Posterior Intraorbital Foreign Body: Take it or Leave it?

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...

Intraorbital penetrating and retained foreign bodies –a neurosurgical case series

“…As a general recommendation, empirical broad-spectrum antibiotics should be administered in each case, and antifungal treatment should be used in cases of wooden foreign bodies (27,36). Removal of the intraorbital foreign body can be very difficult due to the anatomical complexity of the orbit, which is a small space with a high density of functional elements (34).…”

“…Each specialty involved in the management of IOFBs has its own perspective regarding this pathology that is influenced by the signs and symptoms of the patient. Moreover, the literature regarding this pathology is relatively limited, particularly concerning foreign bodies located in the posterior orbit (27). The majority of published articles about IOFBs are case reports or small case series.…”

“…Wooden foreign bodies are particularly difficult to remove due to their soft structure, making them prone to fracture during extraction with the risk of remnant fragments and consequent infection (4). Indications for surgical removal of foreign bodies include sharp foreign body, organic material, foreign body toxicity, mechanical restrictions of ocular motility, neurological deficits, compression of the intra-orbital structures, exophthalmia, development of infection, orbital fistula formation, and pain (1,10,12,24,27). In contrast, surgical removal is not required for blunt inorganic, asymptomatic, or deeply located foreign bodies (10).…”

Combination Surgery for Management of Perforating Eye Injury With Retained Magnetic Intraorbital Foreign Body

“…17,18 Al-Mujaini et al 12 illustrated that surgery should be planned based on certain aspects that included the nature of the IOrFB (poorly tolerated organic objects, or welltolerated objects), location of the foreign body (anterior or posterior orbit), and presence of other injuries or foreign bodyYrelated complications. Ho et al 5 reviewed 43 patients with retained intraorbital metallic foreign bodies.…”

Considerations for a Retained Foreign Body in the Posterior Orbital Apex

“…In many cases, the physician must weigh the dilemma of the risk of surgery and the risks of infection and inflammation from a retained foreign body. The outcomes of previous case reports [10][11][12] demonstrate the delicate balance required in the decision-making process for the management of these traumas. We present a complicated case of an orbital foreign object (presumed metallic) with open globe injury secondary to penetrating trauma that was managed with observation given the object's location in the posterior apex.…”