No abstract
Intraorbital foreign body (IoFB) presents an interesting therapeutic dilemma when located posterior in the orbit. Factors such as foreign body composition, inflammation, infection, functional deficit, and potential for iatrogenic damage are considered when choosing the appropriate treatment. CASE REPORTA 20 year-old male presented to the Bellevue Hospital emergency department one day after suffering a high velocity projectile penetrating injury (BB pellet) to the right orbit. Best corrected visual acuity was 20/40 OD and 20/20 OS. Clinical examination of the right eye revealed an entrance wound 10 mm inferior to the medial canthus but no exit wound, mild pain and limitation of extraocular movements, mild relative afferent pupillary defect (APD) and complete loss of color vision on Ishihara testing. Computed tomography identified a metallic foreign body deep in the posterior orbit near the orbital apex and right optic nerve (Fig. 1). He was admitted and treated with broad spectrum antibiotics (ancef 1g q8h) and intravenous corticosteroids (prednisolone 1 g loading dose followed by 250 mg q6h for two days). Two days after his injury, visual acuity returned to 20/20 OD with full resolution of motility, relative APD, and color vision deficits. The patient then left the hospital against medical advice and was lost to further follow-up. DISCUSSIONThere is a paucity of literature regarding the management of posteriorly located IoFBs, owing most likely to the relatively uncommon nature of this phenomenon. A small retrospective study by Finkelstein et al. reviewed 27 consecutive patients over 7 years [1]. All cases involved metallic foreign bodies, the majority of which were BB gun injuries (20 of 27). 13 of the foreign bodies were located in the anterior orbit, 4 epibulbar and 10 posterior. Practically all (94%, 16 of 17) anterior and epibulbar foreign bodies were surgically removed, whereas only 20% (2 of 10) of those located posteriorly were extricated (which occured during ruptured globe repair). Most common associated ocular morbidities included local trauma (subconjunctival hemorrhage, corneal abrasion, chemosis), ophthalmoplegia, retinal or vitreous hemorrhage, traumatic optic neuropathy, orbital fracture, retinal detachment, retinal tear and choroidal rupture. Final *Address correspondence to this author at the Department of Ophthalmology, New York University School of Medicine, USA; E-mail: jrperalta@gmail.com visual acuity correlated to location of foreign body. 85% (11 of 13) of patients with anterior IoFBs retained final visual acuity greater than 20/40, compared to only 30% (3 of 10) of patients with posterior IoFBs. Additionally, of the 3 patients who developed NLP vision, all had posterior IoFBs. It was deemed that management of each case was dependent on location of the projectile, and foreign bodies not readily surgically accessible may be left safely in place.More recently, a study by Fulcher et al. expanded on the work by Finkelstein and colleagues [2]. In this slightly larger (n=40) retrospe...
The degree of ptosis is significant, and levator function is typically reduced. Ocular surface viability appears to play a key role in preoperative, intraoperative, and postoperative management. While we are aware that congenital aniridia is rather rare, we believe these recommendations are generalizable to patients with severe ocular surface disease.
A 21-year-old female with a history of infantile hydrocephalus and ventriculoperitoneal shunting presented with bilateral persistent tearing. Examination revealed marked bilateral enophthalmos, poor lower eyelid apposition to the ocular surface, and patent nasolacrimal systems. Radiographic imaging demonstrated expanded orbital volumes with high arching orbital roofs, sequestered air under the eyelids, short, straight optic nerves, and expanded paranasal sinuses. Surgical intervention included insertion of mesh and block implants within the subperiosteal space of the orbital roof, resulting in correction of enophthalmos, improved lower eyelid apposition and resolution of tearing. However, new onset myopic astigmatism and bilateral ptosis were noted postoperatively and treated successfully with corrective spectacles and ptosis repair. Current literature has demonstrated the benefit of orbital roof implants through a upper eyelid crease incision. The authors present a case that supports the utility of this approach and addresses its potential complications, including postoperative-induced astigmatism/myopia and ptosis.
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