Cases of Orbital Cellulitis Revealing Neglected Intraocular Foreign Bodies

Background: Orbital cellulitis is defined as acute inflammatory orbital swelling of infectious origin. Most often secondary to sinusitis. Intraocular foreign bodies neglected because of their small size, or sometimes radio-transparent nature, can be difficult to diagnose even with radiology and be responsible for orbital cellulitis. We demonstrate the diagnostic and therapeutic difficulties.Patients and Methods: This is a retrospective descriptive study of patients with unilateral orbital cellulitis revealing neglected intraocular foreign bodies, conducted in the Department of Adult Ophthalmology, Hospital August 20, 1953, involving 58 patients, from January 2015 until December 2020.Results: The average age of the patients was 38.5 years. The most affected age group was between 21 and 30 years with a clear male predominance. A decrease in visual acuity was found in all patients (unilateral blindness 43%) and a cellulitis complicated by a purulent melt (43%). All patients received medical treatment, including intravitreal injections of antibiotics in 71% of cases, and surgical treatment consisting of extraction of the foreign body and immediate evisceration of the eyeball in 25% of cases.Conclusion: Orbital cellulitis, although mostly secondary to sinusitis, can reveal various etiologies such as intra-orbital foreign bodies that can go unnoticed and be life-threatening and functionally damaging, especially when the diagnosis is made late and management is inappropriate. The presence of an intraocular foreign body must be suspected in all cases of orbital trauma associated with a palpebral wound, even if it is minimal, or in the presence of a clinical aggravation. Any delay in diagnosis and/or treatment can lead to serious complications that can affect the functional and even vital prognosis. The surgical treatment consists of the extraction of the foreign body. The recourse to evisceration in our context unfortunately continues to persist at high rates; because of the delay of consultation and thus of the management.

A Missed Periorbital Foreign Body

Trauma involving the eye, orbital and periorbital regions are commonly seen in cases of road traffic accidents, sports injuries and physical assaults, but cases of intraorbital / periorbital foreign bodies are rare. Early presentation, history of trauma, and imaging help in diagnosis. However, sometimes the diagnosis is missed, particularly in cases with late presentation and a vague history of minor trauma and trauma with a non-metallic foreign body. A missed foreign body may present later with infection, repeated inflammation, ptosis, and proptosis and motility defect, further complicating the management.Here, we present a case of missed foreign body during the primary repair of facial injury in a 32-year male with polytrauma sustained in a road traffic accident. Evidence of foreign body was reported in a CT scan head advised for head injury. Re-exploration of wound and removal of foreign body is performed under local anaesthesia.

An intraorbital foreign body with paradoxical radiological interpretations to dive in or not? a surgeon’s dilemma

A 10-year-old girl presented to our O.P.D. with intra-orbital trauma. On radiological workup following admission, USG B Scan, MRI Brain and 3D reconstructed faciomaxillary imaging were indeterminate for presence of foreign body, whereas CT scan showed a hyperdense lesion suggestive of intra-orbital foreign body. In this condition of imaging dilemma, surgical exploration was decided since there was no improvement in clinical symptoms via lateral orbital approach. Two small wooden pieces were detected in orbital exploration. This case highlights the role of history taking, clinical judgement in all cases of intraorbital tumour more so in paediatric population than solely going by the investigative modalities.

Two Cases of Orbital Apex Syndrome after Blunt Orbital Trauma

PURPOSE: To report two cases of orbital apex syndrome caused by blunt orbital trauma without structural damage of the orbit. CASE SUMMARY: (Case 1) A 50-year-old male came to our clinic complaining of visual loss after blunt orbital trauma by a metal bar. The best-corrected visual acuity was no light perception and light reflex was not observed in the affected eye. He also presented with complete ptosis and ophthalmoplegia with relative sparing of adduction and depression. High signal intensity of the orbital soft tissue including the optic nerve sheath was revealed using a T2-weighted image in magnetic resonance imaging. After starting steroid pulse therapy, his visual acuity improved to counting fingers on the third day. Ocular movement and levator function recovered to the normal range while visual acuity remained counting fingers. (Case 2) A 64-year-old female presented with complete ptosis after trauma to her right eyeball. The best-corrected visual acuity was 20/25 in the right eye. Complete ptosis and ophthalmoplegia with relative sparing of abduction and depression in the right eye were observed at the initial presentation. Magnetic resonance images showed enhancement of the right periphery optic nerve and distal rectus muscle. Two months after undergoing steroid pulse therapy, levator function and ocular movement recovered completely, and visual acuity improved to 20/20. CONCLUSIONS: The orbital apex syndrome caused by blunt orbital trauma showed good response to steroid pulse therapy. Steroid treatments may therefore be considered for the treatment of traumatic orbital apex syndrome.

Clinical Characteristics of Intraorbital Foreign Bodies: Our Experience with 14 Cases

PURPOSE: To evaluate the clinical characteristics of intraorbital foreign bodies as well as the treatment outcomes. METHODS: This was a noncomparative interventional case series. Clinical data and radiographic images were gathered via retrospective chart reviews of 14 patients who underwent surgical removal of intraorbital foreign bodies by an oculoplastic surgeon at the Asan Medical Center, Seoul, Korea between July 2012 and November 2015. RESULTS: The mean age of patients was 45.1 years and 13 patients (92.9%) were male. There were 9 metallic; 3 nonmetallic, inorganic; and 2 organic intraorbital foreign bodies in this series. The most common orbital complication was orbital wall fracture (8, 57.1%), and one patient had orbital cellulitis associated with a wooden foreign body. Six patients (42.9%) underwent surgical removal of foreign bodies in a delayed setting, and 4 of them needed surgery to allow for the brain magnetic resonance image tests to evaluate neurologic problems. There were 6 patients (42.9%) who had a postoperative corrected visual acuity worse than 20/200, and all of them had poor visual acuity at the time of injury due to associated eyeball or optic nerve injuries. Four patients (28.6%) had eyeball movement limitations from the initial trauma, but only 1 patient had persistent limitations postoperatively. There were no other complications associated with surgical removal. CONCLUSIONS: The majority of patients with intraorbital foreign bodies were male who had periorbital traumas. The most common foreign body was metal, and orbital wall fractures were common. The poor visual prognosis was related to the eyeball or optic nerve injuries from the initial trauma. The urgent surgical removal should be performed for organic foreign bodies or associated orbital/ocular injuries. Metallic foreign bodies may also be considered for removal to allow for possible brain magnetic resonance image evaluations in the future.

The use of virtual surgical planning and navigation in the treatment of orbital trauma / 中华创伤杂志(英文版)

Virtual surgical planning (VSP) has recently been introduced in craniomaxillofacial surgery with the goal of improving efficiency and precision for complex surgical operations. Among many indications, VSP can also be applied for the treatment of congenital and acquired craniofacial defects, including orbital fractures. VSP permits the surgeon to visualize the complex anatomy of craniofacial region, showing the relationship between bone and neurovascular structures. It can be used to design and print using three-dimensional (3D) printing technology and customized surgical models. Additionally, intraoperative navigation may be useful as an aid in performing the surgery. Navigation is useful for both the surgical dissection as well as to confirm the placement of the implant. Navigation has been found to be especially useful for orbit and sinus surgery. The present paper reports a case describing the use of VSP and computerized navigation for the reconstruction of a large orbital floor defect with a custom implant.

Clinical profile of medicolegal cases presenting to the eye casualty in a tertiary care center in India.

Purpose: The purpose of this study was to analyze the clinical profile of medicolegal cases (MLCs) presenting to the eye casualty in a tertiary care hospital. Materials and Methods: Retrospective review of records. The cases were grouped according to the Ocular Trauma Classification Group classification system. Results: Out of 188 MLCs, 164 (87.2%) were male. Mean age (±standard deviation) was 31.6 (±12.7) years. Age ranged from 7 to 75 years. Twenty‑six (13.8%) patients had bilateral involvement. The fist was the most common mode of injury, which was seen in 109 (58%) cases. A total of 27 (14.3%) patients had associated extraocular injury. No evidence of ocular or orbital trauma (malingering) could be found in 13 (7%) patients. Mechanical trauma was present in 169 (90%) patients with injury to globe in 129 (69%) patients and injury to lid or orbit without damage to the globe in 40 (21%) patients. Chemical injury was observed in 6 (3%) patients. Closed globe injury (CGI) was seen in 116 eyes and open globe injury (OGI) was noted in 29 eyes. The most common type of injury, zone, pupil, and grade of injury in CGI were Type A or contusion (79%), Zone I (72%), Pupil B (absence of relative afferent pupillary defect) in 95%, and Grade A [visual acuity (VA) ≥20/40] in 68% of the eyes, respectively. The most common type of injury, zone, pupil, and grade of injury in OGI were Type B or penetrating (48%), Zone II (38%), Pupil B (59%), and Grade D (VA 4/200‑light perception) (42%), respectively. Conclusions: The most common form and mode of ocular injury in MLC were closed globe injury and fist, respectively. The most common type of injury in CGI and OGI was contusion and penetrating injury, respectively.

Enoftalmos unilateral por várice orbitaria / Enophthalmos secondary to an orbital varix

El enoftalmos es un motivo de consulta poco frecuente en la práctica médica. La mayor parte de los casos se debe a un aumento de la cavidad ósea orbitaria de origen traumático. Presentamos el caso de una mujer de 63 años que consultó por enoftalmos progresivo de su ojo izquierdo, de doce años de evolución. El examen oftalmológico reveló la presencia de un marcado enoftalmos del lado izquierdo, que mejoraba notablemente con maniobras de Valsalva. Una tomografía computarizada y una resonancia magnética de la órbita permitieron diagnosticar una várice orbitaria no complicada. Las várices orbitarias son infrecuentes y por lo general se manifiestan por episodios de exoftalmos intermitente. Sin embargo, en raras ocasiones, la distensión y colapso repetidos pueden llevar a un enoftalmos progresivo por atrofia de la grasa orbitaria.

The enophthalmos is a rare cause of consultation in medical practice. The majority of cases are due to orbital space enlargement of traumatic origin.We report the case of a 63 year old patient with progressive enophthalmos of the left eye, with twelve years of evolution. Ophthalmologic examination revealed the presence of a marked enophthalmos on the left side, which improved significantly with Valsalva maneuvers. A CT scan and an MRI of the orbit allowed diagnosing uncomplicated orbital varices. Orbital varices are rare and usually manifest by episodes of intermittent exophthalmos. However, on rare occasions, repeated distension and collapse can lead to progressive enophthalmos by orbital fat atrophy.

Remoção de corpo estranho em cavidade orbitária: Relato de caso / Removal of foreign bodies from the orbital cavity: a case report

A penetração de corpos estranhos na cavidade orbitária normalmente ocorre pelo trauma direto e penetrante. A depender da localização e da composição do corpo estranho, o diagnóstico pode ser feito por observação direta ou mediante exames de imagens. As radiografias convencionais, as ultrassonografias, as tomografias computadorizadas e a ressonância magnética são exames auxiliares no diagnóstico. Entretanto, a natureza de alguns corpos estranhos pode dificultar a sua identificação a despeito dos exames de imagem utilizados. A presença de corpos estranhos na cavidade orbitária pode resultar em celulites orbitárias, lesões oculares, lesões cutâneas adjacentes, amaurose, perda parcial da acuidade visual, entre outras complicações. O objetivo deste trabalho foi relatar um caso clínico de uma paciente, 17 anos de idade, feoderma, agredida com um pedaço de madeira, diretamente sobre a órbita esquerda. A paciente evoluiu com celulite orbitária refratária à antibioticoterapia e perda da acuidade visual do olho esquerdo. A radiografia de face não revelou a presença de corpos estranhos. Na tomografia computadorizada das cavidades orbitárias, observou-se, na órbita esquerda, imagens com densidade semelhante a ar. A paciente foi, então, submetida à cirurgia exploratória, sob anestesia geral, no Hospital Municipal Miguel Couto /RJ, e nela inúmeros fragmentos de madeira foram removidos, evoluindo com remissão do processo infeccioso.

The intrusion of foreign bodies into the orbital cavity usually occurs through direct and penetrating trauma. Depending on the location and composition of the foreign body, the diagnosis can be made by direct observation or by the analysis of imaging studies. Conventional radiography, ultrasound, CAT scans and MRI are used as auxiliary investigations in the diagnosis. However, the nature of some foreign bodies can make their identification difficult, even with the use of imaging techniques. The presence of foreign bodies in the orbital cavity may result in orbital cellulitis, eye lesions, adjacent skin lesions, blindness, partial loss of visual acuity, among other complications. The aim of this study was to report the clinical case of a female dark-skinned patient, aged 17, injured by a piece of wood directly onto her left orbit. The patient developed orbital cellulitis, which was unresponsive to conventional antibiotic therapy, and loss of visual acuity. Radiography of the face did not reveal the retention of any foreign bodies. Computed tomography of the orbital cavity revealed images with a density similar to that of air were observed. The patient underwent exploratory surgery under general anesthesia at Hospital Miguel Couto - RJ, resulting in the removal of many wood fragments from the orbital cavity and the resulting remission of the infectious process.

Tissue repair after orbital reconstruction using polypropylene mesh implants: A histological study in dogs / Reparo tecidual após reconstrução de órbita com implante de malha de polipropileno: um estudo histológico em cães

Purpose: This experimental study aimed to assess the histological outcomes of orbit reconstruction with a polypropylene mesh implant in an animal model using dogs. Methods: The right and left orbits of 12 dogs were fractured in order to simulate orbital fractures similar to those occurring in humans as a result of trauma. The orbits were reconstructed with a polypropylene mesh positioned approximately 10 mm beyond the bone defect borders. The 24 orbits were divided into four groups of six: one group was given one polypropylene mesh layer; another group received two layers; a third group was given three polypropylene mesh layers; and the fourth group did not receive any implant (control group). The dogs were divided into clusters of four animals and were euthanized 15, 30, or 60 days after the surgery. The orbit medial wall was removed, and samples were subjected to histological polypropylene mesh analysis by optical microscopy. Data were analyzed using a non-parametric test with a 5% level of significance. Results: It was found that the polypropylene mesh caused a mild to moderate tissular reaction. Conclusion: The implant was well tolerated even with two or three overlapping layers.

Objetivo: Trata-se de estudo experimental em que se reconstruíram os continentes orbitais de 12 cães com implante de tela de polipropileno. Metodologia: Os continentes orbitais foram fraturados simulando as fraturas orbitais que ocorrem em humanos devido ao trauma e reconstruídas com tela de polipropileno cortadas com extensão de cerca de 10mm além da margem do defeito ósseo. Utilizaram-se uma, duas ou três camadas de tela de polipropileno nas órbitas teste e algumas órbitas, somente fraturadas, serviram como controle. Os cães foram sacrificados nos tempos de 15, 30 e 60 dias de pós-operatório; os tecidos das órbitas teste e controle foram removidos e preparados para análise histológica em microscopia óptica. Os resultados obtidos pela análise histológica foram submetidos a análise estatística não paramétrica com 5% de significância. Resultados: A tela de polipropileno causou reação tecidual de leve a moderada nos tecidos. Conclusão: O implante foi bem tolerado, mesmo quando a tela foi superposta em duas ou três camadas.

An unusual intraorbital foreign body: A brake lever.

Orbital trauma usually affects the bony parts of the orbit; however, in rare cases foreign bodies are found within the orbit. In this report, we introduce a case with unusual large intraorbital foreign bodies (two parts of a brake lever) after a motorcycle accident. Although one of the foreign bodies was located in the posterior orbit, they required only one simple operation for retrieval. We will discus the management strategy.

Two Cases of Intraorbital Wooden Foreign Bodies

PURPOSE: To report two cases of acute and chronic intraorbital wooden foreign bodies. METHODS: We sutured an 11-year-old boy who had sustained forehead laceration with a pencil (Case 1) and sutured a 43-year-old man who had sustained lower eyelid laceration due to a wooden splinter embedded in the eyelid 1 month before (Case 2). We confirmed the presence of intraorbital wooden foreign bodies in both cases using radiological examinations and removed them. RESULTS: In Case 1, a pencil from the primary wound, and the patient obtained good visual acuity and full extraocular motility for six months. In Case 2, granulated wooden foreign bodies were removed and had limited extraocular motility and diplopia at post-operative three months. CONCLUSIONS: Unremoved intraorbital foreign bodies may lead to many ophthalmologic sequelae. If intraorbital foreign bodies intrude into the adjacent central nervous system, it may lead to fatal complications. The actual presence of intraorbital wooden foreign bodies should require radiological examinations; when confirmed, they should be removed surgically.

A Case of Optic Nerve Evulsion

PURPOSE: The authors report a case of optic nerve evulsion with literature review. METHOD: 15-year-old boy, who had optic nerve evulsion by tear of inferior rectus and medial rectus muscles, and hypotony by retinal and choroidal detachment RESULTS: we could preserve the eyeball with normal pressure by pars plana vitrectomy, endolaser photocoagulation and silicone oil injection

The Utility of Three-dimensional CT in Orbital Diseases

PURPOSE: Orbital computed tomography was useful for evaluation of orbital truama because it can visualize most soft tissues, foreign bodies and bone details. Advancements in computer software makes three diemensional CT available with more higher quality and reasonable cost. We studied the officency, merit and limitation of orbital three dimensional CT. METHODS: We evaluated the conventional orbital CT and three dimensional orbital CT of the patients visited department of ophthalmology and emergency room to orbital trauma or other orbital diseases. RESULTS: The three dimensional orbital CT was not superior to conventional orbital CT in evaluation of orbital soft tissue disease but useful for evaluation of orbital bony details. CONCLUSION: In cases of coexamination with conventional orbital CT, the three dimensional orbital CT was useful for diagnosis and surgical planning in orbital truamatized patient.

Magnetic Resonance Imaging of Orbital Trauma / 中华创伤杂志

The paper describes the appearance of orbital trauma in 5 cases on magnetic resonance imaging (MRI). It helps to show subacute intraorbital hematomas not detectable with plain CT. MRI is better also than CT in the detection of traumatic arteriovenous fistula with proptosis without the use of contrast medium. But, MRI is contraindicated in the search for foreign bodies in the skull, for which CT scan is far superior.