Periocular Skin 'Tattooing' Caused by Neutral Pen Pigment Mistaken for Periorbital Bruising: A Case of Missed Diagnosis of Traumatic Intraorbital Pen Core Foreign Body

doi:10.21203/rs.3.rs-3758695/v1

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Case Report

Periocular Skin 'Tattooing' Caused by Neutral Pen Pigment Mistaken for Periorbital Bruising: A Case of Missed Diagnosis of Traumatic Intraorbital Pen Core Foreign Body

https://doi.org/10.21203/rs.3.rs-3758695/v1

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Background

When an eye trauma occurs, orbital foreign bodies are widespread. The most common types of foreign bodies are metal, followed by plant foreign bodies, while oil foreign bodies are rare. Here, we report a case of misdiagnosis of periorbital bruising caused by the tip of a blue gel pen core. It can easily be misinterpreted as subcutaneous congestion since it causes the skin to become blue, which can result in the orbital foreign bodies being ignored.

Case presentation

The child was stabbed by a gel pen at the upper eyelid of his left eye while playing, resulting in a skin tear under the eyebrow arch, and the surrounding skin was cyan. Because the wound was small and closed smoothly, only local cleaning and disinfection were given without suturing. Within one month after injury, the cyanosis of the skin did not subside, which was considered by the doctors as subcutaneous congestion after injury.

Conclusions

Our report for the blue gel pen orbital foreign bodies can provide some reference for the diagnosis and treatment experience. The reason for the missed diagnosis in this case was that the blue color of the skin in the wound area was mistaken for "bruise". Orbital foreign body impact injury must be thoroughly found all foreign body fragments, if can not be found should be highly suspected foreign body into the body. The wound tract of ocular trauma may be concealed. If conditions permit, it is recommended to perform imaging examination to avoid omission of foreign bodies.

intraorbital foreign body

periorbital bruise

misdiagnosis

gel pen

case report

An object that enters or remains in the orbit is termed an orbital foreign body. Orbital foreign bodies frequently result from ocular trauma[1]. The majority of foreign bodies are composed of metal, followed by plant material, and subsequently, materials such as stone, glass, plastic, and rubber. Grease foreign bodies, however, are uncommon. Owing to variations in the size and composition of orbital foreign bodies, certain patients may exhibit no apparent clinical symptoms in the initial stages, leading to potential instances of missed diagnosis and misdiagnosis[2–5]. Notably, there are no documented cases of misdiagnosis involving periorbital bruising resulting from a foreign body located at the tip of a blue neutral pencil. The distinctive nature of the cyanotic skin caused by the foreign body led many clinicians to misinterpret it as subcutaneous congestion following trauma. In such cases, treating physicians often failed to consider the possibility of a foreign body, contributing to the misdiagnosis.

A 3-year-old female patient was admitted to the hospital presenting with periorbital bruising of the left eye persisting for over 4 months following trauma. According to the family, the child had sustained an accidental injury from a pen, resulting in a skin tear of approximately 5mm in length at the medial 1/3 of the left eyebrow arch. The initial medical intervention at a local hospital involved wound closure without sutures, accompanied by local wound cleaning and disinfection. At that time, the light blue discoloration surrounding the wound was initially regarded as subcutaneous congestion. Following debridement two days later, the eyelid laceration had apparently healed, and the child resumed regular activities with only mild eyelid swelling and no specific complaints (Fig. 1A). However, the observed "bruising" did not diminish and, in fact, slightly expanded. After a few days of monitoring, the family noticed that the "bruising" on the left eyelid persisted (Fig. 1B).

More than 20 days post-injury, the patient sought care at another local third-class A hospital's ophthalmology department, where the condition was still attributed to subcutaneous congestion. The recommendation was for continued observation. Over two months post-injury, the child sought consultation at the ophthalmology department of a third local Class ⅲ Grade A hospital, where the diagnosis remained consistent with subcutaneous congestion, prompting a suggestion for hot compress treatment. Despite more than a month of local hot compresses, there was no improvement in the bruising. After four months, the parents noted a gradual widening and slight deepening of the periorbital "bruised" area, leading them to seek treatment at our hospital's outpatient clinic. A CT scan revealed the presence of an orbital foreign body, leading to the immediate hospitalization of the patient. The infant was born at term and had a history of breastfeeding. There was no reported general medical history, and both personal and family histories were unremarkable.The patient's ophthalmic specialty examination is shown in Table 1.

Table 1

Patients with eye specialist checklist
	Right Eye	Left Eye
Uncorrected visual acuity	0.8	0.8
Corrected visual acuity	+ 0.75DS = 0.9	+ 0.50DS = 0.8
Intraocular pressure	12mmHg	12mmHg
Periorbital skin and eyelids	normal	The skin of the left eye and the nasal side of the eyelid showed a pale blue bruise shape change, normal skin temperature, pain, no pressure, and the eyelids were open/nearly normal(Figs. 2A, 2B)
Cornea	transparent	transparent
Anterior chamber	medium	medium
Aqueous humor flash	(-)	(-)
Iris texture	clear	clear
Pupil	round, 3mm in diameter	round, 3mm in diameter
Direct and indirect light reflex	present	present
Lens	transparent	transparent
Vitreous	transparent	transparent
Fundus	retinal flat under small pupil	retinal flat under small pupil

Orbital CT(horizontal + coronal) showed (Fig. 2C, Fig. 2D) : a fusiform high-density shadow with a size of about 1.1*0.8cm and a CT value of about 2840HU was seen in the medial rectus muscle of the left eye, and a few metal radial artifacts were seen around it. Clinical diagnosis: left orbital foreign body (old).

A definitive history of trauma was evident, accompanied by a visible surface wound subsequent to the injury. However, an orbital CT examination was not conducted immediately post-injury. Prolonged persistence of a blue hue in the skin around the wound, coupled with a deepening of color and an expansion in scope over time, raised suspicions of a potential overlooked diagnosis of an orbital foreign body. To substantiate this suspicion, an orbital CT examination was performed, conclusively confirming the clinical diagnosis of an old left orbital foreign body.

Preoperative antibiotics were administered to forestall infection. Under general anesthesia, the removal of the left orbital foreign body was executed through the superior fornix conjunctival approach. The intraoperative extraction unveiled a roughly 2 cm ballpoint pen tip (Fig. 3A), distinguished by wet blue ink (Fig. 3B) that permeated the surrounding tissue. Despite multiple irrigations with copious amounts of normal saline and iodophor during the procedure, the blue discoloration proved resistant to elimination through washing. Post-surgery, the child's appearance remained unchanged one day later (Fig. 3C), and a follow-up CT scan (Fig. 3D) confirmed the successful removal of the orbital foreign body. The child has been followed up for two years, and has received local pulsed laser treatment for several times in the cosmetological department within two years. Now the blue marks are slightly lighter and the size range is basically the same as that at the first visit.

Foreign bodies can be divided into metal foreign bodies and non-metallic foreign bodies according to types, the latter can be divided into irritating foreign bodies and non-irritating foreign bodies[5]. Irritating foreign bodies are substances with unstable physical and chemical properties, such as plant bodies, gunpowder, oils and waxes, etc.which can cause serious tissue reactions or infection and inflammation[5]. Non-irritating foreign bodies, such as glass, gravel, and plastic, do not cause serious complications other than mechanical damage[5–7]. The tip of the pen refill can be roughly divided into three types of substances, the tip metal is made of copper alloy or stainless steel, the shell is made of plastic material, the internal ink is the pigment of waterlow carbon alcohol suspension and a variety of additives. The properties of the tip metal and the shell plastic are relatively stable for tissue tolerance foreign bodies, that is, inert foreign bodies[8]. The nature of neutral pen ink is between water-based pen and oil-based pen, and its main component is pigment ink. Water-based inks mainly use organic dyes to color. In addition to being 60–80% water, gel inks contain special pigments (usually copper phthalocyanine for blue inks) as well as resins, solvents (such as ethylene glycol), non-ionic surfactants, and additives that give gel inks their unique properties[9]. The foreign body remained in the child for 4 months, except for the local subcutaneous tissue staining cyan and other asymptomatic, it can be judged that the neutral pen ink is a non-irritating foreign body. Therefore, it misled many ophthalmologists who received follow-up treatment. After 1 month of follow-up observation, the cyan range of periorbital skin was equalThere was no significant change in color depth. Whether the neutral pen dye is eventually metabolized by the body and the skin stain gradually fades, it still needs to continue long-term observation and follow-up of patients.

The judgment of orbital foreign body should be considered from various aspects[5]. Orbital foreign body is usually associated with high-speed trauma, and the specific process of injury should be carefully questioned[10], and the integrity of the injury object must be confirmed with the scene witness. When receiving patients, careful observation of clinical symptoms is very important. First, in appearance[4], obvious or hidden scars can be left on the eyelid or periorbital skin after injury, such as subcutaneous bruising, eyelid swelling, and exophthalmos. Because of the small wound and mild appearance symptoms, the possibility of foreign body entry into the orbit should not be ignored. Second, the visual acuity is often affected after injury[11]. Orbital foreign body accompanied by optic nerve injury or eyeball rupture injury, trauma, penetrating injury, and intraocular foreign body can almost cause different degrees of visual impairment. Trauma is often accompanied by eye movement disorders[12], which are limited in eye movement (strabismus, diplopia) and eyelid opening and closing (ptosis) due to foreign body stimulation, scar formation, foreign body injury, extraocular muscles, levator muscle or nerve tissue. Finally, patients often feel uncomfortable[5]. When the foreign body is located in the orbit, some patients may feel resistance during eye movement. The inflammatory response to an active foreign body can produce pain and irritation.

For ocular trauma caused by foreign bodies, regardless of the size of the wound, whether bleeding has stopped or initial healing, orbital foreign bodies should be excluded in all orbital trauma[2–4]. Early and timely diagnosis, accurate localization and targeted treatment are the keys to the prognosis of orbital foreign body[5, 11, 13]. The most common examination method is orbital CT[6, 12, 14, 15]. As early as 1977, Kollarits and other scholars first used CT to detect intraorbital foreign bodies. Conventional thin layer axial scanning and coronal and sagittal image reconstruction should be used for CT examination[16]. Considering orbital craniomaxillofacial fractures, three-dimensional bone window imaging should be performed[2]. Orbital CT allows the doctor to fully and clearly grasp the relationship between ocular foreign bodies and related structures such as extraocular muscle, ocular wall, and optic nerve. It is recommended that the radiographers and receiving physicians should be careful when reading the radiographs. It is recommended to read the radiographs continuously by computer rather than by intermittent film. If the presence of metal foreign bodies is ruled out by orbital CT examination, the presence of low-density shadows like bubbles in the orbit or intracranial, and the presence of low-density foreign bodies or vegetative foreign bodies is suspected, the orbital and craniocerebral MRI examination can be performed[17, 18].

This case has certain reference significance for our future treatment of children with ocular trauma. First, pen pigment can be released slowly and stay under the skin, showing as "bruising". If it does not disappear for a long time after trauma, the possibility of foreign body should be considered. Secondly, children with orbital foreign body injury must find all foreign bodies completely. If foreign bodies are missing, they must be highly suspected of having intraorbital foreign bodies. Finally, for ocular foreign body injuries, no matter the size of the wound, whether the bleeding has stopped or the wound has healed initially, routine imaging examination is required to rule out foreign bodies.

Authors' contributions

CX and ZR conceived and wrote the Article. XL, YC, YL and JY participated in information gathering and editing. YW and HL managed the patient’s ophthalmic conditions and supervised writing. YW, HL, QX and PG performed orbital foreign body removal surgery. QJ, ZS, SW and AW critically evaluated the accuracy and integrity of the work. All authors contributed to refinement of the study and approved the final manuscript. This manuscript has been read and approved by all the authors and each author believes that the manuscript represents honest work. All authors meet the requirements for authorship and all express full consent for publication on jour esteemed Journal.

Funding

None

Data Availability

All data generated or analyzed during this study are included in this published article.

Ethics approval

This case report was approved by the hospital ethics committee, and written informed consent was obtained from the guardian for the publication of the case report and any accompanying images.

consent for publication

Written informed consent for publication has been obtained from the participants in this study.

Competing interests

The authors declare no competing interests.

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No competing interests reported.

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Periocular Skin 'Tattooing' Caused by Neutral Pen Pigment Mistaken for Periorbital Bruising: A Case of Missed Diagnosis of Traumatic Intraorbital Pen Core Foreign Body

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Case presentation

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