A 4 year old male presented to the emergency department with the history of falling off a ladder 3 hours prior. He landed on his face on a wooden spike that embedded itself in the right orbit. His local hospital is not equipped to deal with ocular emergencies so he was transported by car for approximately 40 km to an eye hospital. Unfortunately, no anesthetist was available and the patient was referred to our emergency department. No treatment was instituted prior to referral. To reach our hospital, the patient had to backtrack 22 km and travel an additional 18 km, 40 km in total over rough roads (Figure 1).
On arrival in our emergency department the child was fully conscious. He was hemodynamically stable with no airway or respiratory compromise. He had no past medical history and was not taking any regular medication. History revealed he was up to date with his immunizations, but history was considered unreliable. He lived with his parents and younger brother in a town in Eastern Nepal. On further examination, no other injuries were found specifically the cervical spine. Gross neurological examination was normal. The foreign body, still in situ, was a sharp wooden peg. It had penetrated the right orbit along the medial side. The cumbersome protruding object constituted a rock and a wire mesh attached to the wooden peg. The weight (approx. 1 kg) and shape of the object made stabilization of the object particularly difficult. It was impossible to evaluate the eye further due to the eye being obscured by the protruding object (Figure 2).
Intravenous access was established. Pain was managed with morphine and prophylactic antibiotics were initiated. CT scan was arranged. Patient was sedated with ketamine and midazolam. The patient was transferred to CT scan with the relative supporting the foreign body all the time. The contrast CT was initially reported by a radiology resident as follows, “foreign body lateralizing globe and penetrating through the medial part of the orbit extending through orbital apex to middle cerebral fossa and just impinging right cerebellar hemisphere. Minor contusions in right cerebellum and hemi sinus ethmoidal sinus are suspected. The length of the penetrating part was around 9 cm” (Figure 3). Upon immediate ophthalmology consultation, a decision to remove the foreign body was made. Again, anesthetists were unavailable for timely removal of the foreign body as they were busy in theatre. Due to the time delays pre presentation, it was decided that removal of the foreign body should occur as quickly as possible. The ophthalmologist and the emergency physician removed the foreign body, with the aid of sedation (ketamine, morphine and thiopentone). A lateral canthotomy was performed (Figure 4).
After removal of the foreign body, the eye examined as follows: axial proptosis, mid dilated pupil, clear lens, and clear media. There was no evidence of globe penetration. Pilocarpine drops were instilled and ciprofloxacin ointment used before padding and bandaging the eye. Oral acetazolamide was started. Otolaryngologist and Surgical specialties were consulted with no further management advised. There was no neurosurgeon at the hospital available for consultation. The patient remained in the emergency department for observation (Figure 5).
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.
