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The presence of foreign bodies increases the risk of post-traumatic endophthalmitis (5). Management of POT depends on involvement of vital structures such as the globe and brain. A complete physical examination, including full neurological and/or ophthalmological examinations, is essential for diagnosis and treatment of a patient diagnosed with POT. All patients should undergo a comprehensive exam to rule out any penetrating intracranial injury (10, 11). CT scan imaging should be considered as the primary imaging method of choice in the emergency department. Plain radiographic imaging is recommended when a CT scan is not available. While CT can easily detect metallic foreign bodies, its value in detection of wooden foreign bodies is questionable. For the evaluation of wooden objects, contrast-enhanced magnetic resonance imaging (MRI) is suggested (12). MRI is also useful for differentiating the object from the surrounding air and fatty tissue, particularly in orbital injuries. CT angiography or magnetic resonance (MR) angiography is indicated when there is evidence of bleeding or a possible vascular injury, due to either the location and path of the foreign body or sign of a hematoma on CT scan (13).
The globe occupies approximately one-fifth of the orbit. The rest of the orbit comprises muscles, vessels, and nerves within a matrix of orbital fat. The superior rim of the orbit is formed by the frontal bone. As such, the frontal sinus resides on the medial aspect of the roof, and the fossae for the lacrimal glands reside on the lateral aspect of the roof. The roof of the orbit also serves as the floor of the anterior cranial fossa. The medial wall of the orbit consists mainly of the ethmoid bone, but components of the palatine and lacrimal bones are also present. The maxilla, which is the most commonly fractured orbital bone, forms the floor of the orbit. Lastly, the lesser wing of the sphenoid forms the lateral wall of the orbit. There are two orbital fissures and one canal at the apex of the orbit. The optic canal is formed by the sphenoid bone and allows communication from the orbit to the middle cranial fossa. The optic nerve and ophthalmic artery normally traverse the canal, but there is a potential for foreign objects to penetrate the canal and enter the middle cranial fossa. The fissure between the greater and lesser wings of the sphenoid forms the superior orbital fissure. The oculomotor, trochlear, ophthalmic, and abducens nerves all traverse this fissure. A foreign object lodged in this region will injure these nerves and can enter the cranial cavity, resulting in orbital apex syndrome. The maxilla and the greater wing of the sphenoid form the inferior orbital fissure. This fissure allows communication between the orbit and the pterygopalatine fossa and infratemporal fossa. The superior orbital fissure and optic canal can allow a penetrating object to enter the cranial cavity without breaking any of the orbital bones [3].
As Schreckinger and colleagues discuss, objects entering the superior orbital fissure have the potential to course through the cavernous sinus and penetrate the brainstem, which can be life-threatening. Patients can also present with cavernous sinus syndrome, which presents similarly to orbital apex syndrome with the addition of facial numbness and miosis. Entry into the cranial cavity via the optic canal will position the penetrating object near the internal carotid artery and the optic nerve at the level of the suprasellar cistern [2].
Cases in which foreign objects penetrate the floor of the orbit are relatively rare and usually involve assault. One stabbing victim had a knife lodged in the inferior aspect of his orbit, lacerating the inferior eyelid, traversing the maxillary sinus, penetrating the soft palate, and lacerating the left tonsil. Removal of the knife was uneventful and without complications. The patient reported numbness over the maxilla attributed to laceration of the infraorbital nerve and diplopia with upper-lateral gaze attributed to reactive edema [10].
Cases with objects penetrating the lateral rim of the orbit are not reported in the literature. As Lasky and colleagues suggest, avoidance head turns will generally direct penetrating objects to the medial aspect of the orbit, especially in self-inflicting cases [4]. Furthermore, we hypothesize that the 45° difference between the lateral orbital wall and the sagittal plane would make it difficult for penetrating objects to be directed deep into the orbit.
Sympathetic ophthalmia is a bilateral necrotizing granulomatous uveitis that results from trauma to the globe and can accompany any type of POI. POI and postoperative complications include CSF leaks, traumatic aneurysm, cavernous fistula, cerebral abscess, and meningitis [2]. The risk for abscess formation increases exponentially when the penetrating object is organic. For example, the organic and highly porous nature of a wooden pencil allows bacteria to thrive and can act as an infective nidus if small pieces remain intracranially [6, 11].
Noncontrast CT scanning is the preferred imaging modality for determining the course of the penetrating object and the extent of tissue injury. MRI is useful when the penetrating object is wooden because the foreign object can easily be differentiated from the surrounding tissue. With CT scanning, dry wood has a similar density to air and wet wood has a similar density to adjacent tissue. If there is hemorrhage or injury to a blood vessel is suspected, angiography is indicated [2].
Intraocular foreign body (IOFB) injuries vary in presentation, outcome, and prognosis depending upon various factors. IOFBs can cause perforating or penetrating open globe injuries. The visual prognosis depends on the zone of injury, type and size of foreign body and the subsequent complications. Increased awareness about eye protection, improved surgical techniques, and advancements in bioengineering are responsible for an improved outcome in injuries with IOFB.
Intraocular foreign bodies are seen in 17%-40% of penetrating ocular injuries and represents 3% of all emergency room visits in the United States. Risk factors including metal-on-metal tasks, lack of eye protection, or male gender. These injuries commonly occur at work or at home according to the US eye injury database (Ferenc). The majority of patients injured are between 21 and 40 years of age. The majority of foreign bodies (58-88%) enter the posterior segment.
Visual acuity and pupillary examination should be documented with attention to pupil shape, afferent pupillary defect or anisocoria. If a ruptured globe is suspected, applanation tonometry or other exam techniques that put pressure are the globe are typically not suggested until the wound have been closed to prevent expulsion of ocular contents. Careful examination of eyebrows/lids should evaluate for any lacerations, canalicular injury, or small foreign bodies. A full slit lamp examination should be performed. A scleral entry site may be seen with an area of conjunctival injection, hemorrhage, or chemosis with or without a conjunctival laceration. Pigment over the scleral entry site may suggest uveal tissue prolapse. Entry sites in the cornea may be seen as a disruption in the smooth surface with corneal edema surrounding the entry site and/or a positive Seidel test. However, a negative Seidel test does not rule out a penetrating injury and could be present with a self-sealed wound. Iris transillumination defects or iris heterochromia may be also be signs of a perforating injury. Using the entry point either at the cornea or sclera and the disruption point of the iris may help in localizing the IOFB by creating a trajectory path. Close examination of the natural lens for a focal opacity, especially the lens periphery, or phacodynesis may also provide a clue regarding the trajectory of the FB. It is best to examine the iris before dilatation and the lens after dilatation.
How to cite this article: Al-Mutasim B. Etaiwi1, Mustafa Ismail2, Teeba A. Al-Ageely2, Ayaat F. Alasady3, Alsultan O. Jabbar4, Jaafar AbdulWahid3, Mahmood F. Al-Zaidy2, Samer S. Hoz5. Retrograde cranio-orbital penetrating injury: A case report. 13-Jan-2023;14:11
How to cite this URL: Al-Mutasim B. Etaiwi1, Mustafa Ismail2, Teeba A. Al-Ageely2, Ayaat F. Alasady3, Alsultan O. Jabbar4, Jaafar AbdulWahid3, Mahmood F. Al-Zaidy2, Samer S. Hoz5. Retrograde cranio-orbital penetrating injury: A case report. 13-Jan-2023;14:11. Available from: -articles/12102/
Conclusion: Cranio-orbital penetrating brain injury is a severe yet rare type of penetrating brain injury. The direction of cranio-orbital injury is usually from the orbital region to the cerebrum. In our case, the retrograde fashion of the bullet migration renders it unique and calls for further studies to highlight the differences in injury and management of such cases.
Penetrating brain injuries can be caused by a missile or non-missile mechanisms. Penetration of the missile is more common with high-velocity objects.[ 4 ] The migration of an intracerebral bullet can be attributable to gravitational force, cerebral softening, or local tissue damage. Spontaneous bullet migration through the cerebrospinal fluid and brain parenchyma have been reported in multiple cases in the literature.[ 3 ] Bullet migration is usually seen in the ventricular system, cisterns, ipsilateral cerebral lobes, or cerebellum.[ 10 ] The resulting effective gravitational force on the heavy object is most likely the cause of migration; a bullet will always tend to migrate away or take a retrograde motion in the inlet pathway.[ 3 , 6 ] Cranio-orbital brain injury, although not frequent, is a severe type of penetrating brain injury with a mortality rate reaching approximately 12% of the affected individuals. The direction of the penetrating object in cranio-orbital injury can vary; however, most cases (86%) reported the orbital roof as the main entry point.[ 2 , 4 ] In our case, the penetrative bullet has entered the intracerebral hemisphere from the occipital lobe and managed to migrate to the contralateral orbital region giving it a retrograde direction for cranio-orbital penetrating injury. 2b1af7f3a8