Intraorbital wooden foreign body, legacy of a notorious scrap: a case report

Abstract

Wooden foreign bodies are notorious to be fragile and get retained as bits and bobs in the orbit. A 50-year-old woman presented to casualty with complaints of loss of vision and pain in the right eye associated with discharge from a wound in right eye upper lid. On imaging, a wooden foreign body was seen as continuous track of air. Meticulous dissection and search were done to remove bits and bobs of the wood. Patient, however, after 15 days of primary surgery reported with pus collection over wound site. Keeping suspicion of remnant wooden body piece(s), imaging and further exploration were carried out, removal of a 1 cm residual wooden piece was done. Retained wooden foreign body should always be suspected in postoperative cases of intraorbital wooden foreign body with infection. A close follow-up and knowledge of the same stay useful to remove any needless apprehension both of patient and surgeon.

Background

Retained intraorbital wooden foreign body may manifest in various presentations. They may remain silent without causing any symptoms or signs for days to years, before causing complications. An early diagnosis and prompt removal are the key to the management. They are notoriously known to be difficult to remove in toto and, thus, require expertise and proper planning. Here we report such a case of retained intraorbital wooden foreign body that required additional surgeries.

Case presentation

A 50-year-old woman presented to casualty with a report of loss of vision and pain in the right eye associated with discharge from wound in the right eye upper lid. She had a fall from a cart following which a wooden piece penetrated her right eye upper lid. On examination, visual acuity in the right eye was no perception of light and upper eyelid laceration of around 15 mm was present. The wooden foreign body was visible through the wound (figure 1). The upper lid was chemosed. Mild discharge was present. Extraocular movements were restricted in all directions. Mild ptosis was present. Conjunctival congestion was seen. The pupil was fixed and dilated. Right eye fundus was within normal limits.

Figure 1.

(A) The upper lid wound with visible wooden foreign body. (B) MRI of the right orbit scan showing wooden foreign body as a continuous track of air. (C) CT scan showing wooden foreign body as a continuous track of air. (D) 5 cm long wooden foreign body that was removed.

Investigations

CT scan was done on which right medial orbital wall fracture and fracture of the medial wall of the maxillary sinus with optic nerve avulsion were present. The wooden foreign body was seen as a continuous track of air (figure 1). MRI also showed a wooden foreign body as a continuous track of air (figure 1).

Treatment

The patient was started on intravenous ceftriaxone 1 g two times per day and intravenous vancomycin 600 mg two times per day. A wooden foreign body of 5 cm was removed from the entry wound itself (figure 1). Complete removal of all small pieces of wooden foreign body was ensured, and saline irrigation of the wound was also done. Discharge from the wound was sent for bacterial and fungal culture; it came positive for Aspergillus fumigatus. The patient was discharged on oral voriconazole 100 mg two times per day and oral ciprofloxacin 500 mg two times per day after a 7-day course of intravenous antibiotics.

Outcome and follow-up

Patient reported back on 15th postoperative day with pus collection over the wound site (figure 2). Repeat MRI was done keeping in mind the suspicion of a residual wooden foreign body. It showed a small continuous track of air suggestive of residual foreign body (figure 2). The wound exploration was done again, and a residual wooden foreign body of 1 cm was removed (figure 2). The patient was discharged on oral antibiotics. Postoperatively, there was complete healing of the wound, and no pus collection was there (figure 2).

Figure 2.

(A) Pus collection in the original wound area. (B) A repeat MRI scan showing residual foreign body as a continuous track of air. (C) The left over 1 cm long wooden foreign body removed after second surgery. (D) Final postoperative picture of the patient.

Discussion

The clinical features after orbital injury with a wooden foreign body in orbit depend on the mode of injury, size of foreign body and time since injury. The patient can present with swollen lids, ptosis, limitation of ocular movements and loss of vision.¹ Retained wooden foreign bodies in orbit may remain silent without causing any symptoms or signs for days to years, before causing complications like orbital cellulitis, abscess formation, chronic discharging sinus, noninfectious inflammation, fibrosis and rarely gaze-evoked amaurosis.^2–5 The foreign body can migrate and cause brain abscess or spontaneous extrusion. There risk of infection with retained wooden foreign body is as high as 64% because of the porous consistency and organic nature of the wood, which provides a good medium for microbial agents.

Imaging should be done in cases with wooden foreign body to know the exact size, shape and location of the foreign body. Intraorbital wooden foreign body is not visible on X-ray orbit due to its radiolucent property. Diagnosis of intraorbital wooden foreign body on B-scan ultrasonography needs expertise, and very deep foreign body may be missed.⁶ MRI scan is the imaging modality of choice for the diagnosis of intraorbital wooden foreign body. Intraorbital wooden foreign body can be seen better in MRI scan because density of protons and their relaxation time in the wood are different from the orbital soft tissue.⁷ The wooden foreign body appears hypointense as compared with the orbital fat on T1 and T2. The appearance of intraorbital wooden foreign body on CT scan varies with the time according to the degree of the hydration. In the acute stage, a wooden foreign body is seen as a continuous linear track of air because its density is similar to the air. In the subacute stage, because of the increased hydration, the density of wooden foreign body becomes similar to the orbital fat, making the diagnosis difficult. In chronic stages, its density is more than the orbital fat.⁸

The surgical removal of intraorbital wooden foreign body should be done as early as possible. The surgical approach depends on the location, nature and size of the foreign body. The neurosurgical consultation should be done if base of the skull is involved. The various approaches include anterior transpalpebral approach, anterior transconjunctival approach, lateral approach, superior transfontanel and transnasal endoscopic removal, which is safe, easy and less damaging.^{9 10} Ultrasound-guided removal can also be done. In case of exposed orbital wooden foreign body, the foreign body should be removed from the entry wound, through the same tract to cause minimal orbital tissue damage. In the case of wooden foreign body, multiple small splintered pieces can be present.¹¹ So, surgeon should always ensure to remove all the pieces and patient should also be explained that additional surgeries may be required. The retained wooden foreign body causes infection in most of the patients. The surgeon can use the purulent fistulous tract formed after infection to locate the retained foreign body. The patient should be started on empirical broad-spectrum antibiotics because of the high risk of infection with intraorbital wooden foreign body.¹²

In our case, due to multiple small splintered pieces along with the large wooden foreign body, one small piece was missed during the surgery. The suspicion of retained foreign body aroused due to postoperative infection with pus formation. After complete removal of the foreign body, infection also resolved.

Patient’s perspective.

The swelling, pus collection and recurrence of disease were painful and worrisome. I am happy that the doctors removed it, without any complications.

Learning points.

• A retained wooden foreign body should always be suspected in postoperative cases of intraorbital wooden foreign body with infection. Even after a meticulous primary surgery, they are prone to be leftover and cause subsequent reinfection.

• Suspicion of multiple wooden foreign bodies at the primary sitting of intervention should be kept in mind, so as to achieve complete removal in one go.