April 2023

Chief Complaint

Left eyelid swelling and bruising

History of Present Illness

A 25-year-old male, with an unremarkable medical history, was transferred from an outside hospital after suffering a BB gun shot to his left orbit the preceding day. The patient recounted that he was standing approximately 10 feet from the BB gun. Immediately following the incident, he observed swelling and bleeding in his upper eyelid. He did not experience any alterations to his visual acuity. He denied flashes, floaters, diplopia, photophobia or ocular irritation.

At the outside hospital, he received a single dose of IV antibiotics (ampicillin / sulbactam) and was subsequently transferred for ophthalmic evaluation. He denied vision changes but reported left eye swelling and bruising. A Computed tomography (CT) scan revealed a 5 mm foreign body located at the superior medial aspect of the left orbit, approximately 9 mm from the surface of the upper eyelid. There was no evidence of an injury to the globe. Tetanus vaccinations were up to date.

Ocular History

• None

Past Medical History

• None

Medications

• None

Allergies

• None

Family History

• None

Social History

• No relevant social history reported

Review of Systems

• All other systems within normal

Ocular Exam

Imaging

Laboratory Testing

• None

Differential Diagnosis

• Left intraorbital metallic foreign body
• Left intraocular metallic foreign body
• Globe rupture
• Orbital fracture

Clinical Course

A 25-year-old male patient with no past medical history presented one day following trauma to the left eye after being shot by a gas-powered airsoft gun from 10 feet away with a metal BB. A CT scan revealed a 5 mm foreign object located at the superomedial aspect of the patient's left orbit, approximately 9 mm from the surface of the upper eyelid. His visual function remained intact and there was no demonstrable evidence of an injury to the globe. The patient was prescribed a ten day course of Augmentin and erythromycin 0.5% ointment applied to the entry wound four times daily. The foreign body was ultimately removed without complications

Discussion

An orbital foreign body can be defined as any extraneous object, either wholly or partially, occupying the orbital space. A comprehensive incidence study involving eye injuries treated in American Emergency Departments ascertained that foreign bodies were the leading causative agents, attributing to 44.3% of all cases.1 The foreign object may be present with or without globe penetration or perforation. Furthermore, the orbital foreign body can be categorized as either purely orbital or transorbital.



Injury to the orbital region due to foreign bodies is most commonly traumatic; however, instances of iatrogenic injuries have been documented, especially as a result of surgical orbital implants. A history of trauma, encompassing sport-related incidents, violence, battlefield injuries, or industrial accidents, is a significant risk factor for the occurrence of orbital foreign bodies. Studies also suggest a higher prevalence of these injuries among younger men.2–8



Consistent with our patient's case, ocular trauma primarily affects males, with a male-to-female ratio reported at approximately 6:1.4 The mean age of patients with ocular trauma varies, though one study reported it to be 36.0 ± 20.0 years.4 Most ocular injuries occur at home or within the workplace, with metal, glass, explosions, and intraocular foreign bodies being the common causes. It is estimated that about one-third of all ocular injuries could be preventable, with domestic accidents and children being the primary contributors.8



Factors associated with poor visual outcomes in ocular trauma cases include female gender, advanced age, specific injury types (e.g., zone III injury, eyelid injury), and the presence of intraocular foreign bodies.4 Post open globe injury repair, potential complications such as wound leak and endophthalmitis have been identified. Factors such as stellate-shaped wounds and delayed presentation contributed to wound leaks, while delayed presentation, microbial keratitis, and lens capsule breach were associated with an increased risk of endophthalmitis.



Maxillofacial computed tomography (CT) scan is the preferred imaging modality for evaluating and diagnosing intraocular foreign bodies.12 It's crucial to remember that while CT scans can help assess the presence of globe rupture, they should be seen as a supplement to an ophthalmic evaluation rather than a replacement for a physical exam.13 In situations like our present case where there's ferromagnetic ocular trauma, MRI is firmly contraindicated. Similarly, ultrasound is generally not employed to assess globe rupture due to concerns that direct pressure on the globe could exacerbate the injury.11 It should be noted that in select cases, ophthalmologists may elect to carefully perform ultrasonography without compressing the globe to complete the exam in a suspected globe rupture.



The decision to surgically remove intraorbital foreign bodies is driven by several considerations. The presence of a large or sharp-edged foreign body, indicative of potential further harm, necessitates removal. Signs of infection or inflammation, such as endophthalmitis, call for surgical intervention to manage the infection. Conditions like proptosis, restricted eye movement, chemosis, palpable orbital mass, and optic nerve compression are also strong indications for surgical removal. If imaging reveals an abscess or an enhancing foreign body, surgery becomes a requirement. Foreign bodies composed of wood, vegetable matter, or copper, given their higher risk of complications, should be removed. Fistula formation also mandates surgical intervention. These indications serve as guiding principles when deciding on the removal of intraorbital foreign bodies, although each case should be evaluated individually considering the patient's condition and the healthcare providers' expertise.1



The final visual outcome is prognosticated by the presenting visual acuity.11,14 Several other factors, including longer wound length, relative afferent pupillary defect vitreous prolapse, vitreous hemorrhage, posterior globe involvement, retinal detachment, endophthalmitis, and hyphema, have been associated with poorer post-injury visual acuity.15–18 Ophthalmologists treating a patient with severe ocular trauma can utilize the Ocular Trauma Score (OTS) to predict the prognosis of their post-injury visual acuity. The OTS scores range from 1 (most severe) to 5 (least severe) and take into account the factors mentioned earlier, with the initial (raw) score originating from the patient's presenting visual acuity.19

References

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2. Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology. 1997;104(1):96-103. doi:10.1016/s0161-6420(97)30355-8



3. McGwin G, Owsley C. Incidence of emergency department-treated eye injury in the United States. Arch Ophthalmol. 2005;123(5):662-666. doi:10.1001/archopht.123.5.662



4. Hoskin AK, Low R, Sen P, et al. Epidemiology and outcomes of open globe injuries: the international globe and adnexal trauma epidemiology study (IGATES). Graefes Arch Clin Exp Ophthalmol. 2021;259(11):3485-3499. doi:10.1007/s00417-021-05266-1



5. Kong GYX, Henderson RH, Sandhu SS, Essex RW, Allen PJ, Campbell WG. Wound-related complications and clinical outcomes following open globe injury repair. Clin Exp Ophthalmol. 2015;43(6):508-513. doi:10.1111/ceo.12511



6. Nasr AM, Haik BG, Fleming JC, Al-Hussain HM, Karcioglu ZA. Penetrating orbital injury with organic foreign bodies. Ophthalmology. 1999;106(3):523-532. doi:10.1016/S0161-6420(99)90111-2



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8. Framme C, Roider J. Epidemiologie offener Augenverletzungen. Klin Monbl Augenheilkd. 1999;215(11):287-293. doi:10.1055/s-2008-1034716



9. Smith D, Wrenn K, Stack LB. The epidemiology and diagnosis of penetrating eye injuries. Acad Emerg Med. 2002;9(3):209-213. doi:10.1111/j.1553-2712.2002.tb00246.x



10. Hughes E, Fahy G. A 24-month review of globe rupture in a tertiary referral hospital. Ir J Med Sci. 2020;189(2):723-726. doi:10.1007/s11845-019-02097-2



11. Blair K, Alhadi SA, Czyz CN. Globe Rupture. In: StatPearls. StatPearls Publishing; 2023. Accessed May 10, 2023. http://www.ncbi.nlm.nih.gov/books/NBK551637/



12. Modjtahedi BS, Rong A, Bobinski M, McGahan J, Morse LS. Imaging characteristics of intraocular foreign bodies: a comparative study of plain film X-ray, computed tomography, ultrasound, and magnetic resonance imaging. Retina. 2015;35(1):95-104. doi:10.1097/IAE.0000000000000271



13. Chou C, Lou YT, Hanna E, et al. Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma. Injury. 2016;47(5):1035-1041. doi:10.1016/j.injury.2016.01.014



14. Yeh S, Colyer MH, Weichel ED. Current trends in the management of intraocular foreign bodies. Curr Opin Ophthalmol. 2008;19(3):225-233. doi:10.1097/ICU.0b013e3282fa75f1



15. Yalcin Tök O, Tok L, Eraslan E, Ozkaya D, Ornek F, Bardak Y. Prognostic factors influencing final visual acuity in open globe injuries. J Trauma. 2011;71(6):1794-1800. doi:10.1097/TA.0b013e31822b46af



16. Meng Y, Yan H. Prognostic Factors for Open Globe Injuries and Correlation of Ocular Trauma Score in Tianjin, China. J Ophthalmol. 2015;2015:345764. doi:10.1155/2015/345764



17. Agrawal R, Wei HS, Teoh S. Prognostic factors for open globe injuries and correlation of ocular trauma score at a tertiary referral eye care centre in Singapore. Indian J Ophthalmol. 2013;61(9):502-506. doi:10.4103/0301-4738.119436



18. Lieb DF, Scott IU, Flynn HW, Miller D, Feuer WJ. Open globe injuries with positive intraocular cultures: factors influencing final visual acuity outcomes. Ophthalmology. 2003;110(8):1560-1566. doi:10.1016/S0161-6420(03)00497-4



19. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002;15(2):163-165, vi. doi:10.1016/s0896-1549(02)00007-x



20. Lee SC, Park SH, Han SK, et al. Prognostic Factors of Orbital Fractures with Muscle Incarceration. Arch Plast Surg. 2017;44(5):407-412. doi:10.5999/aps.2017.44.5.407