Transorbital removal of intracranial foreign body in middle fossa.

A limited access to the middle cranial fossa can be achieved by an opening created in the posterior portion of the lateral orbital wall. An intracranial foreign body was removed by this method.     

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.     

Langerhans-cell histiocytosis of the orbit; diagnosis, treatment and outcome in three patients -- children and adults

BACKGROUND: Langerhans cell histiocytosis usually affects children. Systemic Langerhans cell histiocytosis may be present in 37% of affected children. Ten per cent of all children die of the disease. CASE REPORTS: Patient 1. A 9-year-old boy presented with painful upper lid swelling OD. Ultrasonography revealed a space-occupying lesion adjacent to a lytic defect of the frontal bone as shown on coronal CT. MRI showed marked contrast enhancement of the mass which came close to the intracranial fossa. The vascularized tumor was excised using an anterior orbitotomy with upper lid crease incision. No evidence of local or systemic recurrence was present three years postoperatively. Patient 2. A 19-year-old male presented with foreign body sensation, double vision OS and numbness of the left face of six weeks' duration. The ocular findings revealed a sixth nerve palsy OS. Otherwise, the eyes were unremarkable. Sensitivity of cranial nerve V2 was decreased. CT revealed an osteolytic process in the lateral orbital wall and sphenoid wing. MRI demonstrated a space-occupying lesion involving the temporalis muscle laterally, the pterygopalatine fossa medially with intracranial extension into the temporal lobe. Surgical excision was performed using a transcranial approach. Signs and symptoms had completely resolved six months after surgery with no evidence of local or systemic recurrence. Patient 3. A 30-year-old male presented with right-sided headache, painful upper lid swelling and vertical diplopia. Coronal CT scan revealed a lytic defect in the frontal bone laterally. Curettage and complete excision were performed using an infrabrow incision. Follow-up examination four years later revealed an intact ocular motility with no evidence of local or systemic recurrence. In all three cases the tumor showed characteristic light-microscopy and immunohistochemical features of Langerhans cell histiocytosis. CONCLUSION: Langerhans cell histiocytosis of the orbit is an important differential diagnosis of osteolytic and/or space-occupying lesions not only in children, but also in adults. A diagnostic biopsy followed by surgical excision and/or local and systemic corticoid- and chemotherapy are essential regarding the prognosis of local and systemic disease.     

Shaken baby syndrome without intracranial hemorrhage on initial computed tomography

OBJECTIVE: We sought to describe the unique characteristics of children diagnosed with shaken baby syndrome (SBS) despite the absence of intracranial hemorrhage on cranial computerized tomography (CT) on hospital admission. METHODS: Using an international e-mail-based listserv for professionals with an interest in child abuse, we identified and reviewed the charts of children hospitalized in different medical centers who were diagnosed with SBS although CT disclosed no signs of intracranial bleeding. Children with normal imaging were not included. RESULTS: Eight cases were identified. All children had cerebral edema in CT, which was severe on 7/8 cases (88%). All of these children had extensive retinal hemorrhage. The prognosis was poor; 5/8 infants died (63% mortality), and the rest had permanent neurologic damage. CONCLUSION: The diagnosis of SBS can be established even when CT at presentation does not demonstrate intracranial hemorrhage. We hypothesize that rapidly developing cerebral edema may cause increased intracranial pressure and tamponade that prevents the accumulation of intracranial blood. The prognosis in these cases is grave.     

An orbitocranial foreign body. Diagnostic reflections

The authors demonstrate how a delay in diagnosis, in the case of an orbito-cranial foreign body, serves to underscore importance of CT in even minor, orbito-facial injuries, when there is some suspicion of intracranial penetration. This examination, which should be requested as soon as possible in such cases, usually permits detection of the intracranial foreign body. However, if the image is much clearer than those of conventional X-rays, it can in certain cases, remain a matter of subtle interpretation, particularly in cases of less dense materials such as wood.     

A case of retained wooden foreign body in orbit

A 41-year-old man visited our clinic complaining of esodeviation of the right eye. He had been operated on for corneal laceration 3 years before. One month later, exodeviation of the right eye had developed. The result of computed tomography (CT) was reported as orbital abscess and cellulitis. Although antibiotic treatment was administered for 2 weeks, the exodeviation didn't improve. On ocular examinations performed in our hospital in November-2001, his right eye was esotropic and had a relative afferent pupillary defect. Vision of the right eye was decreased to 0.02. Fundus examination showed optic atrophy. A new CT scan disclosed a foreign body introduced into the right medial orbital wall, nasal cavity and ethmoidal sinus. Although foreign body was surgically removed, vision and eye movement were not improved. In the case of a patient who has undergone orbital trauma, complete history taking and physical examinations must be performed. On suspicion of a foreign body, imaging study such as CT or MRI must be performed. However, because CT findings can be variable, careful follow-up is needed.     

Occult orbito-cranial penetrating injury by pencil: role of beta tracer protein as a marker for cerebrospinal fluid leakage

Orbito-cranial foreign bodies present a treacherous situation that can escape detection. The only evidence of these foreign bodies may be the entry wound in the form of a small lid laceration. A two-year-old boy presented with right upper lid laceration following a fall two hours back. Analysis of the fluid around the wound revealed a beta-tracer protein (beta-TP) value of 33.5 mg/l suggestive of cerebrospinal fluid (CSF). Three-dimensional computed tomography (CT) scan revealed a foreign body measuring 4.2 cm x 0.8 cm passing from the orbital roof to the frontal lobe. The foreign body tract was explored through the eyelid laceration and a broken pencil was removed followed by dural patch graft. The patient developed no ocular or intracranial complications. Beta-TP, a highly specific marker of CSF is routinely used in screening patients of neurosurgery and otolaryngology with CSF leaks, however, its use has never been reported in ophthalmic literature based on an online PubMed search.     

超声活体显微镜和CT诊断眼前段异物的对比分析

目的 探讨超声活体显微镜(UBM)和CT两种不同成像方法 对眼前段异物诊断的优缺点及联合应用的价值.方法 为比较研究,收集2000年7月至2007年5月共44例疑诊为眼前段异物的患者同时行UBM和CT检查的资料,并与其手术结果 相对照.结果 CT扫描发现其中40例表现为高密度影,分别为铁、铜、石块、玻璃等;2例稍高密度影,均为塑料;2例无异常发现者分别为竹签和板栗刺.44例患者UBM检查均表现为强回声光斑伴声影.结论 CT对眼前段异物难以精确定位和发现并发症.UBM对所有眼前段异物均可准确定位,并能发现异物相关并发症.但其操作复杂,扫描视野小,检查费时.眼前段异物诊断的最佳方案为先行CT扫描确定异物方位及异物种类,再行UBM检查确定异物准确位置,发现并发症.(中华眼科杂志,2008,44:229-232)     

眼眶植物性异物的诊断和治疗

目的：通过对眼眶植物性异物的临床分析，该病最好的诊断和治疗方法。方法：复习我院收治的眼眶植物性异物21例,分析其各项检查及治疗方法。结果：眼眶瘘管形成占眼眶植物性异物的57．14％；B型超声检查异常者占64．70％，可提示异物存在者占41．18％；CT扫描异常者94．12％，可提示异物存在者占41．18％；2例行MRI检查均清晰地显示出异物影像，21例患者均手术取出异物，证实术前诊断。结论：眼眶植物性异物影像学检查显示率较低，对于显示异物，MRI优于超声和CT。正确诊断必须结合病史和眼部体征，尤其是眼眶瘘管的存在，手术摘出异物的同时需将瘘管一同切除，以求彻底治愈。     

Dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body for diagnostic and surgical purposes. [Case report of orbital injury with ethmoid bone involvement]

The main goal of our dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body following orbital injury with ethmoid bone involvement was to use 3D-information obtained from standard computed tomography (CT) data to explore and evaluate the nasal cavity, ethmoidal sinuses, retrobulbar region, and the foreign body itself by simulated dynamic computed visualization of the human head. A foreign body, 10 × 30 mm in size, partially protruded into the posterior ethmoidal cells and partially into the orbit, causing dislocation and compression of the medial rectus muscle and inferior rectus muscle. The other muscles and the optic nerve were intact. Various steps were taken to further the ultimate diagnosis and surgery. Thin CT sections of the nasal cavity, orbit and paranasal sinuses were made on a conventional CT device at a regional medical center, CT scans were transmitted via a computer network to different locations, and special views very similar to those seen on standard endoscopy were created. Special software for 3D modeling, specially designed and modified for 3D C-FESS purposes, was used, as well as a 3D-digitizer connected to the computer and multimedia navigation through the computer during 3D C-FESS. Our approach achieves the visualization of very delicate anatomical structures within the orbit in unconventional (non-standard) sections and angles of viewing, which cannot be obtained by standard endoscopy or 2D CT scanning. Finally, virtual endoscopy (VE) or a ‘computed journey’ through the anatomical spaces of the paranasal sinuses and orbit substantially improves the 3D C-FESS procedure by simulating the surgical procedure prior to real surgery.     

Dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body for diagnostic and surgical purposes. [Case report of orbital injury with ethmoid bone involvement

The main goal of our dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body following orbital injury with ethmoid bone involvement was to use 3D-information obtained from standard computed tomography (CT) data to explore and evaluate the nasal cavity, ethmoidal sinuses, retrobulbar region, and the foreign body itself by simulated dynamic computed visualization of the human head. A foreign body, 10 x 30 mm in size, partially protruded into the posterior ethmoidal cells and partially into the orbit, causing dislocation and compression of the medial rectus muscle and inferior rectus muscle. The other muscles and the optic nerve were intact. Various steps were taken to further the ultimate diagnosis and surgery. Thin CT sections of the nasal cavity, orbit and paranasal sinuses were made on a conventional CT device at a regional medical center, CT scans were transmitted via a computer network to different locations, and special views very similar to those seen on standard endoscopy were created. Special software for 3D modeling, specially designed and modified for 3D C-FESS purposes, was used, as well as a 3D-digitizer connected to the computer and multimedia navigation through the computer during 3D C-FESS. Our approach achieves the visualization of very delicate anatomical structures within the orbit in unconventional (non-standard) sections and angles of viewing, which cannot be obtained by standard endoscopy or 2D CT scanning. Finally, virtual endoscopy (VE) or a 'computed journey' through the anatomical spaces of the paranasal sinuses and orbit substantially improves the 3D C-FESS procedure by simulating the surgical procedure prior to real surgery.     

Eyelid ptosis associated with an undetected foreign body and a remote entrance wound

A 12-year-old girl presented with ptosis 10 days after falling onto glass that penetrated the frontotemporal region. The immediate ptosis and palpable mass was attributed to an undetected foreign body. CT demonstrated a radiopaque foreign body. During surgery, the foreign body removed was found to be a piece of glass from a soda bottle. The ptosis resolved completely within the next 2 weeks. A retained foreign body should be considered in any case of prolonged ptosis after penetrating ocular trauma, even when the entrance wound is remote.     

磁共振成像与CT在眼内非磁性异物诊断和定位中的比较

目的探讨磁共振成像（ｍａｇｎｅｔｉｃｒｅｓｏｎａｎｃｅｉｍａｇｉｎｇ，ＭＲＩ）和ＣＴ在眼内异物诊断和定位中的特点。方法以手术结果作为验证标准，比较２８例（４２枚）眼内非磁性异物在ＭＲＩ和ＣＴ图像上的显示及定位情况。结果４２枚眼内非磁性异物，ＭＲＩ和ＣＴ的检出率分别为９０．５％和９５．２％（ｘ２检验，Ｐ＞０．５）。ＭＲＩ与ＣＴ显示异物位置的准确率分别为８９．５％和６０．０％（ｘ２检验，Ｐ＜０．０５）。结论ＭＲＩ可用于眼内非磁性异物的诊断和定位，检出率高，在揭示异物与眼内组织的位置关系及显示眼内非磁性低密度异物方面优于ＣＴ，但对于眼球壁异物的显示则不如ＣＴ可靠。ＭＲＩ不宜用于眼内磁性异物的检查。     

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.     

24例眼眶异物诊断和治疗分析

目的 分析目前眼眶异物诊断和治疗中存在的问题.方法 回顾性系列病例研究.收集2002年5月至2007年5月收治的眼眶异物患者24例,根据其临床和影像学资料了解目前眼眶异物诊断和治疗中存在的问题.结果 植物性异物11例,金属异物6例,玻璃异物2例,其他5例.18例曾行清创缝合术,12例曾行异物取出术,7例曾行3次以上各类手术.诊断和治疗中存在的问题:(1)受伤情况询问不详、对眶内异物存留认识不足;(2)未进行必要的CT检查;(3)不能正确阅读CT片,CT显示异物而未能诊断;(4)急诊清创处理、以及后续的化脓性感染切开引流,均未进行必要的探查;(5)对植物性和塑料异物,仅满足术中取出一个或数个异物;(6)对眼眶解剖结构不熟悉,手术技术不熟练,不能取出异物甚至将其推向深处;(7)再次手术时未重新进行必要的CT检查;(8)麻醉方式选择不当.局部麻醉下,患者不能耐受手术.结论 眼科医师应掌握眶内解剖结构、影像学和眶内异物的诊断,熟悉眼眶手术入路,提高异物取出成功率,减少手术并发症.(中华眼群杂志,2008,44:676-680)     

眼眶异物的X线诊断分析

目的：研究影响异物在Ｘ线平片的显影因素。方法：选择５２７例阳性结果的眼眶异物，回顾分析了异物与投射角度的关系。结果：１３例侧位片有异物，后前位片无异物；１２例薄骨位片无异物，后前位及侧位片无异物；１０例无骨影位片有异物，后前位、侧位和薄骨位片无异物，１例第１次拍片后无异物，侧位片有异物，第二次照片后前位片有异物，侧位片无异物。结论：投照位置、异物和Ｘ线投射角度与异物的显影很有关系。眼外伤患者除照常     

Hyphema caused by a metallic intraocular foreign body during magnetic resonance imaging

PURPOSE: To report a 63-year-old man with a retained intraocular foreign body who developed a hyphema during magnetic resonance imaging (MRI) of the brain. METHODS: Case report and review of the current literature on ocular injury caused by intraocular foreign bodies when subjected to an electromagnetic field. RESULTS: Our patient underwent a brain MRI, and the intraocular foreign body caused a hyphema and increased intraocular pressure. The presence and location of the intraocular foreign body were determined by computed tomography (CT). CONCLUSION: Magnetic resonance imaging can cause serious ocular injury in patients with ferromagnetic intraocular foreign bodies. This case demonstrates the importance of obtaining an occupational history, and, when indicated, a skull x-ray or CT to rule out intraocular foreign body before an MRI study.     

Orbital osteoma arising adjacent to a foreign body

A 27-year-old man sustained a blast injury to the face in April 1996, with a resultant foreign body at the right medial orbital wall. He refused to undergo surgical removal of the foreign body at that time and was discharged on oral antibiotics. Five years later, he presented because of recurrent attacks of swelling, redness, and pain at the right medial canthal area. A repeat computed tomography (CT) scan revealed fragmentation of the original orbital foreign body and an adjacent radiodense lesion that appeared to blend smoothly with the orbital bone from which it arose. This lesion was not present on the initial CT scan done 5 years earlier immediately following the blast. The patient was started on oral antibiotics and surgical exploration was carried out. Three fragments of the foreign body were removed in addition to the adjacent orbital lesion, which proved to be an ivory-type osteoma on histopathology. We briefly review previously suggested factors in the pathogenesis of osteoma and present further evidence in favor of both traumatic and infectious factors.     

Treatment of Orbital Roof Blow-Up Fracture Using a Superior Blepharoplasty Incision

In orbital roof blow-up fractures, reduction can be achieved easily using an approach from the anterior cranial fossa but the procedure is highly invasive. In contrast, an orbital approach using a superior blepharoplasty incision is minimally invasive. However, if bone fragments are adhered to the dura mater, there is a risk of dura mater injury when fragments are moved for reduction. In blow-in fractures, reduction is performed by pushing the bone fragments against the anterior cranial fossa. In contrast, the procedure is difficult for blow-up fractures because bone fragments must be pulled out into the orbit through the anterior cranial fossa. Orbital blow-up fractures are often associated with intracranial injuries and frequently treated by an approach from the anterior cranial fossa. There has not yet been a report that discusses whether reduction of bone fragments should be performed in blow-up fracture without intracranial injury. In this report, we describe two cases of orbital roof blow-up fracture that did not require treatment for intracranial injury and that were treated using an orbital approach. The treatment involved only the release of orbital fat entrapped between bone fragments and did not involve reduction. The treatment outcomes were good in both cases.     

Fourth cranial nerve palsy in pediatric patients with pseudotumor cerebri

PURPOSE: To describe three children with acute fourth cranial nerve palsy secondary to pseudotumor cerebri. METHODS: We reviewed the medical records of children younger than 18 years who were diagnosed with pseudotumor cerebri between 1977 and 1997. Pseudotumor cerebri was defined by normal neuro-imaging, elevated intracranial pressure measured by lumbar puncture, and normal cerebrospinal fluid composition. RESULTS: Three children with pseudotumor cerebri presented with vertical diplopia and clinical signs of fourth cranial nerve palsy including a hypertropia of the affected eye, which increased with adduction and ipsilateral head tilt. The fourth cranial nerve palsy resolved after reduction of the intracranial pressure in all three children. CONCLUSIONS: Fourth cranial nerve palsy may occur in children with pseudotumor cerebri and may be a nonspecific sign of elevated intracranial pressure.