MANAGEMENT OF RETAINED FOREIGN BODY FOLLOWING

PENETRATING ORBITAL TRAUMA; A Case Series

Rosmiaty, Suliati P.Amir, Halimah Pagarra

Department of Ophthalmology, Faculty of Medicine, Hasanuddin University, Makassar

PURPOSE: To report a case series of penetrating orbital trauma and it’s management.
METHOD: This three cases was examined completely. Assesing,we underwent medical record, visual
acuity, intraocular pressure, anterior segment evaluation and The Head plain radiography and Computed
Tomography of the orbits . Managing based on location, type, and shape of foreign body .

RESULT: The first cases, a 15 year old, boy with penetrating ocular trauma of a fish arrow, there was
horizontal laceration on cornea ±9mm. Neurosurgical division performed parietalis craniectomy and we
enucleated because intraocular prolapsed. The second cases, a 20 year old,male with penetrating trauma
of an arrow ,straight vertically in medial canthal and penetrating into the brain, neurosurgical division was
performed occipitalis craniectomy to removed the arrow. The third cases, a 5 year old,boy with retained
foreign body in upper eyelid of an airgun bullet. Axial CT scans plane showed a intrapalpebral foreign
body, we were using magnet to pulled bullet onto surface but it doesn’t work thereby we performed
exploration surgery to found the airgun bullet.

CONCLUSION:
Based on ophthalmology examination and Neurosurgical intervention, we have made different kind of
methods of surgery to removed intraocular foreign body, depends on location, type, shape and
composition of foreign body.

Introduction

Trauma can result in a wide spectrum of tissue

lesions of the globe, optic nerve, and adnexa,
ranging from the relatively superficial to vision
threatening. Classification eye trauma based on
BETT(Birmingham Eye Trauma Terminology)(1)

1

Ocular trauma patients are often particularly
stressed and should be made as comfortable and
relaxed as possible. It is important to assess if
two eyes are present and if they are grossly
intact; this can be difficult and examination
under anaesthetic may be required.(1,2,3)
Assesing a ocular trauma patient shoud be
started with Medical Record(MR). A thorough
history will help identify and detail the cause of
injury. The history should include when, where,
and how the injury occurred in the patient’s own
words. The reporting and documentation of the
history and physical exam often have
medicolegal consequences, as many are work-
related or a result of assault. The physician
should inquire into any previous treatments for
the current injury and the events occurring from
the time of injury until the time of presentation.
Past medical history including eye injuries,
ocular surgeries, or history of amblyopia,
medications, allergies, family history, social
history, and date of last tetanus vaccination
complete the highlights of the eye injury history.
(1,2,3,4)
The vision should be assessed using a Snellen
chart, or estimated using typed script. If no
letters can be read, the ability to count fingers, to
see hand movements and to perceive light are
recorded in that order as CF(Counting Finger),
HM(Hand Movement), PL(Perception of Light)
and NPL (nil perception of light), respectively.
Extraocular muscle assessment is then
performed in all nine positions of gaze while
following a pen torch or target. Pupil
examination is performed; shape, symmetry, the
red reflex and pupil reactions to light are
recorded.(3,4,5)
Visual acuity, presence of an afferent pupillary
defect, the type of injury, the location, and extent
of penetrating injury, type of lens damage,
presence and severity of vitreous hemorrhage,
presence of and composition of intraocular
foreign bodies mostly contribute to the final
visual outcome in patients suffering penetrating
ocular injuries. In 2000, Craig M Greven et al
studies in North Carolina reported that 59
patients that undergoing surgical removal of
intraocular foreign body with a minimum 6
month follow up, final best corrected visual
acuity of 20/40 or more was obtained in 42
patients (71%) and ambulatory vision (.5/200)
was achieved in 50 patients (85%) final visual
outcomes were excellent in 71% of patients.
Examination on anterior segment, pre-surgical
examination of plain photo radiography,
ultrasonography and computerized tomography
(CT), helpful to identify the location, type of and
shape of foreign body. Intervention and join
operation can be done with many
department depends on location of foreign
body, join operation with Otolaryngologist if
foreign body had entered sinus and
Neurosurgical if foreign body had entered
brain. (1,4,7,8). In 2001, GN Shuttleworth et al
studies in England reported that 19 cases of
ocular airgun injury investigated
radiologically, a total of 11 series of plain X-
rays, 7 computed tomographic scans and one
magnetic resonance (MRI) scan were
performed. The MRI was done only after an
identical air-gun pellet had been found to be
2
non-magnetic; it revealed a pellet embedded in
the occipital cortex (having transversed the orbit
and the cranium) and the patient had a resultant
defect in the visual field of the undamaged
fellow eye.(6)
A Case Series Report

1. MR is a 15-year-old boy, who

presented to a local emergency
department complaining of sudden
severe right eye pain after being struck
Figure 1.b. Fish arrow extraocular length (±52cm)
by a fish arrow, he was fishing with his
friends before struck by a fish arrow, he Fundus examination cannot be done in the right
can’t identified trauma mechanism eye and left eye showed posterior segment in
clearly, he was falling while holding the normal .
fish arrow and the fish arrow struck into
his right eye, bleeding, no adult Radiography
supervision. There were no complains Plain head radiography showed : metallic
on left eye. Examination on right eye foreign body (fish arrow) penetrated right eye
revealed no visual acuity and on left eye passed under the frontal bone and entered the
twenty per twenty. Intraocular pressure intracranial region frontalis.
on right eye was hard to evaluated and
ocular pressure was 15,7 mm Hg in the
left eye. Anterior segment examination,
on right eye we identified a fish arrow
with extraocular length was 52
centimetres, straight in cornea at 9
o’clock at the limbus, conjunctiva
chemosis, there was horizontal
laceration on cornea ±9mm,iris was
prolaps through corneal laceration, a Figure 2.Plain Head Radiography
shallow anterior chamber, hyphema
Axial Computed Tomography scans plane
±4mm, another segment hard to
showed ;
evaluated.Anterior segment examination
on left eye was normal. (A)

Figure 1a. facies of the patient

3
(B) and the wound was stiched. An external
ventricular drain was inserted.

(C)

Figure 4. Showed a fish arrow had entered cerebrum

frontalis region about 2mm

Figure 3. Computed Tomography of the orbist

A pre-surgical Computed Tomography of the

orbits showed that top of metallic foreign
body(arrowhead) had hook shape, penetrated
right eye passed under the frontal bone, and
entered the cerebrum region frontalis. Figure5. Ophthalmology identified the wound in ocular

The diagnosis of penetrating ocular trauma with

corneal laceration and intraocular metallic
foreign body was made. The patient was given
pantocain for pain control, and informed consent
was obtained from the parents.

Management

Managing, based on location had entered

cerebrum frontalis region, we were deciding for
doing join operation with Neurosurgical divison.
Neurosurgical division was performed parietal Figure 6. We identified the fish arrow had entered into
craniectomy to identify the fish arrowhead and posterior segment dan eye prolapsed

had entered the cerebrum frontalis region Operation continued by ophthalmology, we

(frontalis pole) about 2mm(fig.4) so they identified the fish arrow has entered into ocular
removed the fish arrowhead slowly then released posterior segment(Fig.6) with coroidal rupture,
it from cerebrum. They put back the cranium

4
sclera rupture and intraocular prolapsed, we
decided to enucleated the eye(Fig.7)
Figure 7. Enucleated eye
Postoperatively, intravenously, Ceftriaxone 1
gram twice per day, Metronidazol 250mg three
times per day, Thromentamine 5mg three times
per day. Topical, polymixin B, neomycin
sulphate, and dexametason were administered
three times per day.
On hospital day three, the conjunctiva less
redness, no chemosis, the stitches were fine, and
no sign of infection. The patient was discharged
from the hospital on day seven with a clinic visit
scheduled for the following day.
Figure 7b.Postoperayively, on hospital day two,
conjungctiva chemosis, hyperemis and stitches were fine
2. MR is a 20-year-old, male who
presented to a local emergency
department complaining of right eye
pain after being struck by an arrow.
There was a chaotic happening between
two villages nearby and this man struck
by an arrow. He was hospitalized in
Ambon before brought to Makassar for
advanced therapy. There were less
bleeding. Because the patients was
unable to cooperate we can’t exam the
visual acuity in both eyes and
intraocular pressure was normal in both
eyes. Anterior segment examination, on
right eye we identified an arrow was
straight vertically near to medial canthal
and wood was attached on it, the other
ocular anterior segment was normal and
left eye was normal. Because of pain
thereby we decided for posterior
segment evaluation intraoperatively.
Figure 8. Showed wood attached on arrow on
medial canthal
Radiography
A head plain radiography showed that the arrow
had entered the cerebrum temporal side through
the right orbit near the medial canthal(fig.9)
Figure 9. Head Plain Radiography
A presurgical Computed Tomography revealed
that top of metallic foreign body(arrowhead) had
hook shape. It penetrated under the right
eithmoidal and sphenoid sinuses and entered the
cranial cavity and right temporal lobe continued
obliqually into midcerebrum near the
pons(fig.10).
5
 can identified the arrowhead location, it showed
that arrowhead had entered midcerebrum near
the pons and near to basilar artery they pushed it
down slowly untill arrowhead far enough from
basilar artery and removed it posteriorly, and
operation continued by ophthalmology, we
found that the arrow only made conjunctiva
laceration on superonasal side about 10
millimetres.(Fig.15)
Figure 10. A pre-surgical Axial Computed Tomography
plane revealed that metallic foreign body had entered
midcerebrum
Management
Ophtalmology started with removed the
wood that attached at end of arrow thereby
when neurosurgical division try to removed
the arrowhead posteriorly so it won’t
damage the eye for hook shape and the
wood that still attached on(fig.11).

Figure 13. Neurosurgical was performed occipitalis

craniectomy

Figure 11. Ophthalmology started the surgery with

removed the wood that attached on arrow

Figure14. Length of part of arrow made of metal that

entered eye and cerebrum ±18 centimetres

Figure 12. Length of part of arrow made of wood ±35

millimetres
Neurosurgical division was performed
occipitalis craniectomy in pronation position,
they were trying identified arrowhead by
pushing the arrow from right orbit thereby they

6
 Figure 15. We only found a 10mm conjunctiva
laceration

Postoperatively, the patient was transferred to

Intensive Care Unit. Intravenously, ceftriaxone
1gram twice per day, metronidazol 1 gram per
day, Thromentamine 5mg three times per day,
Ranitidine three times per day,and topical
polimiksin B, neomycin sulphate and
dexametason ophthalmic solution three times
per day was adminishtered. On ICU day two
conjunctiva less redness, less chemosis and
stitches were fine. Figure 16. Ocular anterior segment was
normal and there were a foreign body in
intrapalpebra

Management
Exam under anesthesia revealed an
intrapalpebral foreign body. We started
with undermine from port d’entry by
simply open the upper eyelid skin dan
subcutaneous tissue and tried to identify
Figure 15b. Postoperatively, cnjungtiva no redness, no the location of airgun bullet using
chemosis, and stitches were fine magnet, but magnet can’t pulled it on
surface because airgun bullet did’t made
3. MR is a 5 years old, boy suffer
of metal so we try to undermined upper
penetrating ocular trauma on right eye
eyelid until levator muscle but we find
of an airgun bullet about 2 half hours
no bullet, thereby we expand the
ago while this child was playing with his
exploration into inferolateral side, we
friend without adult supervision.He
undermined skin and subcutaneous
reported the sudden onset of intense
tissue, orbicularis oculi muscle, until
pain in right eye.No bleeding history, he
levator muscle and about 10 mm from
denied wearing any protective or
port d’entry the airgun bullet was found
prescription glases at the time. On
in levator muscle . After we identified it,
examination, his vision in the right eye
we removed the bullet and stitched the
was hard to evaluated because the pain
wound.
child hardly can open his eye , and using
snellen visual acuity card was 20/20 in
left eye . Intraocular pressure was hard
to evaluated in right eye and left eye
was normal. Anterior segment
examination on right eye, swelling
upper eyelid, hyperemis conjunctiva,
and the other segment was normal.
Anterior segment examination on left
eye was normal. A presurgical
Computed Tomography of the orbits
Figure 17. Airgun bullet
revealed a round foreign body in upper
eyelid.

7

Figure 18. The wound were closed
Posoperatively, intravenously, Cefotaxime
500mg twice per day, Dexametasone 2,5mg
three times per day, and Metamizole Na 150mg
three times per day , topically Polymixin B,
Neomycin Sulphate and Dexametasone
ophthalmic solution was administered. On
hospital day three, we found hematom and
swelling on upper eyelid, stches were fine, and
less redness on conjunctiva, the other ocular
segment were normal(fig.19). The patient was
discharged from the hospital on day seven with a
clinic visit scheduled for the following day. We
found no sign of ptosis on right upper eyelid.
Figure 19. On hospital day three, hematom and swelling on
upper eye lid , stitches were fine
Discussion
We have found many cases of ocular penetrating
trauma, such as first cases, we found it hard to
removed the fish arrow because the fish
arrowhead had penetrated into cerebrum region
frontalis through right eye and passes under
frontal bone, arrowhead had hook shape with
neurosurgical intervention, the fish arrowhead
had succeed to removed, eventough we had to
enucleated the eye because the fish arrow had
made intraocular prolapsed and with fear of
postoperatively symphatetic ophthalmia. It quite
a long fish arrow about 52cm at extraocular and
about 3,5cm entered the right eye into posterior
segment penetrated into cerebrum frontalis
region about 2mm. After we enucleated the right
eye, postoperatively , topical Polymixin B,
Neomycin, Dexametason ophthalmic ointment
was administered. On hospital day three, less
redness on conjungtiva , no khemosis, the
stitches were fine. We are put on an ocular
prosthesis soon. In 2009, Shane Havens et al
studies on Penetrating eye injury of Intraocular
foreign body in US, reported that quite hard if
trauma may manifest in posterior segment as
commotio retinae, choroidal rupture, posterior
skleral rupture. Symphatetic Ophtalmia(SO) is
the most feared complication of ocular trauma, if
the case was presented and visual acuity light
perception only, enucleated was recommended.
In 1972, Liddy and Stuart reported an incidence
of symphatetic ophtalmia was 0.19% following
penetrating injury and 0.007% following
intraocular surgery and onset of SO range from
5 days to 66 years that may result very poor
visual outcome without therapeutic intervention.
Definitive prevention of SO requires prompt
(within the first 7 to 10 days following injury)
enucleation of the injured eye. There is concern,
however, that evisceration may lead to a higher
incidence of SO compared to enucleation
(reviewed by Migliori, 2002). The second cases,
this man had suffered ocular penetrating trauma
for 2 days, the arrow had two kind of material
the wood that attached at end of arrow dan the
metal at the arrowhead . The arrowhead had
hook shape so if we removed anteriorly it can
damage cerebrum and can tear the eye because
arrowhead had hook shape. Thereby, we had to
removed the wood that attached at the end of
arrow on medial canthal, then neurosurgical
division turn the patient body around in
pronation position so they can performed
occipitalis craniectomy easily. After performed
craniectomy they can identified the arrowhead
near basilar artery, so they push it down thereby
arrowhead removed far from basilar artery and
then they pulled it posteriorly. After removal of
the arrow and wound closed, the patient body
back on supine position, we identified the
wound on right eye, and found a 10mm
conjunctiva laceration with a normal intraocular
pressure on both eyes. Postoperatively, topical
Polymixin B, Neomycin Sulphate, Dexametason
8
ophthalmic ointment was administered. Katrijn
de Jongh et al studies in US, reported a case
with penetrating injuries of an arrow, 3D CT
scans documented location, type and shape of
foreign body thereby the diagnostically relevant
details and facilitating planning of further
therapy, in this case report arrow entered oral
cavity and exits skull near vertex, 3D CT scans
documented the arrow had penetrated into right
eitmoidal and sphenoidal sinus passes trough
right ocular posterior segment thereby join
operation was done by neurosurgical,
ophthalmologist, and otolaryngologist. (3,5,7)
The third cases, initially we were using magnet
to pulled airgun bullet onto the surface of
palpebra superior, but turn out that the bullet not
made from metal so it not pull out onto surface
of palpebra. Thereby upper eyelid had to opened
and try to find airgun bullet with undermine
slowly. After identified the location we removed
it , and stiching the wound. We were afraid of
ptosis postoperatively for exploration surgey
until the levator muscle but after 14 days
following up, we had found no sign of ptosis on
right upper eyelid. Postoperative visual acuity
on both eyes twenty per twenty. Funduscopy
examination was normal on both eyes. In 2009,
Alok A. Umredkar et al studies in 2010 reported
a case of gunshot injury and an open wound at
the frontal region, A computed tomography (CT)
scan at that time revealed a bullet in the
posterior frontal cortex, just lateral to the
midline. As the patient was asymptomatic, no
intervention was undertaken and at 2.5 years of
follow-up, the patient remains symptom free, the
decision of nonsurgical management is more
likely in case of high-velocity bullet injury due
to the sterile nature of the bullet. Because of the
bullet sterile, we found no sign of infection on
this patient. In 2001, GN Shuttleworth et al
studies in UK, reported that typically all the
victims of an airgun injuries are juvenile male,
injured accidentally and nearly always in
absence of adult supervision, the weapon
directly into the eye at close range thereby they
found 9 injuries were penetrating or perforating
globe ruptures, 8 were severe contusions and 2
were minor contusions. Within the first 2 days, 7
patients underwent a primary repair of the eye, 1
eye was eviscerated and one victim required
intracranial surgery. The remaining 10 patients
were initially managed conservatively, including
one with a ruptured globe which was enucleated
on day 6. The MRI was done only after an
identical air-gun pellet had been found to be
non-magnetic; it revealed a pellet embedded in
the occipital cortex (having transversed the orbit
and the cranium) and the patient had a resultant
defect in the visual field of the undamaged
fellow eye.(6,7)
From all cases that had been reported showed
radiography can really helpful to identified
foreign body location. G N Shuttleworth et all
studies in the UK plastic pellets are the usual
projectiles. All victims, except one with a BB
gun injury, presented immediately to the
emergency department. In the 15 cases
investigated radiologically, a total of 11 series of
plain X-rays, 7 computed tomographic scans and
one magnetic resonance (MRI) scan were
performed.Based on full examination on first
and second cases, because arrowhead had
entered cerebrum we decided to do join
operation with neurosurgical. For doing join
operation with many department considering the
location of foreign body. (3,6,8)Managing
ophthalmic trauma is challenging. Clinical and
surgical skills and equipment vary from place to
place and country to country so that the
management of serious eye injury requires a
variety of alternative strategies. In principle, if a
health care worker can diagnose and treat a
condition and recognise the complications, then
he or she can manage that case.(1,3,7)
The signs are often obvious with an entry/exit
site and extrusion of ocular tissue. If there has
been an occult penetration there may be early
ocular hypotony that recovers after a few hours.
The eye is protected by a Cartella shield and the
patient admitted for bed rest, to prevent an
expulsive haemorrhage. Prophylactic systemic
antibiotics are prescribed and tetanus toxoid is
given if required. A CT scan is performed to rule
out intraorbital, intracranial or intraocular FBs
or penetration. An ultrasound B scan is used to
localize a posterior rupture/exit site.
Management is by urgent primary surgical
repair.(3)
Management of ocular trauma :
9

Figure 20. Flowchart for the evaluation of ocular trauma
Ocular injury is classified into blunt or
penetrating, depending on the causative factor.
Blunt ocular trauma can be defined using the
basic physics concept of energy exchange.
Energy is transferred between the injurious
object and periocular or globe structures without
intrusion of the injured tissue by the offending
object.7 Penetrating injury involves intrusion
into the injured tissue by the offending agent.
Blunt trauma can produce a very different
clinical scenario and pattern of tissue injury
when compared to that of penetrating injury.
Classifying the injury as blunt or penetrating
early in the patient interaction will facilitate a
more focused and effective exam, reducing the
time required to provide definitive management.
Initial evaluation and identification of
penetrating ocular injuries is important in
minimizing further ocular complications. Once
the diagnosis of open globe is made, immediate
referral for surgical exploration and repair
should be made to the eye specialist. The eye
should be protected with a fox metal eye shield
while awaiting definitive treatment. Baseline
exam findings and visual acuity are important in
advising patients and family members on the
prognosis and final visual outcomes. However,
more discouraging findings for final visual
outcome, many present in the case being
discussed, are afferent pupillary defect, visual
acuity of light perception or, worse, prolapse of
uveal tissue, BB injury, and foreign bodies
posterior to the lens. If there is a poor view of
the fundus, one should consider B-scan
ultrasonography to examine integrity of
posterior tissues. Orbital radiographs or
computed tomography (CT) scanning should be
done if a foreign body may be present. Magnetic
Resonance Imaging (MRI) is contraindicated in
cases involving a suspected metallic foreign
body. If a metallic intraocular foreign body is
present, its prompt removal has been shown to
be important in attaining the best visual outcome
possible. In the case that we presented, the
decision to use an external approach to remove
the BB was based on the greater strength of
attraction observed between a BB of the same
composition (copper lining with a steel core)
and the large external magnet compared to that
of the smaller internal magnet.(1,3)
The patient with severe penetrating injuries
should be followed closely for potential
complications like endophthalmitis, recurrence
of hyphema, ocular siderosis, and sympathetic
opthalmia. When considering pediatric
enucleation, the prosthesis takes on special
importance. Proper sizing and adjustments play
a role in the growth and development of the
orbit and facial symmetry, improving chances
for an acceptable cosmetic appearance and
avoiding potential future complications.(1,3)
Penetrating injuries of the cornea also require a
complete eye examination to rule out damage to
intraocular structures and the presence of a
foreign body despite the obvious nature of the
injury. Prolapsed iris tissue may be repositioned
or removed during surgery, depending on the
duration of exposure or the state (necrotic or
not) of the tissue. Small puncture wounds and
shelved lacerations often heal without suturing.
Bandage contact lens and patching are options
for treatment under the close care of an
ophthalmologist. It is important to remove all
10
foreign material and to reform the anterior
chamber before placing corneal sutures. (1,3)
Penetrating eye injuries can be challenging to
assess, given the associated pain and difficulty
with examination. A good history and minimal
examination will prompt referral
management of these serious injuries. Primary
prevention of ocular injury is firmly based in
improving patient education, proper safety
equipment and practices, risk reduction, and
close supervision of all high-risk activities.(3)
on
http://webeye.ophth.uiowa.edu/eyeforum/tra
uma.htm
8. De Jongh, Katrijn et al. “William Tell”
Injury : MCDT of an Arrow Through the
for Head.American Journal of Roentgenology.
Avaiable on
www.ajr.org/content/182/6/1551.full
9. Greven, Craig M, et al . Intraocular Foreign
Bodies. Ophthalmology Jounal 2000;107:
608-612

Conclusion
Managing orbital trauma cases must be based on
location of foreign body such first and second
cases, because of the location of foreign body
was on brain thereby we decide to do join
operation with neurosurgical division. Type of
foreign body such third cases, initially we were
using magnet to pull the foreign body on the
surface of upper eyelid but turn out that foreign
body was not made of metallic. Shape of foreign
body , round or had a hook shape because it can
influence the way to removed the foreign body,
anteriorly or posteriorly. From all the cases that
have been reported, it is very important identify
location, type, and shape of foreign body to
facilitating planning of further therapy.

References
1. Kuhn, Ferenc. Ocular Trauma, Principles
and Practice. Thieme, New York, 2002.
2. Banta, James T. Ocular Trauma. Miami,
Florida.,2007
3. Haven Shane et al. Penetrating Eye Injury :
A Case Study, American Journal Medicine.
Volume six, number one, 2009
4. Holds Bryan, John. Orbit, Eyelids and
Lacrimal System, American Academy of
Ophthalmology. San Fransisco, 2008-2009.
5. Macewen, J.Caroline. Ocular injuries.
Dundee, UK. Available on
http://www.rcsed.ac.uk/journal/vol44_5/445
0010.htm
6. GN Shuttleworth. Ocular air-gun injuries 19
cases. England and South Wales.. Available
on
http://www.ncbi.nlm.nih.gov/pubmed/11461
983
7. Pramanik, Sudeep. Assesment and
management of Ocular Trauma. Available

11