BASICS

DESCRIPTION

Intraorbital foreign bodies (IOFBs) occur as a result of a high-velocity penetrating injury or direct impalement of an object.

EPIDEMIOLOGY

The majority are male, typically of young age (less than 30 years old).

GENERAL PREVENTION

Education and protective eyewear.

PATHOPHYSIOLOGY

Traumatic insertion of a foreign body through the eyelid or conjunctiva.

ETIOLOGY

• Projectile, usually metallic, foreign bodies such as BB pellets and firearms

• Penetrating trauma from nonmetallic foreign bodies, either organic (e.g., tree branch, pencil) or inorganic (glass, plastic, or stone)

DIAGNOSIS

HISTORY

• A history of periocular trauma is usually elicited.

• A delayed presentation from the time of injury is not uncommon, especially with children or patients who sustain trauma while under the influence of various substances.

• A detailed history is essential in patients who present with orbital infections or inflammation.

PHYSICAL EXAM

• Visual acuity can range from normal to complete loss of vision, depending on associated ocular and orbital injuries.

• Afferent papillary defect may be present if optic nerve is involved.

• Extraocular muscle underaction, if extraocular muscles are affected

• Gaze-evoked amaurosis (with apical IOFBs)

• Blepharoptosis

• Proptosis

• Orbital inflammation

• Careful examination of the periocular skin and conjunctiva, especially the fornices, to identify entry wound

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Wound culture (aerobic, anaerobic, fungal)

• Foreign body culture

• CBC may reveal elevated serum white cell count secondary to chronic orbital inflammation

Imaging

• Plain film radiographs for metallic IOFBs

• CT

– Excellent for identifying metal or glass

– Safe in the presence of ferromagnetic metallic foreign bodies

– Inorganic IOFBs (e.g., wood) can mimic air on CT

– Quantitative CT with wide bone window settings can distinguish wood from low-density signals of air or fat

• MRI if CT scan is negative and non-metallic IOFB is suspected

– MRI can be used to localize BB pellets, which are made of steel, and coated with copper or zinc

• Ultrasound (US) can be used to localize the IOFB; however it does not image the orbital apex reliably.

Follow-up & special considerations

• Orbitocranial extension should be ruled out, especially in children who have thinner orbital bones.

– Coronal and parasagittal images should be obtained in suspected transorbital, intracranial penetration.

Diagnostic Procedures/Other

Electroretinography (ERG) to assess for photoreceptor toxicity if iron or copper containing IOFB is adjacent to sclera.

Pathological Findings

With organic IOFBs: Chronic inflammation with or without granulomatous reaction and fibrosis.

DIFFERENTIAL DIAGNOSIS

• Orbital cellulitis

• Idiopathic orbital inflammation

• Orbital neoplasm (children)

TREATMENT

MEDICATION

• Broad-spectrum antibiotic therapy with anaerobic coverage, in cases of orbital cellulitis secondary to chronically retained IOFBs (more common with organic IOFBs)

• Antitetanus prophylaxis

SURGERY/OTHER PROCEDURES

• Surgical removal depends on visual status, composition of IOFB, and location within the orbit.

• Surgical removal is indicated for the following:

– Neurological compromise

– Ocular motility restriction

– All organic IOFBs

– Inorganic IOFBs if they are located in the anterior orbit and are easily accessible

• Inorganic IOFBs that are located posteriorly may be left in place, unless they are causing orbital complications.

• Percutaneous US and fluoroscopy can be used intraoperatively to localize the IOFB.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Ophthalmologist

• Neurosurgeon (if intracranial involvement)

PROGNOSIS

• Vision loss is generally related to initial injury and not as a result of complications from IOFB or management.

• Retained metallic IOFBs are usually well-tolerated and have a good visual prognosis. The exception is metallic IOFBs containing copper, which can cause a chronic suppurative orbital inflammation.

• Organic IOFBs have a higher incidence of vision-threatening complications, and a higher risk of orbital and cerebral infections.

COMPLICATIONS

• Acute orbital cellulitis (usually from organic material such as wood)

• Chronic suppurative orbital inflammation (from copper foreign bodies)

• Sterile abscess

• Orbitocutaneous fistula

• Orbital wall osteomyelitis

• Cerebral infection

ADDITIONAL READING

• Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiological factors, management, and outcomes. Ophthalmology 1997;104:96–103.

• Fulcher TP, McNab AA, Sullivan TJ. Clinical Features and Management of Intraorbital Foreign Bodies. Ophthalmology 2002;109:494–500.

• Ho VH, Wilson MW, Fleming JC, et al. Retained Intraorbital Metallic Foreign Bodies. Ophthal Plast Reconstr Surg 2004;20:232–236.

• Nasr AM, Haik BG, Fleming JC, et al. Penetrating Orbital Injury with Organic Foreign Bodies. Ophthalmology 1999;106:523–532.

• Shelsta HN, Bilyk JR, Rubin PA, et al. Wooden Intraorbital Foreign Body Injuries: Clinical Characteristics and Outcomes of 23 Patients. Ophthal Plast Reconstr Surg 2010;26:238–244.

CODES

ICD9

• 360.60 Foreign body, intraocular, unspecified

• 870.4 Penetrating wound of orbit with foreign body

CLINICAL PEARLS

• Rule out intracranial involvement of IOFB prior to removal.

• All organic IOFBs should be removed.

• Inorganic IOFBs that are easily accessible in the anterior orbit should be removed, while those in the posterior orbit can be left in place unless causing orbital complications.

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