Self-insertion of foreign bodies into the orbit and periocular tissue

Abstract

We describe six patients with twelve separate episodes of self-inflicted periocular foreign body injuries, which presented to our institution recently. All patients were male, relatively young (mean 28.5 years old), incarcerated, and had significant underlying psychiatric conditions. The subjects had inserted staples (6), paperclips (2), or other small metallic wire segments (4) into the periocular region. Most cases (9/12) involved concurrent self-inflicted injury to other body parts. Ten cases involved foreign bodies inserted through the palpebral conjunctiva into the upper eyelid, while two cases involved insertion into the orbit. Identification and surgical retrieval of foreign bodies was successful in most cases (9/11) but was not attempted in one case. Self-inflicted periocular injuries, while rare, are challenging cases for which the ophthalmologist should be prepared. A multidisciplinary approach, including psychiatric assessment and treatment, is important for optimal care.

Self-inflicted eye injuries represent a rare and unusual form of trauma that may present to the ophthalmologist. Such injuries have been described in the literature as case reports and case series.^1–6 In general, self-injurious behavior is most commonly observed in young to middle-aged male patients suffering from psychiatric conditions, and especially psychotic disorders.^4,7,8 Ocular self-injury may range in severity from mild trauma of the anterior periorbital soft tissues to self-enucleation.

A number of factors make the management of patients with ocular or periocular self-injury challenging. Underlying psychiatric disorders may interfere at various points in the clinical management of injury. Similarly, drug abuse and incarceration are common among these patients,^4,9 and may complicate care. The injury may involve embedded foreign bodies for which the optimal management is not always clear.^10–12 Often, eye injuries present with concurrent self-injury to other body parts. Finally, many patients may present with repeated self-injury. In this paper, we describe recent cases presenting from local jails and prisons with orbital and periorbital self-inserted foreign bodies and discuss their management.

Case Presentation

Characteristics of the cases are summarized in Table 1. Six individual patients presented 12 different times for cases of self-injury. Three patients presented more than once for self-injury, including one patient presenting four separate times. All patients were male, were incarcerated, and were relatively young at the time of initial presentation (mean age 28.5). All patients carried a known psychiatric diagnosis. A motivation behind self-harm was not elicited for each presentation, but three patients volunteered that their self-harm was done in an attempt to improve their access to mental healthcare in some way. All patients had previous episodes of self-harm, and most presentations (9/12) involved concurrent self-harm to other body parts. Foreign bodies were inserted into the upper eyelid via the palpebral conjunctiva (10/12) or into the posterior orbit (2/12). 10 patients presented with concomitant eyelid edema, one patient had a corneal abrasion, and one patient had a conjunctival laceration, while two patients had no associated ocular or periocular complications. No case demonstrated signs of infection, hemorrhage, extraocular muscle restriction, or optic nerve or globe damage. Most patients were started on systemic antibiotics (11/12) at the time of presentation. Surgery was attempted in all but one case (11/12), and successful in all but two attempted extractions (9/11). No cases have encountered significant long-term complications of either foreign body insertion, surgical removal, or retained foreign body.

Table 1.

Patient characteristics. Age is given at time of first presentation. FB = foreign body. Foreign bodies in the GI tract and GU tract typically occurred via swallowing and urethral insertion, respectively.

Patient	2			3	1				4		5	6
Visit	1	2	3		1	2	3	4	1	2
Age (years) / Sex (M/F)	24/M			24/M	20/M				27/M		33/M	43/M
Psychiatric conditions	Depression			Bipolar	Anxiety, depression, borderline personality disorder				Depression		Delusional disorder	Borderline personality disorder
FB Description (# objects)	Metal wire (3)	Staple (2)	Staple (2)	Metal wire (2)	Staple (1)	Paperclip (2)	Metal wire (3)	Staple (3)	Metal wire (1)	Paperclip (1)	Staple (1)	Staple (1)
FB Location	Eyelid	Eyelid	Eyelid	Orbit	Eyelid	Eyelid	Eyelid	Periorbit	Eyelid	Orbit	Eyelid	Eyelid
Associated findings	Eyelid edema	Eyelid edema	Eyelid edema	Eyelid edema, conjunctival laceration	Eyelid edema	Eyelid edema	Eyelid edema	Eyelid edema	-	Eyelid edema	-	Eyelid edema, corneal abrasion
Extraocular FB location(s)	Upper extremity	-	Upper extremity	-	GI tract, upper extremity	Upper extremity	Upper extremity	Upper extremity	GU tract, upper extremity	GI tract	-	GU tract, upper extremity

Details of two representative cases are presented below. Many details are omitted in order to maintain patient confidentiality and safety.

Patient 1

A 24-year-old incarcerated male with history of depression presented to the emergency room (ER) after inserting a copper wire in his right upper eyelid the night before. He had also used a metallic object to cut his right elbow, and admitted to performing these acts in tandem with another inmate (Patient 1). Examination was notable only for right upper eyelid swelling. No obvious insertion site was visualized, and the foreign body could not be palpated through the skin. CT of the orbits demonstrated three curvilinear metallic wire structures in the lateral aspect of the right preseptal supraorbital soft tissue (facial X-Ray depicted, Figure 1, top), in addition to a metallic clip in the left mandible. The following day, the patient was taken to the operating room (OR), where a small eyelid crease incision and dissection allowed for the removal of all foreign bodies (Figure 1, middle and bottom).

Figure 1.

Patient 1, visit 1, pre-operative X-Ray of the facial bones demonstrating three radio-dense periocular foreign bodies (top, arrows). Intraoperative removal of metallic foreign body (middle). Extracted foreign bodies (bottom). Similar material was found in a substantial number of cases.

One month later, this patient again presented after placing two unfolded staples into his right upper eyelid through a posterior approach. There were no gross ocular findings. CT of the orbits demonstrated two curvilinear metallic foreign bodies superior and lateral to the right orbit. The staples were readily exposed and extracted in the OR later that day.

Approximately one month later, this patient returned after placing a staple into his right upper eyelid. There were no gross ocular abnormalities aside from eyelid edema. CT of the orbits demonstrated two curvilinear metallic foreign bodies in the right upper eyelid region. The patient was initially observed as an outpatient, and eventually underwent successful surgical foreign body extraction three weeks after presentation. He has not developed any complications at the latest follow-up visit, four months after his last operation.

Patient 2

A 24-year-old incarcerated male with a history of bipolar disorder, schizoaffective disorder, and pervasive developmental disorder was seen in the ER for intraorbital foreign bodies. Five days prior to presentation, the patient had unfolded two staples and inserted them into the medial aspects of his bilateral upper eyelids. He had also cut his left elbow with a metallic object; the upper extremity laceration was sutured at the prison infirmary prior to transfer to the ER. On presentation, small lacerations were noted on the medial conjunctivae of each eye; no discharge was expressed from these. There was diffuse edema and mild erythema. There was no significant restriction of extraocular muscle movements, although there was pain with eye movement, in both eyes. Examination was otherwise unremarkable. CT of the orbits demonstrated one linear metallic foreign body in the inferomedial aspect of the right orbit, and one similar foreign body in the superomedial aspect of the left orbit (Figure 2). He was taken to the OR the same day, where the foreign bodies could not be identified despite thorough exploration. The patient had a left upper eyelid crease wound dehiscence due to eye rubbing two weeks postoperatively which healed without further intervention. He was stable at post-operative month 2, without evidence of ocular compromise, but has been lost to follow-up for ten months since then.

Figure 2.

Patient 2, CT of the orbits, coronal (left) and transverse (right top and right bottom) views, demonstrating one radio-dense foreign body within the inferomedial aspect of the right orbit and the superomedial aspect of the left orbit (identified by arrows). The optic nerve and the rectus muscles were unaffected.

Discussion

Self-inflicted periocular eye injuries are a rare but serious presentation which the ophthalmologist should be prepared to manage. Similar to demographics from prior case reports and case series,^3,4,6,7 the patients presented in this case series were all relatively young, male patients with underlying psychiatric conditions. All of our patients were incarcerated at the time of presentation. The motivation behind self-injury may be difficult to discern in many cases. However, in many of our cases, the episodes of self-injury appeared to be motivated by secondary gain. In our study, many prisoners had expressed the desire to get out of their current holding facilities, or a desire to gain access to different or improved psychiatric care.

Perhaps influenced by their place of domicile and therefore objects at their disposal, the mechanism and tools of injury were similar across all of our cases. All of our patients had used unfolded staples or paperclips, or similar wire structures, and inserted these objects specifically into periocular soft tissues. The fact that two of our patients presented simultaneously from the same prison on two separate occasions suggests some level of communication between the inmates may have also played a role in some cases. Indeed, these two patients admitted to performing their self-injuries in tandem.

Due to the diverse nature of presentations, management of such injuries must be determined on a case-by-case basis. However, several important tenets should be observed. History taking is especially important in these cases, with particular attention to psychiatric history including outpatient medications and compliance with medications or other psychotherapy. Associated suicidal ideations must be evaluated, as the patient may require involuntary commitment. Initial physical evaluation should include a full-body assessment and referral to relevant specialty services as appropriate, as concomitant self-injury to other body parts was a common finding in our cases and may take precedence over the ocular or periocular injury. Ophthalmic examination should include a focus on any signs of ocular involvement, any orbital signs, and signs of cranial nerve involvement. In many cases, the foreign body may not be palpable from external examination, especially in the setting of associated edema or multiple foreign bodies. We recommend CT of the orbits without contrast for these injuries in order to localize foreign bodies, assess for signs of complications such as cellulitis or abscess, and assist in surgical planning. Systemic antibiotics may be used for prophylaxis pre- and post-operatively.

Management of intraorbital foreign bodies, and by extension periorbital foreign bodies, is discussed extensively in the literature, although there are some points of contention.^13–16 In general, all organic foreign bodies should be removed if at all feasible, due to higher risk of inflammatory and infectious complications than inorganic materials. Iron and copper metallic foreign bodies should similarly be removed, as they may incite inflammatory and toxic responses. Other inorganic foreign bodies may be left in place as long as no complications (e.g. strabismus, abscess, or fistula formation) arise. Cases involving paperclips and staples which are made of zinc-coated steel, as in our case series, are unlikely to elicit significant toxic responses. Surgical identification and removal may be readily achieved, but at times the risk of further exploration may outweigh the benefit of foreign body removal. This decision must be made on a case-by-case basis. If a foreign body is left in place, the patient should be followed periodically for the development of complications. There may be a lower threshold for surgical intervention in the case of inmates, as a number of our patients demonstrated poor follow-up after discharge. While no significant long-term complications were noted in our cases, follow-up examinations should assess for orbital complications such as diplopia or pain with eye movements, or evidence of cranial nerve compromise.

Our cases involved consultations with various other services, including psychiatry, internal medicine, emergency medicine, urology, orthopedic surgery, infectious disease, and social work. These services were vital for the co-management of concomitant self-injury, underlying psychiatric or medical conditions, and coordination of care. While acute changes to an established outpatient psychiatric regimen may not be merited, psychiatric evaluation is an important part of management for all presenting cases of self-injury, regardless of pre-existing psychiatric diagnosis.

While many of these challenging cases may be managed successfully, preventing these incidents in the first place would be ideal. Many of the presented patients voiced concerns over access to mental healthcare while in prison, and in several cases the self-harm was reported to be an attempt to gain access to a mental healthcare provider. Mental healthcare is currently lacking in the prison system, and while more than half of all prisoners in the United States have a mental health disorder,¹⁷ only 40–60% of mentally ill inmates receive treatment for their condition while incarcerated.¹⁸ This deficiency may play a role in our cases, and further study into the social and psychosocial factors contributing to self-injury may be beneficial in preventing recurrences.

In conclusion, our cases highlight an unusual presentation of incarcerated patients with self-injury involving insertion of foreign bodies to the periocular region. The ophthalmologist may be the first physician to evaluate the self-injuring patient, and should therefore be prepared for multi-disciplinary management. Psychiatric evaluation at the time of presentation is of particular importance in this patient population. Investigation into the method of procurement of the foreign bodies and the psychosocial factors predisposing to self-injury in prisoners may be helpful to prevent recurrences.