DOI: https://doi.org/10.21203/rs.2.336/v1
Background: Any ocular trauma involving the orbit may involve the adjacent structures and resulting in both sight-threatening and life-threatening injuries. Here we present a unique case of a missed large hollow bamboo in orbit traversing the orbit and infratemporal fossa with minimal sequelae.
Case presentation: The patient is a 31-year-old farmer suffered an injury to his right eye. Although the external wound existed, the intraorbital foreign body was mis-diagnosed by the initial physician. After being admitted to our emergency room, the patient was underwent CT scan. Due to the large and hollow object, an intraorbital foreign body traversing the orbit and infratemporal fossa was detected easily. Emergency operation was performed immediately and the object was removed totally without any complication.
Conclusion: The physician during the initial evaluation of eye trauma patients should take the history and physical examination extraordinarily carefully, and a CT or MRI scan may be recommended to prevent missing such foreign bodies in orbit. Once the diagnosis of such orbital foreign body is established, the object should be removed in time.
Keywords: Bamboo; intraorbital foreign body; computed tomography; minimal sequelae.
Penetrating orbital trauma is not uncommon, which may result in an intraorbital foreign body, and about one out of every six patients with penetrating orbital trauma has a foreign body present. (1,2) It can be caused by inorganic foreign bodies, such as metallic, glass and plastic objects, and organic foreign bodies, such as wood. Metallic objects and glass are the most frequently encountered and well-tolerated, whereas organic foreign bodies can elicit an inflammatory reaction and lead to serious complications. (3) Most of intraorbital foreign bodies are easily detected by the external wound. However, some of them need imaging examination to detect. Plain film is the most cost-effective method, which is helpful to detect metallic objects. (4) Ultrasonography can be useful, but it can not locate the foreign body precisely and the gas in the orbit caused by trauma may affect the sensitivity. (5,6) Computed tomography (CT) is undoubtedly the most useful accessory investigation, which defines the location of the foreign body precisely. (7) So CT is recommended as the best initial examination. (8) Whereas, organic intraorbital foreign bodies are still often difficult to be identified and located by these modern imaging methods.
The orbits are the bony cavities that contain the globes, extraocular muscles, nerves, fat and the blood vessels. It is closely related to the nasal sinuses and cranial fossa. Thereby, any ocular trauma involving the orbit may involve the adjacent structures and resulting in both sight-threatening and life-threatening injuries. (9) Although the consequences of the intraorbital foreign body may be serious, sometimes their effects are much less severe than expected and depend on the location, size, chemical composition and associated damage to surrounding structures. (3,10) In this study, we present a rare case with a missed large hollow bamboo in orbit traversing the orbit and infratemporal fossa with minimal sequelae.
A 31-year-old farmer suffered an injury to his right eye when falling over himself. He was brought to our emergency department 14 hours after the injury. The patient presented with right eye pain and periorbital swelling. Otherwise, he had tenderness and swelling of the right mastoid tip area. The right eyelid wound had been sutured one hour after injury by the surgeon in the local clinic. He denied any significant trauma to the eye. The both eyes visual were 20/20. Extraocular movements were not restricted in all gazes. The intraocular pressures of both eyes were normal. Anterior segment and fundus examination showed no abnormality in both eyes.
A CT scan showed a large straight foreign body in the right orbit medially passing downwards and backwards towards the right mastoid tip and traversing the right infratemporal fossa, which is isodense with the orbital fat. (Fig 1)
An urgent exploration of the right orbit was planned. After an incision along the eyelid wound was made, a segment of a hollow bamboo was appeared medially to the globe. It was removed integrally without injuring the surrounding structures. The bamboo measured about 12.5cm × 1.2cm.
Postoperatively, the patient received intravenous injections of ceftriaxone 2.0g once a day for a week and methylprednisolone 80mg once daily for 3 days. On one-month follow-up, the patient had no complaint of diplopia and his vision remained normal.
Intraorbital bamboo foreign body is extremely rare. A Pubmed-based search indicated that there have been only two cases reported. (11,12) In previous cases, they are both small pieces of bamboo. Different with them, this is the unique case of a missed large hollow bamboo traversing the orbit and infratemporal fossa with minimal sequelae. In Southeast China, bamboo is more productive than other areas. It is widely used in many works. So it is familiar that a patient injured by bamboo in work-related accidents at our hospital emergency department. However, almost all of them involved extremities. In orbital injury, our case is very rare.
Intraocular foreign body is easily misdiagnosed, even if in some patients with external wound. (13) Patients with intraorbital foreign bodies may not notice the presence of the object and may not remember the details of their injury at their initial visit. (14) In our case, due to the patient denied the significant trauma in orbit, the initial doctor he visited overlooked the possibility of intraorbital foreign bodies. Similar with our patient, one previously reported case with the intraorbital bamboo object was also misdiagnosed by the first clinic he visited and 10 month later the foreign body in the orbit was detected. (12)
Unlike metallic object, bamboo or wood has porous consistency and organic nature which provides a good medium for microbial agents. (12) Complications, such as panophthalmitis, periorbital abscess, and fistula formation, can be caused by organic foreign bodies. (15) So it is important to detect and remove such foreign bodies. However, detection of an intraorbital bamboo or wooden material may be difficult.
CT is the best choice for detecting most foreign bodies. (16) Bamboo or wooden foreign bodies have the similar density of soft tissue or fat. (17,18) And bamboo is considered to be more compact than wood and is isodensity with fat in acute phase. (11) Hence, in the acute stage, they are easy to be misinterpreted as air bubbles on CT. (11) In the chronic stage, dry object may become wet object, resulting in dramatic increases. (11) And such foreign bodies are reportedly denser than soft tissue. (12,19) In present case, CT scan was performed 14 hours after trauma and the density of the intraorbital object is similar with that of the orbital fat. Because the object is relatively large, it is easy to be detected by CT scan. In two previous cases, one was underwent CT scan within a day of the accident and the foreign bamboo object was isodense with the orbital fat. Since the left medial rectus muscle was penetrated by a linear structure, a foreign body was identified. (11) The other one was performed CT scan 10 months after facial trauma and CT showed that the object was sightly denser than extraocular muscles. (12) Shelsta et al reviewed clinical characteristics of 23 patients with wooden intraorbital foreign body and found that the radiologist could not make a definitive diagnosis of orbital foreign body in 35% of subjects at the time of presentation. (19) In another study, Dalley indicated that bone windows are more effective in identifying acute intraorbital wood foreign bodies than soft tissue windows. (20) Therefore, it is important that communication with the radiologist before examination and to ask for adjust settings. (19) Magnetic resonance imaging (MRI) may be superior to CT in identifying such foreign bodies. (18,21) While other study demonstrated that MRI is not superior to CT in the evaluation of a bamboo or wooden object in the orbit. (15) However, in most hospitals, CT scan is still the first choice.
Once the diagnosis of an intraorbital foreign body is confirmed, it should be removed in time. Especially the foreign body is an organic material, such as bamboo, which may induce severe complications. It has been indicated that early detection and removal of foreign bodies is associated with better prognosis. (22) In our case, the intraorbital object was removed within a day of the trauma and no obvious necrosis tissues and purulent exudate was found. In two previously reported cases, one was also performed emergency surgery within 24 hours of the accident. (11) But the other one was diagnosed 10 months after the trauma and a surrounding purulent abscess was found in operation. (12) Although the foreign body was large and traversed the infratemporal fossa in our case, it was removed easily without injuring surrounding structures. Since the foreign object is large which is easy to be found and the surface of the hollow bamboo is smooth which makes it move easily.
In summary, we report an unique case of a missed large hollow bamboo traversing the orbit and infratemporal fossa with minimal sequelae. A bamboo foreign body in orbit is extremely rare and is easily misdiagnosed. The physician during the initial evaluation of eye trauma patients should take the history and physical examination extraordinarily carefully, and a CT or MRI scan may be recommended to prevent missing such foreign bodies in orbit. Once the diagnosis of such orbital foreign body is established, the object should be removed in time.
CT: Computed tomography
MRI: Magnetic resonance imaging
Ethics approval and consent to participate
This report has been performed in accordance with the Declaration of Helsinki. As this is a single case report that does not include data that can identify the patient, no ethical approval was required by Ethics Committee of the Second Affiliated Hospital, Zhejiang University School of Medicine.
Consent for publication
Written informed consents were obtained from the patient for publication of this case report and any accompanying images.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Competing interests
The authors declare that they have no competing interests.
Funding
This study was supported by grants from Natural Science Foundation of Zhejiang Province (No.LGC19H120002) and Department of Science and Technology of Zhejiang Province (No.2018C37058). The funding body had no role in the construct of this manuscript.
Authors’ contributions
WW collected the data and drafted the manuscript. WW，HJ and MX-Y participated in diagnosis and treatment of the patient. HJ revised the manuscript. All authors have read and approved the final manuscript.
Acknowledgements
Not applicable