Intraorbital arteriovenous fistula secondary to penetrating injury

PURPOSE:: To describe the clinical and radiologic features and management of an intraorbital arteriovenous fistula secondary to penetrating injury. METHOD:: Interventional case report and literature review. RESULTS:: We describe a 13-year-old girl with a history of penetrating orbital injury who presented with proptosis, eyelid hyperemia, and orbital venous congestion. Computed tomography showed a large foreign body in the superiormedial orbit and an enlarged superior ophthalmic vein (SOV). Doppler ultrasonography revealed arterialized flow in the SOV. Removal of the foreign body did not alter the orbital symptoms. Carotid angiography disclosed a fistula between the ophthalmic artery and the SOV. The patient underwent an attempted coil embolization of the fistula through the femoral vein, which was unsuccessful, but she developed profound thrombosis of the SOV, which propagated through the orbital venous system. Although orbital venous congestive symptoms were acutely exacerbated, they regressed spontaneously within 1 month. The patient was followed for 23 months without recurrence. CONCLUSIONS:: Penetrating injury of the orbital apex may lead to the formation of an arteriovenous fistula, transvenous embolization of which may be complicated by thrombosis of the SOV. In our case, this unintentional result facilitated the resolution of the fistula.     

A 55-mm Object Inside a 40-mm Orbit

ABSTRACT

A 43-year-old man was struck in the left orbit with his board while surfing and sustained a 3-cm laceration above his left eyebrow. The laceration was sutured closed primarily at a local emergency room. When he presented to UCSD oculoplastics for suture removal, he complained of diplopia with upgaze and was found to have hypoglobus on clinical exam. An orbital CT demonstrated a hyperintense linear signal within the orbit. The patient underwent surgical exploration. A 55-mm-length piece of fiberglass from the patient’s surfboard was removed from his orbit. This case demonstrates the importance of having a high index of suspicion for retained orbital foreign bodies, regardless of the size of the object inflicting the injury.     

Cranio-orbital injury with internal carotid artery laceration and a missing eyelid

A 37-year-old man presented to the emergency department with a visor impacted in the left orbit after a motorbike accident. His initial injury appeared to be limited to the orbit. Because the bleeding appeared disproportionate to the orbital injury, an intracranial injury was suspected. Subsequently, on hemicraniotomy, the tip of the visor was found at the bifurcation of the internal carotid artery. The avulsed upper eyelid was found under the frontal lobe. The patient underwent the clipping of internal carotid artery and middle and anterior cerebral artery with replantation of the upper eyelid. Neurologic damage was limited to loss of vision, right foot drop, and bowel and bladder incontinence. This case of penetrating orbital trauma demonstrates that the absence of focal neurologic deficit and radiologic signs suggestive of intracranial injury may not rule out life-threatening intracranial injury.     

An intraorbital metallic foreign body

A 30-year-old male presented with diplopia for 20 days post occupational accident involving left side of his nose, while he was working with a nail gun. He was fully conscious and did not have any neurological deficits. Patient narrated the mechanism of injury and was sure that the nail fell down after hitting the left side of his nose. He had normal vision, but extra ocular movements were restricted and painful. Computed tomography (CT) scan revealed a curved metal object lodged in the posterior aspect of the left orbit extending diagonally from medial wall to the anterior-superior aspect of the orbital roof. The object was removed via a small surgical approach, inflicting least possible surgical trauma. Post surgery, the patient recovered with complete resolution of diplopia. The original aspects of this case are the lack of signs of a foreign body entry and its relative harmlessness in spite of its large size.     

Unnoticed Eyelid Foreign Body Presenting as Ptosis

A patient sustained right orbital trauma with unnoticed penetrating injury and a retained eyelid foreign body. She presented six weeks later with a complaint of persistent ptosis. The circumstances surrounding her injury are described, the issues arising and successful management of the case are discussed.     

Delayed presentation of grease-gun injury to the orbit

A 44-year-old man was examined for marked edema and ptosis of the right upper eyelid after grease from high-pressure hydraulic machinery penetrated his right orbit 20 days earlier. The diagnosis of residual grease in the injured orbit was confirmed by CT and MRI, and the clinical presentation. During orbital exploration, the grease was removed completely. Among the wide variety of orbital foreign bodies, grease is rarely reported. We present the sixth case of grease-gun injury to the orbit to be reported in the English language literature since 1964.     

An unusual case of total ophthalmoplegia

An eight-year-old male child presented with drooping of the left eyelid with a history of penetrating injury of hard palate by an iron spoon seven days ago, which had already been removed by the neurosurgeon as the computed tomography scan revealed a spoon in the left posterior ethmoid and sphenoid bone penetrating into the middle cranial fossa. On examination, visual acuity was 20/20 in each eye and left eye showed total ophthalmoplegia. Oral cavity revealed a hole in the left lateral part of the hard palate. We managed the case with tapering dose of systemic prednisolone. The total ophthalmoplegia was markedly improved in one month. Cases of foreign bodies in the orbit with intracranial extension are not unusual, but the path this foreign body traveled through the hard palate without affecting the optic nerve, internal carotid artery or cavernous sinus makes an interesting variation.     

Delayed presentation of orbito-cerebral abscess caused by pencil-tip injury

This report describes the clinical and radiologic findings of a child who was stabbed with a pencil tip in his right upper eyelid, in what initially appeared to be an innocuous injury. The child presented again 3 weeks later with a combined orbital and frontal lobe brain abscess. The mechanism of injury is discussed, the orbital and neuro-surgical interventions are detailed, and the medical treatment is presented. Ophthalmologists should have a high index of suspicion for orbital foreign bodies and possible intracranial injury in cases of penetrating eyelid trauma.     

Perfluoro-n-octane in orbital cavity after posterior vitrectomy and suture of eye perforating injury: case report

A case of a perfluoro-n-octane leakage into the orbital cavity after corneoscleral suture, scleral buckling and pars plana vitrectomy in an eye with perforating injury after trauma is reported for the first time. A previously healthy 39-year-old man was sent for ophthalmic evaluation one day after suffering a penetrating ocular trauma in his right eye while hammering a nail. On the initial evaluation, the patient presented sudden reduction of visual acuity on his right eye with a perforating corneoscleral injury, intraocular foreign body and retinal detachment. The patient was submitted to corneoscleral suture, pars plana vitrectomy with perfluoro-n-octane administration to flatten the retina and scleral buckling, when it was found transfixation of the globe by the intraocular foreign body. Postoperatively, computed tomography scans of the orbit were ordered due to proptosis, which showed the presence of hyperdense images, suggesting leakage of perfluoro-n-octane into the orbital cavity. Thus, in cases of perforating eye injury, one should be suspicious about the possibility of intraocular foreign body, as well as possible occurrence of transfixation of the globe when scheduling the surgery.     

肿瘤内出血导致眼眶神经鞘瘤暴露1例

目的:报告1例肿瘤内出血导致的眼眶神经鞘瘤迅速增大暴露于皮肤表面的患者。方法:病例报告。结果:患者,男,79岁,左侧上眼睑内侧有一个缓慢增长2a的肿物,近期肿物迅速增大。切取一部分活组织进行检查。4wk后,左眼肿物继续增大,视力则下降为6/18。检查发现肿物位于左眼眼眶鼻上方,眼睑呈机械性下垂及眼球受压向下外方移位。左眼眼球运动受限,向上注视时尤为明显。CT扫描显示在左眼内侧有巨大肿物突出。左眼前径路眶切开术活检显示包膜完整。组织学检查显示神经鞘瘤囊性改变和有血管血栓形成。患者手术顺利。术后视力提高至6/6和没有复视现象出现。结论:眼眶神经鞘瘤应作为一个重要与缓慢增长的肿瘤鉴别诊断,但快速增长的良性肿瘤也可以因为肿瘤内出血而高度怀疑恶性肿瘤或炎症。     

An extraordinary orbital foreign body

The authors report a unique case of a broken motorbike handle that presented as a bilateral orbital foreign body. A 30-year-old male sustained an injury to the right side of his face when he skidded from his motorbike while riding. He had bilateral sudden loss of vision and presented to emergency services with bilateral proptosis, motility restriction, and a right lower eyelid laceration. CT scan revealed a 7-cm-long motorbike handle lodged in the retrobulbar space of both orbits, close to the cribriform plate. Left lateral orbitotomy was performed to remove the foreign body; the right eye regained normal vision and function. The unique features of this case include the nature of the foreign body, its bilateral location, its proximity to the optic nerve and cribriform plate, and the challenges in its removal. The clinical presentation and management is presented, along with the surgical video.     

Penetrating orbital injury with organic foreign bodies

OBJECTIVE: The authors reviewed the clinical features, diagnostic workup, and management of patients of penetrating orbital injuries with retained organic foreign bodies. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Nineteen patients (15 males, 4 females) with penetrating orbital injuries due to organic foreign bodies. RESULTS: The series included 15 (78.9%) males and 4 (21.1%) females who ranged in age from 6 months to 40 years (mean = 14.6 years); 12 (63.2%) patients were younger than 12 years of age. Twelve (63.2%) right and 7 (36.8%) left orbits were involved. Time between injury and presentation varied from a few hours to 9 months. Most common injury site was the superior orbit in 11 (57.9%) patients leading to abnormal extraocular motility (84.2%), proptosis (68.4%), and upper lid ptosis (47.4%). Associated pathologies also included acute cellulitis in 11, orbitocutaneous fistula in 5, and osteomyelitis in 2 patients. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) identified the foreign bodies in 42% and 57% of the patients, respectively. CONCLUSION: Preoperative identification of the foreign material in the orbit was found to be very helpful for patient management but was only possible in approximately 50% of our cases with the use of CT and MRI. The vision in our patients usually improved shortly after treatment; the long-term complications more often included extraocular muscle and eyelid motility problems and periorbital scarring.     

Conjunctival squamous cell carcinoma of the orbit 40 years after enucleation

Conjunctival squamous cell carcinoma developed in a 51-year-old man 40 years after he had enucleation of his left eye because of an explosion injury. He had worn several ocular prostheses for more than 40 years. Recently he had noticed an increasing sanguineous conjunctival discharge, a foreign body sensation, and swelling of his left lower eyelid. Incisional biopsies of an underlying conjunctival mass revealed squamous cell carcinoma. His work history did not involve exposure to radiation, chemicals, or the sun. The authors concluded that squamous cell carcinoma in this case was caused by chronic irritation as the result of long-standing use of a poorly fitting ocular prosthesis.     

Orbito-cranial injury caused by penetrating metallic foreign bodies: report of two cases

Two cases of orbito-cranial injury caused by foreign bodies (FBs)penetrating the lateral wall and roof of the orbit are described.In the first patient, a long rusted nail acted as a missile andwas only detected by X-rays and CT scan. The nail penetratedthe orbit, the eyeball, the lateral orbital wall, and thetemporal lobe of the brain. Lodged partly in the orbit andpartly in the brain, this nail caused leakage of cerebrospinalfluid (CSF) through eye and led to orbital cellulitis andlocalized meningitis. The foreign body (FB) was removed throughan extradural pterional approach with rapid resolution oforbital cellulitis and meningitis. In the second patient,large metallic FB, having penetrated the orbital roof was lodgedintracranially above the chiasma. This was removed via frontalcraniotomy. Mechanism of such injuries and appropriatesurgical approaches are described as well.     

Penetrating eye injury from a rigid infant pacifier

Background: The use of infant pacifiers (dummies) is common in Australasian communities and has been reported to be associated with various injuries, but to date ocular trauma has not been reported.
Case report: A 14-month-old child sustained a penetrating eye injury from the infant pacifier that was in his mouth during a minor fall. Only a lid laceration was detected at the time. One week later he presented with mydriasis, heterochromia and a poor red reflex. Diagnosis of a penetrating eye injury was made by examination under anaesthesia, with B-scan ultrasonography demonstrating hypotony but no retinal detachment or intraocular foreign body. Funduscopy revealed a small inferior vitreous haemorrhage. Exploration of the globe adjacent to the lid wound showed a 6 mm laceration through the sclera plugged with prolapsed vitreous.
Conclusion: Serious ocular injury may result after a minor fall with some designs of rigid infant pacifiers. Heterochromia and anisocoria noted by the mother heralded more serious ocular injury in this case. The delay in diagnosis of this injury emphasises the importance of ocular examination to exclude eye trauma when injuries occur around the orbit.     

Intraorbital wood foreign body: a case study

A 12-year-old child had left orbital trauma by wood. He consulted 4 months after for orbital cellulitis with cutaneous fistula. The CT scan showed the presence of a left orbital wood foreign body extended to the homolateral cavernous sinus and intracranial. Extraction of the wood fragment associated with an adapted antibiotic treatment led to clinical improvement without visual recovery. A situation of orbital trauma and secondary orbital inflammatory syndrome must raise the suspicion of a foreign body of the orbit and motivate emergency imaging for optimal management of the disorder.     

Foreign body orbital cyst

PURPOSE: To present the clinical and histopathological characteristics of a retained orbital foreign body. METHODS: A 34-year-old male was hit in his left eye by a flower stake. At first examination there was a massive haematoma of the left orbit and eyelids, reduced movement of the left eye and a small conjunctival lesion beneath the upper lid. There were no signs of deeper orbital or ocular lesions. During the subsequent months the haematoma disappeared, but increased proptosis and impaired eye movements with diplopia were noticed. One year after the injury, ultrasound and CT-scan revealed an ovoid cystic tumour behind the globe. During surgery the content of the cyst appeared purulent and from the centre of the cyst a foreign body measuring 25 x 13 x 1 mm was removed. RESULTS: Microscopy of the foreign body showed the typical structure of a decidual leaf. The superficial cells were empty, whereas the centrally located cells contained remnants of cytoplasm. Confined to the border between the empty and the filled cells, a band of cells containing groups of gram positive cocci was noted. Staining for immunoglobulins revealed traces of IgG in the superficial empty cells only. CONCLUSION: The high degree of preservation of the leaf and the survival of the cocci may be due to a barrier function of the intact plant cell walls with their high content of cellulose.     

Missed Diagnosis of an Intraorbital Foreign Body of Homemade Fireworks Origin: A Case Report

Purpose

We report a rare case of traumatic injury to the eye caused by homemade fireworks in a Chinese juvenile patient with a metal ring left in the orbit after having been sutured at the Emergency Department.

Methods

An 11-year-old boy presented with a traumatic injury to the right eye from homemade fireworks. Following initial assessment involving maxillofacial computed tomography (CT) and suturing at the Emergency Department, he was transferred to our department for further evaluation because of his poor sight 1 day later. On examination, a skin laceration beneath the right eyebrow was noted, but the superior orbit was not fully visible on the maxillofacial CT performed 1 day previously. Therefore, an orbital CT scan was carried out on the second day, which showed a hyperdense ring embedded in the superior border of the orbital wall; the ring was surgically removed. On postoperative day 7, a fundus examination revealed resolving vitreous hemorrhage, blunt traumatic retinal detachment, and a large retinal tear superior to the macula. The patient refused to take surgery for retinal detachment into consideration. Therefore, we opted for oral steroids and careful observation.

Results

After 2 months’ observation, the large retinal tear had healed and white fibrous scar tissue had developed, and the retinal detachment superior to the macula had reattached itself spontaneously. The patient''s vision had further improved to 20/200. During 1 year of follow-up, he remained clinically stable.

Conclusion

To avoid missing the diagnosis, a complete history of the mechanism of injury and accurate imaging still prove most useful. Complete removal of the foreign body by the emergency physician is necessary because of the ocular toxicity of an iron-containing foreign body. As evidenced by the current case, oral steroids and observation for a period of several months is a management of choice for traumatic retinal detachment and retinal tear superior to the macula associated with homemade fireworks in children.Key Words: Homemade fireworks, Maxillofacial and orbital trauma, Orbital foreign body, Retinal detachment     

Salivary duct carcinoma metastatic to eyelid and orbit—a case report

BACKGROUND: Salivary duct carcinoma is a rare, extremely aggressive malignant tumor, demonstrating invasive growth with early regional and distant metastasis. We describe a case of parotid gland salivary duct carcinoma metastatic to the eyelid and orbit, as confirmed by immunohistochemical analysis. To the best of our knowledge, this is the first such case reported in the literature. METHODS: A 43-year-old male had left lower eyelid and left inferior fornix/anterior orbital masses. The patient underwent left lower eyelid and anterior orbital biopsies for histopathological evaluation. Immunohistochemical analysis for markers like androgen receptors, gross cystic disease fluid protein-15, cytokeratins, HER-2/neu, epithelial membrane antigen, S-100 proteins, progesterone receptors, and estrogen receptors were performed to establish diagnosis. RESULTS: Specimens from the eyelid and orbit revealed lobules of tumor cells exhibiting solid, micopapillary, and glandular appearance with central necrosis-comedo patterns. The tumor cells showed immunohistochemical reactivity to androgen receptor proteins, pankeratin, HER-2/neu and epithelial membrane antigen. Focal reactivity to gross cystic disease fluid protein-15 was also present. Immunoreactivity to S-100 proteins, progesterone receptors, and estrogen receptors were negative. Diagnosis was metastatic paratoid duct carcinoma to the left lower eyelid and left inferior orbit. CONCLUSIONS: Although metastatic SDC of the eyelid and orbit is a rare phenomenon, the possibility of this extremely aggressive entity should be included in the differential diagnosis when dealing with a patient with an eyelid and/or orbital tumor.     

Orbitocranial injury caused by wood

A rare case of a patient with orbitocranial injury by a wooden foreign body is reported. Penetrating periorbital wound by a wooden stick with entry site at the right upper eyelid was related to the invasion into the temporal lobe. Fortunately, the anterior and posterior segments of eye were unharmed, but right ocular motility was markedly restricted mechanically in all directions. Forced duction test was strong positive, especially the dextroversion of the right eye. Computed tomography scan showed a well-delineated low density from the orbital wall into the temporal lobe. The wooden foreign body was subsequently removed from the orbit and the temporal lobe, through the neurosurgical frontotemporal approach. After the wooden foreign body was removed, the ocular movement of the right eye fully recovered without any intracranial or ocular complications.