:374 – 6. 6. Kazarian EL, Stokes NA, Flynn JT. The orbital puncture wound: intracranial complications of a retained foreign body. J Pediatr Ophthalmol Strabismus 1980;17:247–50. 7. Bard LA, Jarrett, WH. Intracranial complications of penetrating orbital injuries. Arch Ophthalmol 1964;71:332– 43. 8. Ferguson EC III. Deep, wooden foreign bodies of the orbit. A report of two cases. Trans Am Acad Ophthalmol Otolaryngol 1970;74:776 – 87. 9. Tsaloumas MD, Potamitis T, Kritzinger EE. Two cases of retention of wooden foreign bodies in orbit of eye. BMJ 1998;316:1363– 4. 10. Macrae JA. Diagnosis and management of a wooden orbital foreign body: case report. Br J Ophthalmol 1979;63:848 – 51. 11. Brock L, Tanenbaum HL. Retention of wooden foreign bodies in the orbit. Can J Ophthalmol 1980;15:70 –2. 12. Guthkelch AN. Apparently trivial wounds of the eyelids with intracranial damage. BMJ 1960;5202:842– 4. 13. Fanning VL, Willett MR, Phillips CF, Wallman LJ. Puncture wound of the eyelid causing brain abscess. J Trauma 1976; 16:919 –20. 14. Green BF, Kraft SP, Carter KD, et al. Intraorbital wood detection by magnetic resonance imaging. Ophthalmology 1990;97:608 –11. 15. Ossoinig KC. Detection of wood foreign bodies [letter]. Ophthalmology 1991;98:274 –5. 16. McGuckin JF Jr, Akhtar N, Ho VT, et al. CT and MR evaluation of a wooden foreign body in an in vitro model of the orbit. AJNR Am J Neuroradiol 1996;17:129 –33. 17. Ho VT, McGuckin JF Jr, Smergel EM. Intraorbital wooden foreign body: CT and MR appearance. AJNR Am J Neuroradiol 1996;17:134 – 6. 18. Reshef DS, Ossoinig KC, Nerad JA. Diagnosis and intraoperative localization of a deep orbital organic foreign body. Orbit 1987;6:3–15. 19. Wilson WB, Dreisbach JN, Lattin DE, Stears JC. Magnetic resonance imaging of nonmetallic orbital foreign bodies. Am J Ophthalmol 1988;105:612–7. 20. Specht CS, Varga JH, Jalali MM, Edelstein JP. Orbitocranial wooden foreign body diagnosed by magnetic resonance imaging. Dry wood can be isodense with air and orbital fat by computed tomography. Surv Ophthalmol 1992;36: 341– 4. 21. Weisman RA, Savino PJ, Schut L, Schatz NJ. Computed tomography in penetrating wounds of the orbit with retained foreign bodies. Arch Otolaryngol 1983;109:265– 8. 22. Zinreich SJ, Neil RM, Aguayo JB, et al. Computed tomographic three-dimensional localization and compositional evaluation of intraocular and orbital foreign bodies. Arch Ophthalmol 1986;104:1477– 82. 23. Bullock JD, Warwar RE, Bartley GB, et al. Unusual orbital foreign bodies. Ophthal Plast Reconstr Surg 1999;15:44 –51. 24. Bulluck MH, Baker GS, Henderson JW. Injuries of the brain caused by penetration of the orbit (pitchforks, sled runners, arrows, etc.) Minn Med 1959;42:1408 –13. 25. Doucet TW, Harper DW, Rogers J. Penetrating orbital foreign body with intracranial involvement. Ann Ophthalmol 1983; 15:325–7. 26. Michon JJ, Miller NR. Management of combined penetrating intraorbital and intracranial trauma [letter]. Arch Ophthalmol 1993;111:438 –9. 27. Vander JF, Nelson CC. Penetrating orbital injury with cavernous sinus involvement. Ophthalmic Surg 1988;119:328 –30.
Liu and Al Shail 䡠 Retained Orbital Wooden Foreign Body 28. Heyner FJ, Passmore JW. Pseudotumor of orbit caused by retained foreign body. Am J Ophthalmol 1965;59:490 – 2. 29. Cartwright MJ, Kurumety UR, Frueh BR. Intraorbital wood foreign body. Ophthal Plast Reconst Surg 1995;11:44 – 8.
30. Tuppurainen K, Mantyjarvi M, Puranen M. Wooden foreign particles in the orbit—spontaneous recovery. Acta Ophthalmol Scand 1997;75:109 –11. 31. Buus DR, Tse DT, Farris BK. Ophthalmic complications of sinus surgery. Ophthalmology 1990;97:612–9.
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Case Report Patient 1 A 19-year-old male was struck in the left lower eyelid by a tree branch in mid-April 1998, with a large piece protruding from the Originally received: November 6, 2000. Accepted: June 1, 2001. Manuscript no. 200761. 1 Oculoplastics/Orbit Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. 2 Ophthalmology Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. 3 Neurosurgery Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. The authors have no financial interest in any of the equipment, instruments, drugs or laboratory facilities mentioned in this article. Correspondence and reprint requests to Don Liu, MD, FACS, Mason Eye Institute, University of Missouri, 1 Hospital Drive, Room EC149, Columbia, MO 65212. © 2002 by the American Academy of Ophthalmology Published by Elsevier Science Inc.
right orbit. Reportedly, an ophthalmologist removed this wooden foreign body completely and irrigated the wound thoroughly before wound closure. In the next few days, the same ophthalmologist performed additional “lid surgery” related to the WFB injury before referring the patient to a regional hospital. At the regional hospital, the patient presented with 20/20 vision in both eyes and a large draining right lower lid abscess. Computed tomography, performed at the end of April 1998, revealed “thickening of [the] right lateral rectus muscle with a small hyper-dense area, which could correspond to a hematoma or residual foreign body.” More specifically, there was no comment of an orbital roof fracture or possible retained foreign body made by the radiologist. An ophthalmologist at the regional hospital drained the lid abscess and prescribed systemic antibiotics for the patient. The culture from the abscess was sterile. The patient returned 10 days later with recurrence of lid abscess and draining fistula. At that time, the patient had normal vision and motility and was referred to a tertiary eye care center. Computed tomography performed in May at this tertiary eye care center revealed that the density previously described had now migrated toward the orbital apex. An orbital roof fracture near the orbital apex was also noted at that time. In May 1998, two oculoplastic surgeons at the tertiary eye care center proceeded with an exploration and drainage via the right lower lid fistula track. Reportedly at this time, approximately 20 pieces of wooden fragments were removed, with the largest one measuring 15 ⫻ 6 mm. The patient was discharged in satisfactory condition. However, the patient returned to the same center in early August 1998 with a history of more spontaneously extruding wood fragments from the fistula. He was readmitted for further management. A magnetic resonance image obtained in August 1998 demonstrated a mass, likely a granuloma containing a foreign body, located along the lateral orbital wall near the apex. The same two ophthalmologists performed exploration and drainage using the same approach via the same fistula as before. Three more pieces of wood were removed, with the largest one measuring 15 ⫻ 6 ⫻ 3 mm. The patient was given systemic antibiotics. The patient reISSN 0161-6420/02/$–see front matter PII S0161-6420(01)00928-9
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Ophthalmology Volume 109, Number 2, February 2002 ported an annoying diplopia on the first postoperative day. Follow-up examination in mid-September 1998 showed vision in the right eye to be 20/30 with a dilated right pupil. He also had 3 mm of right proptosis, restriction in both horizontal and vertical gazes, and a right lower lid retraction. Subsequently, in early 1999, a magnetic resonance image obtained at another institution suggested the mass had further migrated towards the apex and by that time had involved the “frontal basal area” with “focal signs of meningitis” (Fig 1).2 A standard orbital B-scan confirmed the presence of an orbital mass at the apex. Based on these findings, the patient was referred to another institution where a neurosurgical service was available. However, the service was not offered initially because of his lack of neurologic deficits. In February 1999, one author (DL) became involved, immediately admitted the patient to his care, and used a combined approach to remove the residual foreign bodies (see Surgical Technique for description). Intraoperative cultures later showed Haemophilus parainfluenzae, coagulase negative Staphylococcus and alpha hemolytic Streptococcus. Cultures of anaerobes, acid fast bacilli, and fungus were negative. One author (DL) requested identification of the wood, but the laboratory was unable to provide this service due to its limited capability. There was no postoperative complication whatsoever. The patient was followed-up regularly and was last seen in September 2000 for a 19-month follow-up. He maintained 20/20 vision in the right eye and had a dilated right pupil. He enjoyed full motility and single binocular vision. There was no proptosis, no draining fistula, and no more extruding wooden fragments. His right lower lid was in good position.
Patient 2
Surgical Technique
Discussion
A coronal flap was created, and the cranium was opened. The brain was retracted to expose the orbital apex. An intracranial mass was clinically evident. It appeared to be a pseudoencapsulated granuloma. The mass was carefully dissected from the surrounding normal tissues and was removed in piece-meal fashion. Several large pieces of wooden fragments, visible to the naked eye, were removed. The largest of these measured approximately 5 ⫻ 2 mm. With the removal of the intracranial portion of this mass, the orbital roof could then be removed in a controlled manner. The mass was easily identified and followed into the orbit. As much as is allowed by this approach and good exposure, the orbital portion of the mass was removed. At this point, more than 30 small pieces of wooden fragments were counted, not including those too tiny or those deeply embedded in the tissue. Next, an incision was made in the right lower eyelid using the existing scar. The fistula tract was followed gently from the skin opening to the surgical opening at the orbital apex. A small, soft catheter was next inserted in the orbital apex from the cranium above. While irrigating with antibiotics solution through the catheter, gentle repeated curettage was applied to the soft tissue of the fistula track both in circular and in to-and-fro manners. This was done so gently that no bleeding and no abrupt movement of the globe was observed. At the same time, the curettage was performed with enough force to remove suspected WFBs embedded in the fistula track. Indeed, an occasional gritty sensation or minor resistance was felt. Using this technique, we observed many fine particles in the irrigation fluid coming out of the skin wound. Only when no more particles were seen, no gritty sensation was felt, and a few drops of blood became visible in the irrigation fluid, did closure begin. The lid retraction was repaired with a Z-plasty.
A variety of orbital foreign bodies have been reported. These include glass, stone, metal, wood, graphite, button, faucet handle, fish jaw, iron hat peg, chopstick, pencil, large wooden plank, pocket knife, meat hook, and pitchfork.1,2,23–26 In general, a penetrating foreign body orbitocranial injury may be categorized either as a low-velocity or high-velocity injury, with most of them in the former category. Young men appear to have a propensity to these injuries, and children tended to get injured by falling onto a pencil.1– 4 In the preantibiotics era, the mortality rate was as high as 25%, and the morbidity rate 76%.2,3 In the 1970s, before the advent of modern computed tomography or magnetic resonance imaging technique, intracranial WFB was not initially suspected in 74% of cases.1– 4,7 Although there has been no large series to clearly document a decrease in the mortality and morbidity rates, it seems reasonable to assume such a trend exists. The reasons include the advent of antibiotics, heightened awareness on the part of the general public and physicians, improved diagnostic imaging techniques, and refined surgical instruments and techniques. Intracranial foreign body injury is managed by the neurosurgeons. Hence, its diagnosis, management, and potential complications are not discussed here. Because each orbital foreign body injury is different, and the diagnosis and management of a patient in the acute stage is beyond the scope of this article, our discussion will be limited to only missed or retained orbital WFBs. Ophthalmologists are usually the first to see patients with
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A 20-year-old male was assaulted in the left eye with a wooden stick in mid-1999. His vision was 20/20 in the right eye and 20/200 in the left eye. Reportedly, an ophthalmologist removed the foreign body completely and explored and irrigated the wound before closure. A few weeks later, the patient went to a local hospital with a draining fistula. At that time, his vision was 20/20 in the right eye and counting fingers in the left eye. Apparently a computed tomography revealed an orbital lesion and more exploration, drainage, and fistula repair were performed. Toward the end of 1999, he presented to the emergency room of the same tertiary center. At that time, his vision was 20/20 in the right eye and hand motion in the left eye. Hertel measurement with a base of 110 showed 22 mm in the right eye and 26 mm in the left eye. There was a large left exotropia with limited ocular motility in all gazes. There was a 2-mm left ptosis with a levator function of 13 mm. The right eye was normal. The patient was then referred to the authors. Computed tomography and magnetic resonance imaging at that time showed a complex intraorbital and intracranial lesion protruding nearly 1 cm into the left subfrontal region. The patient was taken to the operating room in January 2000. Using the same surgical technique and noting essentially the same intraoperative findings, we removed the retained foreign bodies and granulation tissue without difficulty (Fig 2). There were no postoperative complications. His vision remained 20/20 in the right eye and counting fingers in the left. He regained full motility of the left eye. There was no clinical evidence of proptosis or ptosis. There was no recurrence of draining fistula or extruding wooden fragments. He was last seen in September 2000, a 9-month follow-up without any recurrences or new complaints.
Liu and Al Shail 䡠 Retained Orbital Wooden Foreign Body
Figure 1. A, Computed tomographic scan of the patient’s orbit and brain, taken in April 1998. The coronal view demonstrated that the lesion involved mainly the lateral aspect of the right orbit. B, Axial view of the patient’s orbit and brain, taken in April 1998. C, Computed tomographic scan obtained in May 1998. Coronal cut of the patient’s orbit showed a roof fracture near the apex. No foreign body could be identified. D, Magnetic resonance image (MRI), obtained in August 1998, showed involvement of the orbital apex and cranium. E, Axial view of the MRI from August 1998. F, Magnetic resonance imaging scan in January 1999 showed migration of the foreign body-granuloma complex toward the cranium. G, Axial view of the MRI obtained in January 1999.
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Ophthalmology Volume 109, Number 2, February 2002 a penetrating orbital WFB injury, and are also usually participants in surgical intervention, whether it is in the acute or secondary stage. Therefore, their diagnostic skills, surgical armamentarium, and awareness of the potential complications of a missed or retained orbital WFB are crucial to the proper care of these patients. There are many case reports and imaging technique studies of orbital WFB injuries. These case reports mainly emphasize the potential devastating effects of an orbital WFB. All of these reports also emphasize the importance of recognizing the latent period (the time between the initial injury and when a serious complication was apparent). Such a latent period could vary from hours to many months.3–13 The imaging technique studies chiefly stressed the usefulness and limitations of various imaging techniques.14 –20 Suffice to say, no imaging modality to date, whether computed tomography, magnetic resonance imaging, or standardized orbital B-scan, can detect an orbital WFB with 100% sensitivity. Hence, in addition to relying on the best imaging technology, a thorough history and meticulous examination coupled with a high index of suspicion remain critical factors in making the correct diagnosis of orbital WFBs. There are several reasons why an orbital WFB results in serious complications. Its relatively soft and organic nature coupled with porosity makes it easy to fragment and to harbor various microorganisms.3,7,10 Unless it is relatively large or it contains otherwise radiopaque materials, it is difficult to detect.14,17,20 Consequently, it is essential to make the proper diagnosis and effect timely surgical intervention when an orbital WFB is suspected. A team approach is often used in an acute situation. When a patient presents with an acute injury due to a large orbitocranial foreign body, a team approach involving neurosurgeons and ophthalmologists under emergency conditions is obviously required. For example, Doucet et al25 reported a large wooden plank in the right orbit with clear computed tomographic evidence of cranium penetration. Michon and Miller26 reported their joint efforts with neurosurgeons in removing a large steel rod impinging on the brain stem of a child. Vander and Nelson27 also worked with neurosurgeons to remove a large nail impinging on the cavernous sinus. Albert et al4 reported an emergency right front temporal craniotomy performed by neurosurgeons 12 hours after they had admitted a patient with a pencil lodged in the right orbit. Mutlukan et al5 had a patient who underwent an emergency right frontal craniotomy along with right optic canal decompression 6 hours after admission. A team approach involving a neurosurgeon is occasionally used in a secondary manner, mainly when late neurologic complications become evident. Kazarian et al6 described an 8-year-old boy who presented with a small puncture wound in the right upper eyelid. Six weeks later, the patient was admitted for proptosis of the right eye with drainage from the puncture wound, headache, vomiting, and nuchal rigidity. The diagnosis of a right temporal lobe abscess was made and a temporal craniotomy was performed by a neurosurgeon. An ophthalmologist and an otolaryngolosist also participated in the exploration and drainage of the fistula. A few weeks later, the patient’s
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condition deteriorated and a different team performed another exploration. Once the orbit had been unroofed, a WFB was extracted from the superior orbital fissure. Despite successful removal of the WFB at that time, the patient had permanent ocular complications and neurologic deficits. In 1964, Bard and Jarrett7 reported a series of nine patients with various penetrating orbital injuries. These patients underwent cranial and/or orbital exploration at different times for various reasons. As the patient series was collected from the late 1950s to the early 1960s (i.e., before the advent of modern imaging technology), most of the patients did not do very well and many had ocular and neurologic complications. Other authors in those early days also reported missed orbital WFBs with serious complications and often after repeated explorations.8,28,29 Therefore, it is extremely important for ophthalmologists to recognize the serious consequences of a missed or retained orbital WFB and the rationale of a timely and effective surgical intervention. Furthermore, it should be recognized that when an orbital WFB is initially missed, the diagnosis and subsequent management can become even more challenging. Our two cases presented herein were unique and instructive in several aspects. Both patients had undergone repeated exploration and drainage by ophthalmologists at major centers. Despite best efforts, the ocular problems for both patients recurred and, in fact, became worse. Although both patients were free of acute or serious intracranial complications at the time of our initial examination, this did not diminish our sense of urgency of the problems. In fact, this only served to heighten our preparedness. Our discussion now centers on two major points: (1) the retention and subsequent migration of the WFBs, and (2) our surgical technique and rationale. It is known that a retained orbital WFB may migrate or extrude spontaneously.1–3,30 In the two cases reported herein, however, there are strong suggestions that other mechanisms, including iatrogenic ones, could play a role in the observed orbital WFB retention and migration. Understandably, it is very difficult to completely remove a piece of wood, particularly a tree branch, from living tissue. The wood “catches” the tissue and tends to disintegrate as force is applied to it during an attempted removal. Usually large orbital WFBs can be extracted under direct visualization. Copious irrigation is generally used to remove the smaller foreign body particles and fragments, whether directly visualized or suspected. Given this, it is likely that when a patient’s problem persists, ophthalmologists tend to become more aggressive. In other words, a more extensive exploration with more irrigation will follow. In both of our patients, the observed subsequent migration of the retained orbital WFB (and the granuloma that surrounds it), usually perceived as a natural course may have an additional mechanism.1–3,30 It is possible that that course may have been exacerbated if not directly caused by the subsequent and repeated, albeit well-intentioned attempts to remove the WFB using the same skin wound approach and copious irrigation. At first glance, it appears logical to utilize the existing skin wound and to explore the fistula track. It may very well
Liu and Al Shail 䡠 Retained Orbital Wooden Foreign Body
Figure 2. A, Computed tomographic scan from January 2000. Coronal view demonstrated the intracranial position of the foreign body granuloma. B, Axial view. C, Magnetic resonance imaging scan from January 2000. The intracranial location of the foreign body is clearly demonstrated. D, Part of the wooden fragments that were surgically removed.
be the technique used initially by most surgeons. However, we would like to stress that it is not the best technique to use repeatedly when a patient continually returns with complications. Emphatically, this approach offers only a very limited exposure of the anterior orbit and permits no direct visualization whatsoever of any deep orbital anatomy. It should be avoided when the pathology is known to be located deep at the orbital apex. In fact, it is very likely that the remaining orbital WFB was further disintegrated and pushed deeper into the surrounding tissues due to such blind surgical manipulations. Additional irrigation with hydraulic pressure directed inward, from the skin wound toward the deep end of the orbit, may further facilitate the deeper migration of these remnants. Careful review of the computed tomography obtained for patient 1 in May 1998 revealed a small orbital roof fracture near the apex (Fig 1). This breach of anatomic integrity made the subsequent intracranial migration of the WFB and granuloma complex possible, whether natural or iatrogenic. Although it was not possible for anyone to state with certainty if any WFB was present at the fracture site, the following argument highlights the crux of the problem. If one assumes that there was no WFB present initially at the fracture site, then the iatrogenic mechanism for the intracranial migration of the WFB is a valid concern. The subsequent clinical course of this patient appeared to render
good support of this hypothesis. However, if one assumed that some WFBs (detectable or not) were, indeed, initially present at the fracture site, then the clinician has to rely on a well-conceived and well-planned combined approach from the very beginning. A blind surgical manipulation has no place in the management of these patients at all, let alone repeating it. An orbital roof fracture with a possible retained WFB was evident in patient 2 at the time we obtained a computed tomography in January 2000 (Fig 2). This fracture, if it was initially present, also allowed the subsequent intracranial migration of the WFB and granuloma complex. We were unable to obtain any detailed information or previous scans from the previous physicians. It would be hard to imagine that the radiologist could miss such a large fracture or retained WFB, if indeed it were initially present. Accordingly, the management of this patient (and patient 1) by the other ophthalmologists did not demonstrate their concerns of a possible intracranial WFB. Therefore, an iatrogenic mechanism for the intracranial migration of the WFB remained a strong consideration. It must be emphasized again that maintaining a high index of suspicion and correlating clinical findings with imaging studies are the most helpful guide in managing these patients. The ophthalmologist should provide a de-
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Ophthalmology Volume 109, Number 2, February 2002 tailed history and the clinical findings when reviewing the imaging study with the radiologist. Emphatically, it is not prudent for any clinician to make a decision based solely on the negative findings of an imaging study. Although it is realized that no surgical technique is 100% effective, our combined surgical approach took various considerations into account. We began with the retraction of the brain to locate the intracranial portion of the WFB granuloma complex. Once the intracranial portion of this complex was removed and the orbital apex was exposed from above, there was direct visualization of everything thereof. As much as possible, this WFB granuloma complex was removed from the deep orbit under direct visualization. Subsequent removal of the WFB granuloma complex was achieved with a two-prong approach and we felt this was the critical maneuver. The circular plus to-and-fro curettage within the fistula, with simultaneous irrigation from deep orbit out to the skin wound, helped bring out fragments and particles embedded in the tissues. This maneuver continued until the fluid coming out became clear. Of critical importance too was the direction of irrigation fluid flow. If irrigation was performed in the usual skin-to-orbital-apex manner, it was possible that our patients’ problems might have persisted or worsened as these particles could easily have been dispersed intracranially. Constantly watching the globe to make sure there was no abrupt movement or change in pupil size was also important to avoid complications.31 Using this combined approach, both of our patients did very well at follow-up (one patient at 9 months and one at 19 months). There were no complications whatsoever, and all of their preoperative symptoms were resolved. In summary, an initial good history-taking, keen clinical observation and high index of suspicion, coupled with modern imaging techniques, are necessary to make a correct diagnosis of a retained orbital WFB. A retained orbital WFB is known to have the potential to migrate or extrude spontaneously. Ophthalmologists must do their best to prevent such migration deeper into the orbit or the cranium during their attempt to explore the orbit and extract the WFB. When one surgical technique repeatedly fails to achieve the expected results, a surgeon must use other viable alternatives or an early referral. Our technique seems to have been effective in these two patients. As each patient is unique, modification of this surgical technique is expected, although the basic principles remain the same.
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