Unrecognized intraorbital wooden foreign body

Abstract

Intraorbital wooden foreign bodies may present difficulties in diagnosis due to their radiolucent nature. Delayed recognition and management can cause significant complications. We present a case report that demonstrates these problems and the sequela that can follow. A 56-year-old man presented with a 3-cm laceration in the right upper eyelid, sustained by a slipping accident. After computed tomography (CT) scanning and ophthalmology consultation, which revealed no fractures and suggested only pneumophthalmos, the wound was repaired by a plastic surgery resident. Ten days later, the patient's eyelid displayed signs of infection including pus discharge. Antibiotics and revisional repair failed to solve the infection. Nearly 2 months after the initial repair, a CT scan revealed a large wooden fragment in the superomedial orbit. Surgical exploration successfully removed the foreign body and inflamed pocket, and the patient healed uneventfully. However, the prolonged intraorbital infection had caused irreversible damage to the superior rectus muscle, with upgaze diplopia persisting 1 year after surgery and only minimal muscle function remaining. We report this case to warn clinicians of the difficulties in early diagnosis of intraorbital wooden foreign bodies and the grave prognosis of delayed management.

Keywords: Delayed diagnosis; Eye foreign bodies; Penetrating eye injury.

Fig. 1.

Initial computed tomography (CT) scan taken at the emergency room. The wooden foreign body (arrows) embedded deep in the superomedial orbit was mistaken for emphysema by the ophthalmology, radiology and plastic surgery departments.

Fig. 2.

Secondary computed tomography (CT) scan taken almost 2 months after injury, clearly displaying the retained wooden foreign body (arrows) with perilesional retrobulbar fat stranding, superimposed infection and superior rectus muscle displacement with swelling.

Fig. 3.

Intraoperative findings. Surgical exploration successfully removed a 2.3-cm-sized wooden foreign body from the superomedial orbit. (A) Intraoperative view of the wooden foreign body inside the surgical field. (B) Removed wooden object.

Fig. 4.

Preoperative and postoperative clinical photographs. (A) Preoperative clinical photo displaying upgaze limitation of the right eye and pus discharge on medial upper eyelid. (B) Postoperative 9 month photo. Upgaze and upper lid function have improved but upgaze is still severely limited; secondary scar revision with contracture release on the upper medial lid area has also been performed.

Fig. 5.

Initial plain skull radiograph taken at the emergency room. The radiolucent wooden foreign body is entirely invisible on these images.