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- A rare orbital foreign body penetrating into maxillary sinus: A brake lever
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Subodh Saraf ,MS;Ravindra Singh,MS; Vijay Gupta, MS; Kamal Arora, MS
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- Corresponding Author:
- Dr. Subodh Saraf, MS
- Registrar
- Global Hospital Institute of Ophthalmology
- Abu Road 307510
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| Article Code RJO20110108 |
| Abstract |
In this report, we introduce a case with unusual large foreign body (part of a brake lever around 7cm in length) which entered in the orbit after a motorcycle accident. The brake lever made a laceration in the left lower lid and then displacing the eyeball upward, its bigger rounded end fractured the floor of orbit and entered in maxillary sinus. Rest of the part was protruding outside from the eyelid. There was no ocular laceration, extra ocular muscle and optic nerve injury. Management strategy is discussed in the report. Patient had final post operative vision of 20/200. Ocular movements were normal. There was no enophthalmos or hypoglobus post operatively.
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Introduction
Large orbital foreign bodies (FBs) usually associated with ocular laceration and occur after a high-velocity injuries such as a gunshot or industrial accident. [1, 2] Only few cases have been reported with motorcycle brake lever acting as foreign body. Large size of foreign body, simultaneous involvement of orbit and maxillary sinus & excellent post operative results make this case unique.
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| Case Report
A 40-year-old man presented to our outdoor who had a motorcycle accident. Part of brake lever (7 cm in length) had lacerated the left lower lid and had entered the orbit displacing the eyeball upward. [Fig. 1]. No ocular laceration or hypotony was seen. Pupil was semidilated non reactive. Since the patient was not cooperative, owing to discomfort following trauma, slit-lamp examination and visual acuity assessment could not be done. X-ray of the orbit A.P and lateral view was performed which revealed that the foreign body was not only involving orbit, but also maxillary sinus. Rounded bigger end of the brake liver had fractured floor of the orbit was lying in the maxillary sinus. Rest of the part of foreign body was protruding outside the skin. To know about further extent of injury and to plan the approach for the operation, 3 Dimensional Computerized tomography (CT) was done. To our surprise, none of the extra ocular muscles were damaged. The optic nerve and optic nerve canal were also not injured. Orbital margins were secure. Fracture was less than 50% of total floor area and it was located more towards the temporal side. Nasal bone was fractured. [Fig. 2]. The patient was taken for operation under general anesthesia. Surgical area was cleaned of sand particles and broken lashes. Securing the globe using optic nerve guide, we tried to simply pull out the foreign body but were unable to mobilize it. So we decided to explore the fracture site. Taking care of bleeders, we displaced orbital fat and fascial tissue and again tried to remove the brake lever. This time we could slightly mobilize it. Looking into the 3D CT scan we slightly enlarged the fracture opening temporally with the help of artery forcep. Ultimately, the foreign body was removed by pulling it out in the same direction through which it entered. The operation was done in presence of maxillofacial surgeon. Then we assessed the fracture size clinically. The findings correlated with CT findings. There was no entrapment of muscles. No significant prolapsed of orbital tissue was seen. So it was decided to follow up the patient for 6 weeks to look for development of any enophthalmos or diplopia. Entry wound was sutured 2 layers using 5-0 catgut for internal and 4-0 silk for external sutures. Next post operative day, patient’s vision was 20/200. On slit lamp examination anterior chamber was found to be shallow and the lens was subluxated. No enophthalmos was seen and ocular movements were normal
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 Figure 1 Penetrating orbital injury with brake lever |
Figure 2 3 D computerized tomography shows foreign body: rounded end s has fractured the floor of orbit and lying in maxillary sinus.
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 Figure 3 Computerized tomography shows foreign body: rounded end s has fractured the floor of orbit and lying in maxillary sinus.
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 Figure 5 Eyeball guarded by optic nerve guide. |
 Figure 6 The brake lever after surgical removal |
 Figure 7 Finally repaired wound |
Figure 8 1st postoperative day
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Discussion
Intraorbital FBs can be associated with severe injuries leading to loss of vision or may lead to sight-threatening complications.[1,2] A retained metallic intraorbital FB may cause a variety of signs, symptoms, and clinical findings, based on its size, location, and composition.[5] Loss of vision is usually due to the initial trauma and is generally not influenced by surgical intervention.[1] The best management of retained metallic intraorbital FBs remains a controversial subject.[5,6] The decision regarding surgical removal depends mainly on the location and type of intraorbital FBs.[5] However, the removal of foreign body from the orbit, which is crowded with delicate structures, is not safe.[6]
Retained metallic intraorbital FBs are well tolerated and should be managed conservatively in the absence of specific indications for removal.[1,2] When the foreign body is impinging on neurological structures or causing mechanical restriction to ocular movements or is composed primarily of copper, one should consider removal of the FB after detailed and precise localization to minimize damage to the adjacent ocular structures.[1,2,5,6] Our experience shows that some orbital FBs especially those with round and smooth surfaces can simply be removed from their tract through which they entered, obviating the need for more sophisticated surgery. This approach may especially be useful in large orbital FBs in which the tract is easily visible radiologically and removal of foreign body with other approaches may cause significant trauma to orbital structures.
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References
1. Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit; A retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology. 1997; 104:96–103. [PubMed]
2. Michon J, Liu D. Intraorbital foreign bodies. Semin Ophthalmol. 1994;9:193–9. [PubMed]
3. Sukhija J, Bandyopadhyay S, Ram J, Bansal S, Das P, Brar GS. Unusual intraorbital foreign body: A case report. Ann Ophthalmol (Skokie) 2006;38:145–7. [PubMed]
4. Cartwright MJ, Kurumety UR, Frueh BR. Intraorbital wood foreign body. Ophthal Plast Reconstr Surg. 1995;11:44–8.
5. Cooper W, Haik BG, Brazzo BG. In: Smith's Ophthalmic Plastic and Reconstructive Surgery. Nesi FA, Levine MR, Lisman RD, editors. Mosby: St. Louis; 1998. pp. 260–9.
6. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology. 2002;109:494–500. [PubMed]
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The Rajasthan Journal Of Ophthalmology an Official Publication Of TheRajasthan Ophthalmological Society
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