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Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 108-110

Post-traumatic chronic discharging orbital sinus: An interesting case report


Department of Ophthalmology, Yenepoya Medical College, Deralakatte, Mangalore, Karnataka, India

Date of Submission18-Feb-2014
Date of Acceptance14-Nov-2014
Date of Web Publication7-May-2015

Correspondence Address:
Vidya Hegde
Department of Ophthalmology, Yenepoya Medical College, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.156608

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  Abstract 

We report a rare case of a chronic discharging orbital sinus with retained multiple pieces of wooden stem. A 50-year-old male presented with swelling and discharge of 8 months duration on the medial aspect of right upper lid following a fall. Magnetic resonance imaging (MRI) showed presence of a foreign body granuloma. Orbital exploration revealed presence of multiple fragments of plant stems. Removal of these stem pieces along with granulation tissue resulted in resolution of his symptoms. The patient, on retrospective enquiry, gave the history of presence of Parthenium plants in the area where he fell. This case report highlights the need to suspect a retained foreign body in the presence of a non-healing wound.

Keywords: Discharging sinus, intraorbital organic foreign body, multiple wooden pieces, non-healing orbital wound, parthenium weed, post trauma


How to cite this article:
Hegde V, Jain R, Bappal A. Post-traumatic chronic discharging orbital sinus: An interesting case report. J Clin Ophthalmol Res 2015;3:108-10

How to cite this URL:
Hegde V, Jain R, Bappal A. Post-traumatic chronic discharging orbital sinus: An interesting case report. J Clin Ophthalmol Res [serial online] 2015 [cited 2020 Oct 22];3:108-10. Available from: https://www.jcor.in/text.asp?2015/3/2/108/156608

The orbit is involved in about 15% of all the serious injuries. [1] Foreign bodies gain entry into the orbit either by traversing between the globe and orbital wall or by double perforation of the globe. Organic foreign bodies are poorly tolerated, elicit intense inflammatory reactions, and need to be removed urgently. [2],[3] A retained organic foreign body in orbit can cause inflammations like orbital cellulitis, orbital abscess, gangrene, chronic discharging sinus, osteomyelitis, and sight-threatening complications like optic atrophy and cavernous sinus thrombosis, [4] thereby providing a great therapeutic challenge. We report a case of chronic non-healing wound in the orbit, following trauma, which on exploration revealed presence of multiple wooden fragments that were probably Parthenium plant stems.


  Case Report Top


A 50-year-old man presented with swelling and wound with discharge in the right upper eyelid of 8 months duration. He had no other ocular complaints except itching of skin of right upper lid. About 8 months back, he had a fall by the side of the road, striking his right eye against a stone. He noticed a small open wound on the medial side of the right upper lid for which wound dressing was done in a hospital. There was no other injury and he did not have any episode of loss of consciousness, vomiting, bleeding from the eye, diplopia, or decreased vision following trauma. After 5 months of fall, as there was no sign of wound healing, patient consulted a doctor, who sutured the wound. Following suture removal, wound persisted along with discharge. The patient subsequently consulted an ophthalmologist, who advised magnetic resonance imaging (MRI) of the orbit. MRI revealed presence of a foreign body granuloma, in superomedial aspect of right orbit, anterolateral to lacrimal sac with a small sinus tract anterior to the lesion. The patient was referred to our centre for further management. On examination, vision in each eye was 6/6. There was minimal limitation of movement in up gaze in right eye. The upper eyelid showed presence of a sinus, 3 mm in diameter along with purulent discharge and granulation tissue [Figure 1]. Surrounding skin showed hyperpigmentation and excoriated healed scar [Figure 2]. There was right eye mild mechanical ptosis [Table 1]. The anterior segment and fundus examination findings were unremarkable in both eyes. The patient had no systemic illnesses.
Figure 1: A discharging sinus seen on the superomedial aspect of right upper lid with mild ptosis

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Figure 2: Right upper lid showing hyperpigmented healed scar and discharging sinus

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Table 1: Pre-operative ptosis evaluation


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No organisms were isolated on microbiological evaluation of pus. Dacryocystogram showed normal patent lacrimal drainage pathways with no connection to the sinus. Under antibiotic cover, the wound was explored under general anesthesia, which surprisingly revealed presence of multiple small fragments of plant stems [Figure 3] and [Figure 4]. The granulation tissue extending deep into the orbit was excised. At the time of closure of the wound, a vacuum drain was placed and sutured. Histopathological examination of excised tissue revealed sinus tract lined by non-specific granulation tissue. Microbiological examination showed presence of few gram-positive cocci and gram-negative bacilli.
Figure 3: Peroperative picture showing wound exploration and a piece of plant stem

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Figure 4: Peroperative picture showing numerous pieces of plant stem retrieved after wound exploration

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On re-enquiring, patient confirmed the presence of Parthenium plants around the place where he fell. He was administered systemic antibiotics, intravenous Ampicillin 500 mg bd, and intramuscular Gentamycin 80 mg bd for 5 days, followed by oral Ampicillin 500 mg four times daily for 5 days. Oral steroids in the dose of 1 mg/kg body weight was also administered and then tapered over a period of 1 month. The patient had an uneventful postoperative period with improvement of movement in upgaze in the right eye. The wound had healed well with normal lid position in that eye [Figure 5].
Figure 5: Post-operative appearance of the patient at the end of 1 week showing healed wound and normal lid position

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  Discussion Top


Intraorbital foreign bodies are usually caused by injuries with high-velocity objects. Sometimes even in a trivial trauma, foreign bodies can penetrate the orbit and later cause secondary complications. [5] The most common orbital foreign bodies following penetrating orbital injury are glass and wood. The risk of infection is high with organic foreign bodies. The soft and porous nature of wood makes it easy to fragment and susceptible for infection. Orbital foreign bodies are commonly seen in males and younger population. If a patient presents with a history of orbital trauma along with motility disturbance, chronic red eye unresponsive to treatment, fistula in the area of injury, decreased vision, or localized pain on eye movement, it is imperative to have a high index of suspicion of retained foreign body. [6]

Imaging techniques help in the detection and localization of foreign bodies in the orbit. In computed tomography (CT) scan, organic matter like wood may have varying appearance over a period of time and with the degree of hydration. MRI is a better imaging modality to detect organic foreign bodies. [4] Neither CT nor MRI can detect all foreign bodies. [7] Retained orbital foreign bodies, like wood, may remain quiescent for a sizeable length of time ranging from days to years following injury. [8] In our case, the patient was unaware of any foreign body entering the wound at the time of fall. He had symptoms for 8 months. MRI report and a discharging sinus made us suspect presence of foreign body for which he underwent surgical exploration. To our surprise, there were multiple fragments of plant stems from the sinus. The scar and the granuloma can produce mechanical effect of a space occupying mass which in our case manifested as ptosis. Removal of the foreign body along with the sinus tract resulted in the resolution of his symptoms.

Parthenium is an aggressive, ubiquitous, herbaceous weed with no economic importance but known to cause several health problems. The weed is known by various names like carrot grass, the "Scourge of India," and congress grass. This noxious weed is known to grow on abandoned lands, established gardens, plantations, etc. It is one of the world's seven most devastating and hazardous weeds. [9] About 35 million hectares of land in India have been infested with this weed. Parthenium is notorious for causing allergic reactions like skin inflammation, eczema, asthma, allergic rhinitis, hay fever, blackspots, and blisters around the eyes. In our case, the patient had multiple pieces of plant stem in the orbit inciting the formation of the granuloma and a sinus. Its presence went unnoticed. He had itching in the skin around the wound. We assumed that the plant stems belonged to Parthenium species based on patient's assertion and appearance of the foreign body. We were unable to confirm the species of the wooden stems in a botany laboratory. Hence, it is important to elicit a good detailed history regarding mode, place, and circumstances of injury. A thorough exploration of wound is essential in any penetrating injury.


  Conclusion Top


The clinical history in an orbital trauma may at times be deceptive. A latent period may be present between initial injury and the complication occurring due to the retained foreign body. This case report highlights the need to have a high index of suspicion of retained intraorbital foreign body in the presence of a non-healing wound.

 
  References Top

1.
Long JA, Tann TM. Orbital trauma. In: Kuhn F, Pieramici DJ, editors. Ocular Trauma: Principles and Practice. 1 st ed. New York: Thieme Medical Publishers; 2002. p. 383.  Back to cited text no. 1
    
2.
Al-Mujaini A, Al-Senawi R, Ganesh A, Al-Zuhaibi S, Al-Dhuhli H. Intraorbital foreign body: Clinical presentation, radiological appearance and management. Sultan Qaboos Univ Med J 2008;8:69-74.  Back to cited text no. 2
    
3.
John SS, Rehman TA, John D, Raju RS. Missed diagnosis of a wooden intra-orbital foreign body. Indian J Ophthalmol 2008;56:322-4.  Back to cited text no. 3
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4.
Nasr AM, Haik BG, Fleming JC, Al-Hussain HM, Karcioglu ZA. Penetrating orbital injury with organic foreign bodies. Ophthalmology 1999;106:523-32.  Back to cited text no. 4
    
5.
Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494-500.  Back to cited text no. 5
    
6.
Liu D. Common denominators in retained orbital wooden foreign body. Ophthal Plast Reconstr Surg 2010;26:454-8.  Back to cited text no. 6
    
7.
Lin KY, Ngai P, Echegoyen JC, Tao JP. Imaging in orbital trauma. Saudi J Ophthalmol 2012;26:427-32.  Back to cited text no. 7
    
8.
Reddy SC. Retained wooden foreign body in the orbit. Int J Ophthalmol 2013;6:255-8.  Back to cited text no. 8
    
9.
Patel S. Harmful and beneficial aspects of Parthenium hysterophorus: An update. 3 Biotech 2011;1:1-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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