Penetrating orbit injury: challenge to emergency medicine
© Malla et al.; licensee BioMed Central Ltd. 2013
Received: 4 September 2012
Accepted: 23 November 2013
Published: 28 November 2013
Penetrating orbital injuries pose a serious threat to vision, ocular motility, and in some cases, life. The setting and causes of eye injury are diverse, but previous studies have demonstrated that the risk and type of injury is often correlated with age, gender, and race. Pediatric ocular injury is often accidental and may be preventable. A focused history and prompt ocular examination are essential to immediate management.
This article describes a case of protruding foreign body-related penetrating orbit injury with a retained foreign body in a 4-year-old male from a town in the eastern part of Nepal. The child presented to the emergency with foreign body in situ without receiving any pre emergency care without any medical attendance. The patient was managed with non-operative removal of foreign body in the emergency. The case discussion will review the initial presentation, examination, resultant management decisions, and final outcome.
Foreign body presentations may be diverse and non-operative management may be considered in selected cases. Resource availability and conditions at presentations may also influence the management decisions. This case presentation has described such a scenario in developing country like Nepal and is expected to be interest across various medical specialties.
Ocular injury is a frequent, preventable cause of visual impairment, with a lifetime prevalence of 19.8% . Pediatric patients account for a large proportion of these injuries (8-14%). Pediatric ocular injury is usually accidental and uniocular [2, 3]. Assessment of these injuries in pediatric patients is challenging given the difficult examination.
This case report outlines the presentation of a child with a penetrating orbitocranial injury. Although similar cases are published, this 4-year-old child presented fully conscious, with an orbitocranial foreign body and massive intracranial penetration, after traveling far on rough roads with relatives supporting the large protruding object (approx. wt. 1 kg and length of 9 cm). This case demonstrates a positive outcome for a potentially catastrophic injury in a resource limited environment.
At 48 hours the patient remained neurologically intact. His dressing was removed and his eye examined as follows: subconjunctival hemorrhage, clear cornea, mid dilated pupil, clear lens. Patient had no light perception in the right eye. A repeat CT showed no deleterious changes. On discharge on day 3, patient was advised to follow up with a neurosurgeon in another city.
3 month follow up revealed the following examination: mild proptosis, no blinking, no eye movement, pupil dilated and non-reactive, cornea clear and no light perception. Fundoscopy revealed a pale optic disc. Eye taping was advised. At 6 months, he had regained some blinking, but had not recovered any light perception.
Evidence of penetrating orbitocranial injury escaping with minimal or no serious complications has been noted in the literature. The pattern of injury generally reflects the type of society one lives in. On presentation to the emergency department, the emergency physician should co-ordinate the multidisciplinary care of a patient with a penetrating eye injury . The orbit is shaped like a cone; hence penetrating objects are directed towards the apex and usually pass through the superior orbital fissure and optic canal to enter the intracranial space. [5, 6]. Complications range from traumatic cranial neuropathies to potentially fatal intracranial injuries . Ocular complications include optic nerve damage with resultant visual loss, extra-ocular muscle paralysis secondary to direct muscle trauma or nerve damage, proptosis or macular edema . Finally, given the orbit’s close proximity to the paranasal sinuses, infection, specifically abscess formation is a common complication. Even if the cranium has not been breached, the presence of orbital hematomas, abscesses, optic nerve sheath hematomas and some foreign bodies (organic material, copper) are deemed true emergencies [9, 10]. Wooden foreign bodies require expeditious removal and broad spectrum antibiotic coverage to reduce infective complications. The decision to remove the foreign body in Emergency Department in this case was made taking this into consideration, together with the fact that a theatre and anesthetist were not available. Referral of this patient to another hospital exposed the patient to further transport risk with an unstable, cumbersome foreign body still in situ.
Ketamine is favored in developing countries due to its availability, safe profile, ease of use, analgesic, sedative and amnesic properties while maintaining airway muscle reflexes and tone. It is safe to use in children and requires minimal monitoring [11, 12]. This justifies our use in low doses together with midazolam. The sedation was supervised by a consultant general practitioner who supervises the emergency department.
Penetrating ocular foreign bodies can have varied presentations. Transfer for investigation of these patients can be extremely challenging, especially in children. Resource availability, time constraints and complications guide the management. This case shows that successful removal of a penetrating oculo-cranial foreign body by non-operative methods can be done in the emergency department in carefully selected patients.
Written informed consent was obtained from the patient’s mother (as patient is a minor) for the publication of the case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Wong T, Dlein BE, Klein R: The prevalence and 5-year incidence of ocular trauma. The beaver dam eye study. Ophthalmology. 2000, 107 (12): 2196-2202. 10.1016/S0161-6420(00)00390-0.PubMedView ArticleGoogle Scholar
- Scribano PV, Nance M, Reilly P, et al: Paediatric nonpowder firearm injuries: outcomes in an urban paediatric setting. Paediatrics. 1997, 100: E5-View ArticleGoogle Scholar
- Takvam JV, Midelfort A: Survey of eye injuries in Norwegian children. Acta Ophthalmol (Copenh). 1993, 71: 500-505.View ArticleGoogle Scholar
- Havens S, Kosoko-Lasaki O, Palmer M: Penetrating eye injury: a case study. Am J Clin Med. 2009, 6 (1): 42-49.Google Scholar
- Kaiser P, Freidman N, Pineda R: The Massachusetts and Ear Infirmary Illustrated Manual of Ophthalmology. 2004, Philadelphia PA: Saunders, 112-13-152- 153. 2Google Scholar
- Soheilian M, Rafati N, Mohebbi M, et al: Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection. Report 2. Arch Ophthalmol. 2007, 125: 460-465. 10.1001/archopht.125.4.460.PubMedView ArticleGoogle Scholar
- Newman TL, Russo PA: Ocular sequelae of BB injuries to the eye and surrounding adnexa. J Am Optom Assoc. 1998, 69 (9): 583-90.PubMedGoogle Scholar
- Laraque D, the Committee on Injury: Violence, and _poison prevention. injury risk of nonpowder guns. Pediatrics. 2004, 114 (5): 1357-61. 10.1542/peds.2004-1799.PubMedView ArticleGoogle Scholar
- McGwin G, Hall TA, Xie A, Owsley C: Gun-related eye _injury in the United States, 1993- 2002. Ophthalmic Epidemiol. 2006, 13 (1): 15-21. 10.1080/09286580500477309.PubMedView ArticleGoogle Scholar
- McGwin G, Owsley C: Incidence of emergency _department–treated eye injury in the United States. Arch Ophthalmol. 2005, 123 (5): 662-666. 10.1001/archopht.123.5.662.PubMedView ArticleGoogle Scholar
- Green SM, Clem KJ, Rothrock SG: Ketamine safety profile _in the developing world: survey of practitioners. Acad Emerg Med. 1996, 3 (6): 598-604.PubMedView ArticleGoogle Scholar
- Pun MS, Thakur J, Poudyal G, Gurung R, Rana S, Tabin G, Good WV, Ruit S: Ketamine anaesthesia for paediatric ophthalmology Surgery. Br J Ophthalmol. 2003, 87: 535-537. 10.1136/bjo.87.5.535.http://bjo.bmj.com/content/87/535.long,PubMedPubMed CentralView ArticleGoogle Scholar
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