British Journal of Ophthalmology, 1979, 63, 848-851

Diagnosis and management of a woodenorbital foreign body: case reportJOHN A. MACRAEFrom the Department of Ophthalmology, Ninewells Hospital and Medical School,Dundee DD2 1UB, Scotland

SUMMARY The case history of a patient with a retained wooden orbital foreign body is presented.The report illustrates the diagnostic limitations of orbital CAT scanning and ultrasonography.Systemic corticosteroid therapy facilitated the localisation and surgical removal of the foreign body.

A wooden orbital foreign body may present con-siderable diagnostic difficulty, as illustrated bythe reports of Von Marton (1969), Ferguson (1970),and Legras and Lecoq (1970). The radiolucentnature of the foreign material prevents localisationby routine orbital radiography, but with the adventof orbital CAT scanning and ultrasonography thelikelihood of identification should be increased.The report which follows demonstrates the

diagnostic and therapeutic problems still presentedby such cases despite orbital investigations by CATand ultrasonography.

Case report

A 46-year-old man attended the local casualty de-partment after sustaining an injury to his left eye.While pruning a tree he had received a glancing blowfrom the terminal twig of a branch. The casualtyofficer diagnosed a conjunctival abrasion, prescribedantibiotic ointment, and advised the patient to seekspecialist advice if the eye did not settle.

During the next 3 days the patient's left eye be-came increasingly painful and swollen. Four daysafter the injury he attended the ophthalmology clinicat Ninewells Hospital.On examination the unaided visual acuity of the

left eye was found to be 6/9. There was markedchemosis of the lower bulbar conjunctiva withprolapse between the eyelids. A bulbar conjunctivallaceration approximately 10 mm in length wasnoted (Fig. 1). The cornea was clear, anteriorchamber quiet, pupil normally reactive, and fundusnormal on direct ophthalmoscopy.The patient was admitted to the ophthalmology

department and systemic and topical antibiotic

Correspondence to Mr Macrae.

therapy begun. Orbital x-rays did not reveal anyevidence of a radioopaque foreign body or fracture.The conjunctival wound was explored, cleaned, andrepaired under general anaesthesia.

Postoperatively the conjunctival chemosis did notresolve and the ocular movements of the left eyewere noted to be limited. Repeated conjunctivalswabs were sterile, microscopy of conjunctival

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Fig. 1 Diagram of left eye showing position andextent of the conjunctival laceration

scrapings did not reveal any micro-organisms orfungal elements, and culture on Sabouraud's agarwas negative.The conjunctiva remained prolapsed, and 7 days

after the surgical repair a mattress lid suture wasinserted under local anaesthesia to provide protec-tion and tamponade. The chemosis then subsidedconsiderably and the patient was discharged from

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Diagnosis and management of a wooden orbital foreign body

Fig. 2 Orbital CA T scan afterintravenous injection of contrastmedium. An area of increaseddensity is apparent postero-laterally in the left orbit inassociation with the lateralrectus muscle

hospital with the lid suture in situ. Two weeks laterthe suture was removed and the conjunctivalchemosis reappeared, particularly at the nasal side,where a pedunculated lesion developed. This lesionwas excised under local anaesthesia and subjected tohistological examination, which indicated a mixedacute and chronic inflammatory cellular infiltration.Special staining techniques did not reveal any micro-organisms or fungi.

Diplopia then became a prominent symptom. Thepatient developed a left convergent strabismus of40 prism dioptres in the primary position, withlimitation of all ocular movements of the left eye,especially abduction, which was almost absent.An orbital CAT scan was performed. This showed

an area of increased density corresponding to the leftlateral rectus muscle. Slight enhancement followedthe injection of contrast medium, raising the pos-sibility of a granulomatous lesion. No positiveevidence of an orbital foreign body was detected(Fig. 2).

Similarly, orbital ultrasonography did not provideany definite evidence of a retained orbital foreignbody.Fundus examination of the left eye was per-

formed by binocular indirect ophthalmoscopy. Thisrevealed a lesion identical in appearance to a shallowradial scleral buckle, extending from the inferiortemporal periphery to the posterior pole below themacular area (Fig. 3). This finding was consistentwith external pressure on the sclera, possibly dueto a localised granulomatous lesion or a foreign bodylying in contact with the globe.The chemosis of the lower bulbar conjunctiva

persisted.

After the conjunctival biopsy and orbital CATscan, both of which suggested a granulomatouspathology, and in the absence of an infective aetio-logy, it was decided to initiate a trial of corticosteroidtherapy. The patient received oral prednisolone,40 mg daily, and topical betamethasone to the lefteye, in addition to antibiotic therapy.The conjunctival chemosis rapidly subsided, the

range of movement of the left eye increased, and thefundus lesion became shallower. The visual acuityof the left eye remained 6/9. The dose of oral pre-dnisolone was retained at the level of 40 mg per dayfor 2 weeks, then gradually reduced to 20 mg dailyover a further 4-week period. By this time the

Fig. 3 Diagram showing fundus appearance of lefteye with a radially situated scleral 'buckle'

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John A. AVIacrae-

Fig. 4 Removal of the woodenforeign body from the leftorbit. The eye is rotated upwardsand the lower eyelid retractedwith a squint hook

chemosis had almost resolved and the fundus ap-pearance become normal.With the subsidence of the tissue swelling it was

then possible to palpate, through the left lower eyelidwith the eye in upgaze, a circumscribed hard masssituated on the surface of the globe just lateral to theposition of the inferior rectus muscle.The patient underwent exploratory surgery under

general anaesthesia. The operative findings weredramatic. Approximately 15 mm from the limbus atthe lateral border of the inferior rectus muscle a hardcircular mass was found in contact with the scleraand encapsulated by fibrous tissue. The mass wasgrasped with forceps and withdrawn to reveal itsidentity as the broken end of a wooden twig measur-ing 23 X 4 mm (Figs. 4 and 5). The wound wassutured and a subconjunctival injection of genta-micin given. Postoperative recovery was uneventfuland the patient was discharged from hospital 2 daysafter surgery. The systemic corticosteroid therapywas gradually reduced and was discontinued 10 dayspostoperatively.The residual conjunctival chemosis and limitation

of movement of the left eye subsequently resolved,and the visual acuity improved to 6/5.

Discussion

The preceding case history plots the clinical courseof a patient who sustained an eye injury which re-sulted in an undetected wooden foreign body re-maining in his left orbit for a peiiod of 14 weeks.Several factors prevented early recognition of thetrue nature of the orbital lesion.The history elicited from the patient did not

suggest direct penetration of the periocular tissues.He was aware of the bianch merely brushing across

his left eye and did not suspect any more seriousinjury.The delay of 4 days before surgical repair could be

carried out probably precluded any possibility ofidentifying such a deeply situated foreign body be-cause of the profuse tissue swelling and closure of thesubconjunctival tract along which the wooden twig

Fig. 5 The woodentwig removedfromthe left orbit

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had passed. Exploration of the wound did not revealany subconjunctival extension beyond the im-mediate confines of the conjunctival laceration, andapart from several particles of dirt no significantforeign body was apparent.The conjunctival chemosis was consistent with the

tissue trauma, particularly in view of the delay be-

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Diagnosis and management of a wooden orbital foreign body

tween the injury and wound repair. Furthermore, inthe absence of proved infection, the persistence ofthe chemosis could have been the result of prolapseand desiccation of the conjunctiva.

Limitation of movement of the left eye could havebeen attributed to the mechanical restriction imposedby the bulbar conjunctival chemosis and also inter-ference with extraocular muscle function by in-creased tissue tension. In retrospect, both the che-mosis and interference with the movement of the lefteye were the direct consequence of the granulo-matous reaction induced by the wooden foreignbody. Orbital radiography was unhelpful becauseof the radiolucent nature of the wooden foreignbody.The CAT scan was equivocal. The increased

density noted in association with the left lateral rectusmuscle was probably the manifestation of a granu-lomatous myositis, and the enhancement whichfollowed the injection of contrast medium was inkeeping with this interpretation. The foreign bodywas not positively identified by the CAT scan forseveral reasons. The foreign body lay close to theorbital floor possibly within the 'blind area' of theCAT scan described by Gawler et al. (1974). Thesituation of the twig, adjacent to and parallel withthe inferior rectus muscle, and also the similarity indimension and density to the muscle, would renderlocalisation virtually impossible by standard CATscanning techniques.The failure of ultrasonography to localise the

foreign body can also be explained in terms of itsposition. The close proximity of relatively densetissues with good sound-reflecting interfaces possiblymasked the foreign body to the sound wave. Further-more, the sound emission from the ultrasonic probewould be directed towards the broken end of thetwig, a structure 4 mm in diameter, surrounded bytissue of similar density. The foreign body wouldtherefore possess poor sound reflecting propertiesand would produce a correspondingly weak echo,rendering ultrasonic diagnosis most unlikely. Thecase dramatically illustrates the limitations of bothCAT scanning and ultrasonography in the diagnosisand localisation of a wooden foreign body situatedin the orbit.The presence and situation of a retained orbital

foreign body were suggested by the fundus ap-pearance of a scleral buckle on indirect ophthalmo-scopy. However, it was the administration of cortico-steroid therapy which brought about sufficient re-duction in the inflammatory reaction to permit

positive localisation of the anterior end of the twigby palpation through the lower eyelid. Thesefindings provided adequate direct localising evidenceto justify the surgical exploration which ultimatelyled to the removal of the foreign body.The anti-inflammatory effect of corticosteroid

therapy produced 2 distinct clinical benefits. Firstly,the foreign body, which had previously been maskedby tissue swelling, was revealed to the palpatingfinger when the swelling subsided. Secondly, thesurgical approach to the foreign body was renderedless hazardous by a reduction in the granulomatousreaction and conjunctival chemosis. In this particularpatient the administration of systemic corticos-teroids was therefore of diagnostic and therapeuticvalue, though the decision to start such therapy wasoriginally made on an empirical basis.When a patient presents with a history of an

ocular injury caused by organic material such aswood, the possibility of a retained orbital foreignbody must be considered, particularly when inflam-matory signs persist and limitation of ocular move-ment is evident. The indication of a normal orbit byCAT scanning or ultrasonography does not exclude aretained wooden foreign body. However, as Duke-Elder (1972) stressed, it should be consideredpotentially hazardous to embark on a blind explora-tion for a suspected orbital foreign body withoutpositive proof of its position or even of its existence.In circumstances as illustrated by the case describedit is prudent to temporise until definite localisingsigns become apparent before surgical explorationis contemplated. Such management facilitates aplanned surgical approach, thus minimising theoperative trauma to the orbital structures.

I am grateful to Mrs A. Gearce for secretarial services andto Mrs A. Ellingford and Mrs R. McNeil for the preparationof photographic material.

References

Duke-Elder, S. (1972). System of Ophthalmology, Vol. 14,Part 1, pp. 666-667. Kimpton: London.

Ferguson, E. C. (1970). Deep wooden foreign bodies of theorbit. Transactions of the American Academy of Ophthal-mology and Otolaryngology, 74, 778-787.

Gawler, J., Sanders, M.D., Bull, J. W. D., du Boulay, G.,and Marshall, J. (1974). Computer assisted tomography inorbital disease. British Journal of Ophthalmology, 58,571-586.

Legras, M., and Lecoq, P. J. (1970). Orbital lesions withretention of (radio-transparent) foreign bodies. Archivesd'Ophtalmologie, 30, 57-60.

von Marton, D. (1969). Foreign bodies in the orbit. Ophthal-mologica, 159, 49-54.

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