Penetrating Orbital Trauma by Large Foreign Body: Case Series Study with Treatment Guidelines and Literature Review

Abstract

Purpose

The present study aims to describe a case study of large penetrating orbital trauma and treatment guidelines associated with a review of English-language literature of large foreign bodies impacting the orbit from 1997 to 2020.

Patients and Methods

Five patients suffered large penetrating orbital trauma and required emergency surgical procedures.

Results

Together with this present study, a total of 33 cases were selected. The present work has data similar to the literature, and emergency surgical treatment was required in the majority of the cases.

Conclusion

Penetrating orbital trauma by large objects is a challenge. The initial assessment and treatment are fundamental to determine the case severity. The large foreign body should be surgically removed by a trained and experienced team in an advanced hospital unit as soon as possible to minimize visual, functional and aesthetic sequelae.

Introduction

Penetrating orbital trauma by large foreign body is an infrequent type of facial trauma. This type of trauma can occur from accidents, suicide, murder attempts with penetrating tools and ballistics [1]. Both organic and inorganic foreign bodies that can be involved in penetrating orbital trauma may include wood, pencils, bamboo stick, broken glass, eyeglass, pin, needle, nail, knife and metallic pieces. Traumatic lacerations should be inspected as they may contain foreign objects [2]. Large foreign body impacted into the orbit can be a challenge for both maxillofacial surgeons and ophthalmologists resulting in irreversible sequelae for those patients. The present study aims to describe a case study of large penetrating orbital trauma and treatment guidelines associated with a review of English-language literature of large foreign bodies into the orbit from 1997 to 2019.

Case Reports

This study was approved by the Ethics committee of the João XXIII Hospital under the protocol number n. 924322182.2.0000.5119, and informed written consent forms were obtained from all patients and/or families. Five patients with noncontributory medical, social and cultural records were referred to the emergency unit of João XXIII Hospital/FHEMIG (level 1 in trauma), Belo Horizonte, Brazil, after having been a penetrating orbital trauma by large foreign bodies. Previous studies of penetrating orbital trauma by large foreign bodies, published between 1997 and 2020, were researched by means of a detailed investigation of English-language literature across PubMed, by searching the following keywords: penetrating orbital trauma, large foreign body and facial fractures.

Case 1

Thirty-nine-year-old man was hit by a large piece of polishing disk when using an electric polishing machine at his residence. The patient was admitted with a partial polishing disk impaled in the left orbit through an infra-orbital traumatic wound (Fig. 1a). No signs of hemodynamic alteration and no loss of consciousness were noted. Physical examination of the eyes demonstrated no light perception in the left globe, and the right globe was normal. Computed tomography (CT) demonstrated a large foreign body impaled in the left orbit (Fig. 1b) with signs of optic nerve transection. Fractures of the roof, medial wall and floor of the left orbit were observed. No signs of cerebral-spinal leak were noted in the physical examination. The ophthalmologic examination was performed, and a team of ophthalmologists were consulted in the surgery. The patient was taken immediately to the operating room to remove the large foreign body of the left orbit. A Lynch approach was performed in the left orbit to permit direct examination of the entire disk. Also, the traumatic wound was increased by 1 cm to facilitate manipulation of the foreign body. The disk was impaled in the left inferior orbital rim, and a chisel was used to release the disk. After that, discrete traction under direct vision was performed to remove the disk (Fig. 1c). No important bleeding was observed after withdrawal of the disk. Copious saline solution irrigation was applied to clean the traumatic wound. The wound was closed and sutured, and the patient received intravenous antibiotics and high doses of corticoids. Ocular examination on the first postoperative day showed mydriatic and non-reactive pupils and no light perception, in the left eye. Extraocular movements were limited in all directions. The postoperative period was uneventful, and the patient was discharged after 7 days with no signs of infection, after the active tetanus prophylaxis. After 3 months, the patient returned with no improvement in the visual acuity in the left globe; however, the extraocular movements of the left globe were better with restrictions only in the medial and upper aspects of the motion (Fig. 1d). The patient denied left orbital reconstruction and others secondary surgical procedures to improve extraocular movements due to no visual acuity in the left eye.

Fig. 1.

Clinical features of patient hit by a large piece of polishing disk. a On physical examination, a large foreign body penetrating the medial aspect of the left orbit. b 3D CT demonstrating a large fragment within the orbit. c Large fragment of the polishing disk measuring to 13 cm. d Clinical aspect of the patient after 6 months of follow-up with no visual acuity in the left eye and satisfactory esthetic outcome

Case 2

Thirty-five-year-old man was stabbed with a kitchen knife by his intoxicated brother during the Brazilian carnival party. The patient was admitted with no loss of consciousness and no alteration in the hemodynamic parameters. Upon physical examination, the knife was impaled into the left orbit through the superior aspect of the globe (Fig. 2a). During the Ophtalmologic examination the patient reported no light perception and important restriction of extraocular movements was observed. In addition, the patient reported restricted opening of his mouth. A CT demonstrated the blade passing through the lateral wall of the left orbit, the infratemporal fossa and stopping near to the left mandibular condyle (Fig. 2b). Also, the CT revealed no lesions of the large vessels. The patient was taken immediately to the operating room to remove the large foreign body. A hemi-coronal approach was performed to access the entire knife blade. Also, osteotomy with a chisel was carried out in the zygomatic-frontal suture and the zygomatic-temporal suture to release the knife’s blade due to its impalement. Direct traction with slight ‘to and fro’ movements was used to remove the entire blade from the patient (Fig. 2c). A large laceration of the cornea was observed in the superior aspect of the globe and sutured by the ophthalmologic team. The wound was closed, and the hemi-coronal approach sutured properly. The patient received active tetanus prophylaxis with anti-tetanus serum and human immunoglobulin for anti-tetanus, intravenous antibiotics and high doses of corticoids. Ocular examination on the first postoperative day showed mydriatic and non-reactive pupils and no light perception, in the left eye. The postoperative period was uneventful and the patient was discharged after 7 days with no signs of infection. The patient returned 2 months later with no visual acuity in the left globe, extraocular movement preserved in all directions and satisfactory aesthetic outcome, and no secondary surgical treatment was needed (Fig. 2d).

Fig. 2.

Clinical features of patient stabbed by a kitchen knife. a Clinical aspect of the patient with a knife penetrating the superior aspect of the left globe. b 3D CT demonstrating the lateral orbit wall penetration of knife blade into the infratemporal fossa nearby to the left condyle. c Photograph showing the kitchen knife compared with a 22-surgical blade. d Clinical aspect of the patient after 6 months of follow-up with no visual acuity in the left eye and satisfactory esthetic outcome

Case 3

Twenty-two-year-old was victim of a car crash collision against a solid wall. The patient was admitted hemodynamically unstable with multiple traumas. The patient was admitted taking 35 ml/h of noradrenalin and already infused 6000 ml of crystalloids and blood components. On physical examination, the patient presented subnasal laceration with important telecanthus associated with mobile nasal, maxilla and mandible bones. The bilateral globe seemed to be intact, despite the loss of examining the visual acuity due to the neurological status of the patient. Symphysis of the mandible was also fractured. After initial stabilization, CT of the entire body demonstrated fractures of the pelvis, thoracic vertebras, costal arch and multiple craniofacial fractures. CT of the head and face demonstrated a large foreign body into the nasal complex and left orbit with comminuted fractures of the nasal bones, maxilla, frontal sinus with signs of cerebral-spinal leak and bilateral orbital walls. The patient was taken to the operating room for the initial treatment of the pelvis fracture and to remove the large foreign body with initial stabilization of the facial fractures and treatment of the dural lesion. Tracheostomy was carried out to definitive airway protection. Coronal approach was performed for treatment of the dura lesion, and a pedicle pericranium flap was used to close the CSF leak and the foreign body was removed by the same approach. The ocular globes were observed with no grossly lesions. Parietal bone graft was applied to reconstruct the comminuted nasal bone, and a cantopexy was used to treat the traumatic telecanthus. Bilateral reconstruction of the orbits was performed using 1.5 mm titanium meshes and maxillo-mandibular stabilization was applied using Erich arch bars and steel wires. Due to instability of the patient, fixation of the mandible and the maxilla fractures were left for a second procedure. Unfortunately, the patient died 7 days after the accident due to the severity of the lesions.

Case 4

Twenty-year-old man was stabbed with a knife by his intoxicated brother during a family party. The patient was admitted stable and with no loss of consciousness. On physical and ophthalmologic examination, the knife was impaled into the left orbit through the lateral aspect of the globe (Fig. 3a). The patient reported no light perception in both eyes. The CT demonstrated the blade passing through the lateral wall of the left orbit, left globe, medial wall of the left orbit, nasal cavity and medial wall of the right orbit (Fig. 3b). Also, the CT revealed no lesions of the large vessels. The patient was taken immediately to the operating room to remove the large foreign body. Direct traction was used to remove the entire blade from the patient. The wound was closed and sutured properly. The patient received active tetanus prophylaxis with anti-tetanus serum and human immunoglobulin for anti-tetanus, intravenous antibiotics and high doses of corticoids. Ocular examination on the first postoperative day showed mydriatic and non-reactive pupils and no light perception in the left eye. The postoperative period was uneventful, and the patient was discharged after 5 days with no signs of infection. The patient returned 3 months later with no visual acuity in the left globe, extraocular movement preserved in all directions and satisfactory aesthetic outcome and declined further surgical procedures (Fig. 3d).

Fig. 3.

Clinical features of patient stabbed by a knife. a Clinical aspect of the patient with a knife penetrating the lateral aspect of the left globe. b CT demonstrating the lateral orbit wall, left globe and nasal cavity penetration of knife blade. c 3D CT demonstrating the impalement of the blade. d Clinical aspect of the patient after 3 months of follow-up with no visual acuity in the left eye and satisfactory esthetic outcome

Case 5

Twenty-seven-year-old woman was stabbed with a knife in the left orbit by her abusive ex-husband. The patient was admitted stable and with no loss of consciousness or traumatic brain injury. On the physical examination, the knife was impacted on the lateral aspect of the left orbit. The patient presented ophthalmoplegia on the left eye; however, no signs of loss of visual acuity were observed. The CT demonstrated a non-displaced fracture of the lateral wall of the left orbit with no damage to the eye globe; in addition, no signs of intraorbital hematoma were observed. The patient was taken immediately to the operating room to remove the large foreign body. Direct traction was used to remove the entire blade from the patient. The wound was closed and sutured properly. The patient received active tetanus prophylaxis with anti-tetanus serum and human immunoglobulin for anti-tetanus, intravenous antibiotics and high doses of corticoids. On the first postoperative day, no signs of loss of visual acuity were observed and the patient presented normal ocular movements on both eyes. The postoperative period was uneventful, and the patient was discharged after 5 days with no signs of infection. Unfortunately, due to the protective government measures that the patient received due to the aggression she suffered, she was unable to attend the postoperative appointments to maintain her personal safety and her location was not disclosed as protection from her aggressor.

Discussion

All studies that used clinical radiographic diagnoses were included in this review [1–18]. Together with this present study, a total of 33 cases were selected. The data from all studies are presented in Table 1.

Table 1.

Clinical aspects of penetrating orbital trauma by large foreign bodies between 1997 to 2018

Authors	Age	Gender	Etiology of trauma	Globe repositioning	Orbital reconstruction	Visual acuity
Orbay et al. (1997)	15	Male	Fall	No	No	Blindness
Chung et al. (2007)	63	Male	Other	No	Frontal bone flap	Visual sequelae
Reddy et al. (2009)	15	Male	Assault	No	No	Blindness
Naik et al. (2011)	30	Female	M. V. A	No	No	Visual sequelae
Schreckinger et al. (2011)	21	Male	M. V. A	No	No	Blindness
	42	Male	Other	No	No	Visual sequelae
	21	Male	Assault	No	No	Blindness
	5	Male	Fall	No	No	Normal
Subaşı et al. (2012)	10	Female	Assault	No	No	Normal
Kang et al. (2012)	43	Male	Assault	No	Porous polyethylene	Normal
Miscusi et al. (2013)	35	Male	Fall	No	Titanium plate and screws	Normal
Malla et al. (2013)	4	Male	Fall	No	No	Blindness
Berrington et al. (2014)	28	Male	Other	No	No	Normal
Chen et al. (2014)	66	Female	Fall	No	No	Blindness
Rezae et al. (2014)	6	Male	Fall	No	No	Normal
Elia et al. (2014)	64	Male	Fall	No	Titanium mesh	Visual sequelae
Estebanez et al. (2015)	19	Male	Other	No	No	Blindness
	23	Male	Assault	No	No	Visual sequelae
	24	Male	Assault	No	No	Normal
	23	Male	Fall	No	No	Blindness
Sarkar et al. (2015)	4	Male	Fall	No	No	Normal
Morais et al. (2015)	31	Male	Assault	No	No	Blindness
Gonollu et al. (2016)	25	Male	Assault	No	No	Normal
	17	Male	M.V.A	No	No	Normal
	48	Male	Fall	No	No	Normal
	38	Male	Other	No	No	Normal
Blackhall and Laraway (2016)	53	Female	Fall	No	No	Normal
Amaral et al. (2020)	39	Male	Assault	No	No	Blindness
	35	Male	Assault	No	No	Blindness
	22	Male	M.V.A	No	Titanium mesh	NA
	20	Male	Assault	No	No	Blindness
	27	Female	Assault	No	No	Normal
Total 33 patients	Range: 4 to 66 Mean: 27.7	84.85% Male 15.15% Female	33.3% Falls 36.3% Assault 12.1% M.V.A 18.3% Others	100% No	84% No 6% Titanium mesh 3% Frontal bone flap 3% Porous polyethylene 3% Titanium plate and screws	42.4% Normal 36% Blindness 16% Visual Sequelae 3% NA

NA, not available; M.V.A, motorcycle vehicle accident

The main cause for the orbital penetration by large foreign bodies was assaults (36.3%), followed by falling over blunt objects (33.3%) and motor vehicle accident (M.V.A.) (12.1%). The majority of cases published in the literature were observed in patients from male gender (84.85%), with an average age of 27.7 years (range 4–66 years). The present work has data similar to the literature with four male patients and one female patient with an average age of 28.6 years (range from 20 to 39); however, the causes of the injuries were work-related and assault.

In all the cases described in the literature, CT provided a three-dimensional view of the fragments inside the orbit and its relation to the globe and adjacent soft tissues [1–18]. The authors suggest CT angiography if large vessels can be associated with or nearby to the foreign body to minimize bleeding complications during the surgical procedure.

There is no case of globe luxation with repositioning associated with large foreign bodies into the orbit in the current literature and four cases described orbital reconstruction with different type of material as frontal bone flap [5], porous polyethylene [8], titanium plate and screws [10] and titanium mesh [6]. This study applied 1.5 mm titanium meshes for orbital floor reconstruction in one of the cases. The authors believe that titanium mesh is a better choice for immediate orbital reconstruction due to its easier and fast bending, high tolerability by the traumatic tissues and relative low cost. As recommended, the titanium mesh was used in the third patient in the table, sadly the unsatisfactory outcome due to the patient’s death did not allow the postoperative advantages of the titanium mesh usage to be observed (Case 03, Table 1).

In the current literature, twelve patients totally lost their visual acuity (36%) [4, 7, 9, 11, 13–15, 17]. Therefore, considering the visual status of the patients, 52% of the cases had blindness or visual sequelae associated with penetrating orbital trauma by foreign bodies.

The present study reports five cases of large objects penetrating the orbital cavity that led to permanent sequelae like blindness and one death. These fragments were a partial polishing disk, a foreign body from a car crash and two knives. These patients required advanced hospital care and surgical procedures for the removal of the objects and reconstruction of the orbital walls with 1.5 mm titanium mesh was preconized in one patient, as described in Table 1. The main complication of injuries caused by impalement of the objects into the orbits is blindness [17], also, partial deficit of ocular movement can be observed due to direct lesions of the orbital muscles. No enophthalmus was observed in all the five cases of this study, which is a good prediction to good aesthetic and functional outcomes.

The first care is a gold standard in the evaluation of severity and in the direction of a correct treatment. Complete physical examination, including full neurological and ophthalmological status, should be performed and compared with those presented by the patient, if possible, before the trauma. The CT of the orbit and face is necessary for these patients. CT angiography also should be considered if large vessels are associated with the trauma. All patients with large objects penetrating the orbit should be surgically approached as soon as possible; otherwise, the ophthalmological consequences could be serious and often irreversible. The patients should be treated under general anesthesia, and the fragments must be removed carefully and under direct vision. In the cases in which the orbital walls are fractured, the reconstruction can be performed with titanium mesh. On the postoperative care, the patient should be kept under strict observation for at least 7 days, in which antibiotics should be used to counteract grossly contamination of the traumatic wounds.

Conclusion

Penetrating orbital trauma by large objects is a challenge. The initial assessment and treatment are fundamental to determine the case severity. The large foreign body should be surgically removed by a trained and experienced team in an advanced hospital unit as soon as possible to minimize visual, functional and aesthetic sequelae.

Compliance with Ethical Standards

Conflict of interest

The authors declare that have no conflict of interest. All authors have viewed and agreed with this present submission.