Key Takeaways
Eye injuries, often caused by foreign body penetration, are common causes of vision loss. Retained foreign bodies can lead to delayed complications but may not always damage the eyeball wall. CT is the preferred imaging method for detecting metallic foreign bodies. Raising awareness of workplace safety measures, such as the use of protective eyewear, can prevent such injuries.
This case describes a 59-year-old man with acute right eye pain and double vision, 7 years after an industrial accident, who fully recovered after the surgical removal of a metallic foreign body from the eye.
The Patient and His History
The man presented to the Orbital Unit of the University of Naples Federico II with severe right eye pain and double vision. The symptoms began a month earlier and progressively worsened, requiring analgesics.
The patient had sustained a work-related facial injury 7 years prior, during which an intraorbital foreign body was overlooked and not removed. Remarkably, he remained asymptomatic throughout this period and reported no issues with his left eye.
Findings and Diagnosis
On ophthalmologic examination, the right eye’s visual acuity was 9/10 on the Snellen visual acuity chart. Direct and consensual pupillary reflexes were present, and the intraocular pressure was measured at 15 mm Hg (normal values, 10-21 mm Hg). A flashlight examination revealed no facial abnormalities, and the anterior and posterior segments of the right eye appeared normal with no visible signs of previous trauma. However, the patient reported diplopia in all gaze directions, raising concerns about the underlying cause.
A pre-surgical CT scan of the orbit was performed. The scan revealed a high-density shadow in the medial orbit corresponding to a metallic foreign body, with no associated bone injury.
After reviewing the findings, surgical removal of the foreign body was performed via an anterior orbitotomy under general anaesthesia. A metallic foreign body measuring 30 mm in length was successfully removed from the medial orbital wall. The capsule surrounding the foreign body was piecemeal removed without damaging the extrinsic ocular musculature and the ocular globe, which were not involved with the foreign body. No inflammatory tissue was observed. The patient tolerated the procedure well, with no complications. Post-operatively, his right-sided visual acuity improved to 10/10, and both pain and diplopia completely resolved. Normal extraocular movements were restored. He was initially treated with artificial tears and low-dose corticosteroids, which were tapered off before discharge 4 days after the procedure.
Discussion
Despite advances in surgery, traumatic eye injuries remain a leading cause of blindness and visual impairment, particularly among working men. Common causes include glass, thorns, wood, metal, and sharp objects, with injuries ranging from corneal abrasions to ruptured globes.
Ocular injuries are broadly classified as:
- Closed globe injuries caused by blunt trauma, chemical burns, or contusions. These may result in hidden scleral ruptures, which can be masked by an intact conjunctiva and normal intraocular pressure, especially in cases of anterior chamber haemorrhage.
- Open globe injuries include ruptures, foreign body penetration, and perforation of the globe. Penetrating injuries often have a better prognosis because of less disruption of the globe’s configuration.
The type, location, and extent of the injury, as well as the presence and nature of intraocular foreign bodies, are critical factors for determining visual prognosis. Foreign bodies can cause lens damage, vitreous haemorrhage, and secondary infections.
In this case, the inert metallic foreign body remained asymptomatic for 7 years because it was well tolerated by the surrounding tissues. However, the patient eventually developed pain and diplopia, likely due to chronic orbital inflammation and the formation of a surrounding granuloma.
This case demonstrates that even small foreign bodies can cause delayed complications, including chronic orbital inflammation, osteomyelitis, thrombotic vasculitis, and sepsis, if left untreated. Additionally, complications such as orbital haematoma, cellulitis, diplopia, proptosis, abscess formation, and blindness may occur.
CT is commonly used to evaluate orbital trauma, particularly for identifying metallic foreign bodies. In contrast, MRI is generally avoided in cases involving metallic foreign bodies because of the risk of exacerbating tissue damage. The eyeball wall should be examined for organic or non-metallic foreign bodies, such as wood.
Surgical removal techniques vary depending on the location and nature of foreign bodies. Endoscopic or minimally invasive approaches are preferred for symptomatic patients or those at risk for complications. In challenging locations, such as the orbital apex, asymptomatic small foreign bodies may be left in place to avoid surgical risks, including orbital bleeding or optic nerve damage.
This case underscores the importance of a thorough imaging evaluation for suspected retained intraorbital foreign bodies, even if they are asymptomatic for an extended period. The patient’s rapid recovery and resolution of symptoms following surgery highlight the importance of timely surgical intervention.
This article was translated from Univadis Germany using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.