Background: Intraorbital foreign bodies can result in various complications if not appropriately managed. Aim: To report a case of lower lid entropion secondary to a missed intraorbital foreign body. Case Presentation: A 7-year-old boy presented with inward turning of the left lower lid for three days prior to admission. A week before, the child was in the garden when part of the roof of their home suddenly broke off, with pieces of the debris falling near him. He complained of left eye irritation, but a visit to a general practitioner found no eye abnormalities. Three days after that, the mother sought an ophthalmology opinion as she noticed inversion of the left lower lid. On examination, visual acuity in both eyes was 6/6. There was left lower lid entropion, and a deeply embedded foreign body seen in the lower lid. No other eye abnormalities noted. Computed tomography scan of the orbits revealed a welldefined foreign object in the lower orbit, fracturing the antero-superior wall of the left maxillary sinus. The left eye foreign body was removed uneventfully via a transconjunctival approach. Conclusion: A thorough examination is mandatory in any case of ocular trauma especially in young children, who are usually unable to provide a clear history of the injury.
Children are particularly prone to orbital injury because the developing orbital bone offers little resistance. Foreign bodies most often encountered in the orbit are metallic objects and glass fragments [
A 7-year-old boy presented to our eye clinic with a complaint of inward turning of the left lower lid for 3 days duration. According to the mother, the child was playing alone in the garden a week ago when part of the roof of their home suddenly broke off. She was alerted by the noise, and when she stepped into the garden, she noted a few bits of broken tiles on the ground. The child appeared to be unharmed, but complained of left eye irritation. She immediately brought him to a general practitioner, who reassured them that the patient had a normal eye examination. The left eye irritation resolved spontaneously, and the vision was good, with no double vision. However, after three days, the mother noticed that the left lower lid appeared to be inverted. When this did not resolve spontaneously, she brought her son to the ophthalmology clinic.
On examination, the visual acuity in both eyes was 6/6. Extraocular movements were full in both eyes, but there was pain in the left eye on upgaze position. There was a left lower lid entropion, and palpation of the left eye revealed a deeply embedded foreign body in the lower lid (
Skull X-ray showed a left lower lid radio-opaque foreign body. Computed tomography (CT) scan of the orbits revealed a well-defined foreign object with sharp edges in the lower orbit (
The left eye foreign body was removed via a transconjunctival approach. The object was embedded in the inferior lower fornix, extending until the inferior orbital rim. It was identified as a stone, which was removed in one piece (
The patient was started on a five-day-course of intravenous amoxicillin clavulanate and metronidazole, which was continued orally for another week. Topical ceftazidime was also instilled 4 hourly. On post-operative day one, there was slight oedema of the left lower lid region, which resolved on subsequent follow-up. He was last seen 2 weeks post op and his wound had completely healed. He was planned for an entropion repair after 6 weeks.
Intraorbital foreign bodies usually occur secondary to high velocity injuries, such as in gunshot or industrial accidents [
Early clues giving rise to a clinical suspicion of an intraorbital foreign body include eyeball displacement, persistent inflammation and conjunctival chemosis. In cases where there is an associated fracture of the orbital floor, limitation of ocular movement with diplopia usually occurs, mainly due to inferior rectus entrapment and rarely, from nerve injury or muscle contusion [
patients may be completely asymptomatic. It is likely that the initial discomfort experienced by the patient stemmed from the associated conjunctival wound. The latter was likely a self-sealing wound, which partially explains how the diagnosis was missed at the first presentation. A recent review highlights the importance of detailed examination of the conjunctiva and fornices as intraorbital foreign bodies usually penetrate the conjunctiva without causing eyelid laceration [
Imaging is invaluable in the evaluation of the globe and orbital integrity post trauma. Although X-ray is the initial imaging in cases of suspected intraorbital foreign bodies, computed tomography (CT) scan is the investigation of choice when there is a definitive history of penetrating injury, as even in cases of a radio-opaque object clearly visualised on X-ray, CT assists in planning of the surgical approach [
The choice of imaging modality chiefly depends on the nature of the suspected foreign body. Plain film radiography is an economical method of visualising radio-opaque objects, but computed tomography still remains the gold standard of initial imaging [
Although complications associated with intra-orbital trauma include visual loss, orbital inflammation, secondary infection, osteomyelitis, ptosis and even brain abscess, in rare cases, no visual morbidity occurs [
Patients with suspected intraorbital foreign body are usually started on systemic antibiotics because of the high incidence of secondary orbital infections [
Management of the intraorbital foreign body depends on clinical presentation, nature and the location of the foreign body in the orbit. Because foreign bodies can cause irritation of the mucosa that can be result in sinusitis [
Presentation of the patient with visual compromise, ptosis, diplopia, orbital inflammation or infection mandates urgent removal. Likewise, surgical removal is indicated for all organic foreign bodies because of the high rate of secondary complications [
Entropion is a rare presentation of an intraorbital foreign body. As intraorbital foreign bodies in children may not cause any significant symptoms, and history taking in this age group may be unreliable, the circumstances surrounding the injury should be examined closely. Care must be taken to correlate the history with a thorough clinical examination. A CT scan of the orbit is the imaging modality of choice for detection and localisation of a suspected foreign body. Early diagnosis and surgical exploration where indicated can prevent complications which may be sight threatening or even permanent disfigurement.
The patient and his guardian have given full consent for publication of this case report.
Khairuddin, O., Suraida, A.R., Evelyn Tai, L.M., Adil, H., Liza-Sharmini, A.T. and Mohtar, I. (2016) Lower Lid Entropion Secondary to Missed Intraorbital Foreign Body in a Child. Open Journal of Ophthalmology, 6, 198-204. http://dx.doi.org/10.4236/ojoph.2016.64028