Vol 31 No 1 Brief Reports PDF

Chopstick splinter: A rare cause of bilateral frozen orbits

Lieh Bin O., Lee Ong C., Min Tet C., Selva Raja V., Liza-Sharmini AT, Balaravi P., Gurdeep Singh M.

A MENTALLY challenged Chinese male presented with a 6-month history of painless progressive caruncular growth in his right eye associated with mucoid discharge. He was previously treated for conjunctivitis. His family members also noted progressive inability to move his eyes. He initially denied any history of trauma to his eyes, but later disclosed an alleged assault 5 years prior with supposedly no eye injury, ocular pain, or bleeding from the incident. His best-corrected visual acuity was 6/9 bilaterally. Slitlamp examination revealed a 4 x 5 mm pedunculated granulation tissue arising from the right caruncle and extending 3 to 4 o’clock of the right corneal limbus. The granulation tissue was mobile with areas of early keratinization. There was bilateral marked restriction of gaze in all directions. No ptosis, proptosis, or orbital cellulitis was present in either eye. The pupillary reflexes, intraocular pressures, and fundi of both eyes were normal. Conjunctival swab failed to detect any organism. A nasal endoscopy revealed presence of granulation tissue in the right middle meatus with no obvious foreign body. Orbital and brain computed tomography (CT) revealed the presence of a hyperdense rod-like structure traversing the nasal area, extending from the superomedial wall of the right orbit to the apex of the left orbit with surrounding inflammatory reaction. The optic nerves were spared. The sinuses and nasopharyngeal spaces were clear (Figures 1 and 2). An elective surgery under general anesthesia was performed to remove the foreign body. A right lateral rhinotomy approach was employed and the right anterior and nasal bridge was removed. Intraoperatively, the foreign body, a 6- cent imeter splinter of a plastic chopstick, was noted extending from the right orbital floor and traversing the ethmoidal sinuses posteriorly to the left orbit. No pus was noted in the ethmoidal sinuses or in the orbit. The chopstick splinter was removed and the wound meticulously explored and irrigated. Postoperatively, the patient was started on intravenous co-amoxiclav (Augmentin, GlaxoSmithKline, Middlesex, UK) and dexamethasone. He was discharged on the third postoperative day with oral co-amoxiclav. At discharge, visual acuity remained and eye movements were still restrictive. Patient failed to return for follow-up evaluation. Intraorbital foreign bodies are usually diagnosed with ease in the presence of obv ious penet r a t ing injuries.
1, 6 In less obvious history of trauma, especially in special patients or children, intraorbital foreign bodies are frequently missed. 2, 4 A high index of suspicion is important to identify such cases. In the case of our patient, the presence of the intraorbital plastic chopstick splinter remained undetected for 5 years because of his lack of recollection of any ocular injury. The absence of visual deterioration and presence of bilateral frozen orbit further confused the situation. Retained organic material may lead to infection and eventual abscess formation. This may affect the optic nerve directly or spread to the adjacent structures, leading to sinus abscess, cavernous sinus thrombosis, or intracranial abscess. 2, 3, 5 In our patient, there was no active infection despite presence of the splinter for 5 years possibly because the chopstick was inert or he was partially treated with systemic antibiotics. The presence of a persistent intraorbital foreign body, nonetheless, induced a chronic inflammation that resulted in fibrosis of his extraocular muscles, leading to bilateral frozen orbits. The restrictive ophthalmoplegia may be permanent even after the removal of the splinter. Intraorbital foreign bodies can be detected by plain radiographs, ultrasonography, CT, and magnetic resonance imaging (MRI). 4 Although CT is very sensitive in detecting highdensity material such as metal, it is less effective in detecting low-density objects like organic foreign bodies. 5 MRI is a better method of investigation in such cases. 7 Nevertheless, MRI is contraindicated in cases where metallic foreign bodies are suspected. In summary, intraorbital foreign bodies should always be suspected in the presence of a mass in the eye, especially when the history is unreliable and clinical presentations are atypical. An imaging investigation should be carried out in such cases as it is potentially life saving.

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