1. EMERGENCY CALL ON A
FRIDAY AFTERNOON…
DR. HAYAT KHAN
DR. DAN DEANGELIS

2. PRESENTATION
4 year healthy girl
sustained trauma left infra-nasal periorbital area
by running into a tree while tobogganing.
1cm X 1 cm laceration of skin.
Referred to HSC Emergency within 24 hours of injury.
CT Scan Brain and Orbit ordered by Emergency Team at HSC
Referred to eye clinic…

3. PRESENTATION (CONTD.)
Seen by Oculoplastics services at HSC.
H/O:
• Increasing swelling of eye lids since injury(LE).
• Redness of the periorbital area(LE).
• Painful eye movements left side (LE).
• Diplopia since injury.
Child irritable, uncooperative with examination.
Eyelid chemosis & erythema (Lower> Upper) LE
Proptosis associated with Motility restricted.
Visual acuity was difficult to evaluate.
Pupils were equal, round, and briskly reactive to light both eyes.

6. CT SCANS : AXIAL VIEW

7. CT SCANS : AXIAL VIEW

9. CT SCAN CORONAL SECTION

10. CT SCAN CORONAL SECTION

11. SAGITTAL VIEW

23. “If wood has a sharp end and is elongated it can penetrate deep into the orbit
and the intracranial cavity through a small entry wound”
(Greany, 1994; Mutlukan et al., 1991)

24. SURGICAL MANAGEMENT – 3RD MARCH 2010
• Examination under Anaesthesia – Nasolacrimal system carefully examined.
• IOP in LE – 32 mmHg … Lateral Canthotomy?
• Wound was cleaned and Specimen collected from the surface.
• Wooden Foreign Body 30 mm removed.
• Retrobulbar irrigation done with Bacitracin mixed with BSS.
• Retrobulbar abscess was drained and drainage tube was left in to be removed in 2 days.
• Suturing done to close the wound and 5-0 silk was used to anchor the drainage tube.
• IOP 18 mmHg in LE at the end of procedure.
• I.V. Antibiotics started – Vancomycin, Ceftriaxone and Metronidazole after discussion
with ID.

25. FOLLOW UP
I.V. Antibiotics continued for 1 week and then changed to Oral
Ciprofloxin at the time of discharge and given for 1 week.
Unremarkable eye exam except -2 adduction LE on 1st postop day one
which improved in 7 days. Vision was recorded 4/6 in each eye.
Drainage tube was dry the next day and was removed on the 2nd
postoperative day. Steri-strip was used to close the wound.
Discharged at 1 week with Tobramycin Ointment to be applied locally.
At 1 month Follow – good healing

26. 8 DAYS POSTOPERATIVE PHOTOS

27. ONE MONTH
POSTOPERATIVE PHOTOS

28. BACTERIOLOGY REPORTS
Deep Orbital Aerobic & Anaerobic Swab Left Eye:
• Gram Staining: Many Neutrophils & No Organism
• Results:
• Pantoea Agglomerans(Scanty Growth)
• Sensitive to Gentamicin, Piperacillin, Trimethoprim- Sulpha,
Tobramycin.
• Resistant to Ampicillin& Cephazolin
• Clostridium perfringens (Scanty Growth)
• Clostridium Tertium (Scanty Growth)
• Klebsiella Ozaenae (Scanty Growth)
• Sensitive to Gentamicin, Piperacillin, Trimethoprim- Sulpha,
Tobramycin.
• Resistant to Ampicillin.

29. MICROBIOLOGY LITERATURE ON
ORGANIC FOREIGN BODIES
Case of penetrating orbitocranial injury caused by Wood.
Pus from the brain abscess grew Bacteroides asaccharolyticus and
small numbers of anaerobes.
Fusobacterium sp. and Leptotrichia buccalis known to be found.
• British Journal of Ophthalmology, 1991,75, 374-376
Expect rare organisms like Veillonella species to grow from organic
foreign bodies like small gram-negative anaerobic diplococcus of
which little is known was discovered.
• Orbit - 1987, Vol. 6, No. I, pp. 3-15
Staphylococcusaureus &Citrobucter diversus found- sensitive to
gentamicin and co-trimoxazole
• Orbit - 1989, Vol. 8, No, 2, pp. 139-142

30. RADIOLOGICAL ASPECT
Plain film radiography is not useful in detecting intraorbital wooden
foreign bodies.
Standardized ophthalmic ultrasonography (combine of standardized
A-scan and B-scan) has been suggested to be used as an alternative.
Limitations:
• May not be able to evaluate the complete orbit
• Cannot detect intraorbital wood surrounded by air.
Orbit, 27:131–133, 2008.Intraorbital Organic Foreign Body – A Diagnostic Challenge.
BritishJournal ofOphthalmology, 1991,75, 374-376 Case of penetrating orbitocranial injury caused
by Wood. Erkan Mutlukan, BrianW Fleck, James F Cullen, Ian R Whittle

31. CT SCAN ROLE
With the use of CT, several authors were able to detect intraorbital wood.
CT also allowed detection of associated problems such as fractures
and abscesses. Wide window widths (up to 1000 HU) were proposed to
optimize visibility of intraorbital wood.
Intraorbital wooden foreign body mimics air on standard CT window
setting and MR.
Ophthalm Plast Reconstr Surg 1990;6:108–114
Am J Ophthalmol 1988;105:612–617
Radiology 1992;185:507–508.
AJNR Am J Neuroradiol 1993;14:892–895

32. INTRAORBITAL WOOD FOREIGN BODIES ON CT:
USE OF WIDE BONE WINDOW SETTINGS TO DISTINGUISH WOOD FROM AIR
The wide-bone window settings usually reveal the reticulated matrix of
wood, which distinguishes wood from simple gas collections.
If wood volume averages as fat density, it is difficult to identify in the orbit on
CT.
However, with strong clinical suspicion of wooden foreign bodies and
metallic foreign bodies excluded by CT, MR imaging is indicated because
of its superiority to CT in detecting dry wooden foreign bodies.
Ophthalm Plast Reconstr Surg 1990;6:108–114
Am J Ophthalmol 1988;105:612–617.
Surv Ophthalmol 1992;36:341–344.
Ophthalmology 1990; 97:608-11

33. The radiologist reported an “oval gas shadow” between the right medial rectus and
the lateral wall of the ethmoid sinus suggestive of a possible collection of pus.
Intraorbital Organic Foreign Body – A Diagnostic Challenge.
Orbit, 27:131–133, 2008.

34. Small objects and those
composed of wood or
plastic difficult to be
detected by imaging.
Orbit – 1998, Vol. 17, No. 4,pp. 247-269
Weisman RA, Savino PJ, Schut L, Schatz NJ. Computed tomography in penetrating
wounds of the orbit with retained foreign bodies.

35. Retrospective, non-comparative case series.
Nineteen patients (15 males, 4 females) with penetrating orbital injuries
due to organic foreign bodies.
Time of presentation: few hours to 9 months.
Most common injury site superior orbit in 11 (57.9%) patients leading to:
• abnormal extraocular motility (84.2%)
• proptosis (68.4%)
• upper lid ptosis (47.4%)
Associated pathologies also included:
• acute cellulitis in 11
• orbitocutaneous fistula in 5
• osteomyelitis in 2 patients.
Preoperative CT and MRI identified the foreign bodies in 42% and 57% of
the patients, respectively.
The vision improved shortly after treatment
The long-term complications - extraocular muscle and eyelid motility
problems and periorbital scarring.
Penetrating Orbital Injury with Organic Foreign Bodies. Ophthalmology 1999;106:523–532

36. TAKE HOME MESSAGE
Early clinical signs suggesting a foreign body in the orbit:
• may be displacement of the globe
• persisting inflammation
• limitation of ocular movement with diplopia.
(Macrae, 1979)
Wood has a density similar to air and fat and can be difficult to
distinguish from soft tissue in both a plain X-ray film and a computed
tomogram.
(Green et al., 1990; Macrae, 1979;Mutlukan et al., 1991; Specht et al., 1992)
Magnetic resonance imaging is a better method of investigation in
cases of a suspected organic intraorbital foreign body.
(Green et al., 1990; Specht et al., 1992)

37. THANK YOU

38. BACTERIOLOGY REPORTS
External Aerobic Left Eye Swab:
• Gram Staining: Many Neutrophils & No Organism
• Results:
• Staph. aureus (Scanty Growth) – Sensitive to Oxacillin/
cefazolin / cefuroxime, clindamycin, Erythromycin
• Gm. –ve Bacilli (Scanty Growth)
• Clostridium species but not perfringens (Scanty Growth)

39. KLEBSIELLA OZAENAE
A member of the family Enterobacteriaceae
Causes:
• Bacterial endophthalmitis - relatively uncommon.
• Rhinoscleroma, a chronic granulomatous infection
• Ozena or primary atrophic rhinitis.
• Community-acquired pneumonia -◦◦An increased tendency exists toward
abscess formation, cavitation, empyema, and pleural adhesions.
• Urinary tract infection
• Nosocomial infection
• Colonization
Has a role as an invasive pathogen, especially in immunosuppressed hosts
Case reported of a cerebral abscess caused by K. ozaenae.
J Clin Microbiol. 1987 August; 25(8): 1553–1554.

40. PANTOEA AGGLOMERANS
Gram-negative bacterium that belongs to the family Enterobacteriaceae.
Formerly called Enterobacter agglomerans
Known to be an opportunistic pathogen in the immunocompromised.
Commonly isolated from plant surfaces, seeds, fruit (ex. - mandarin
oranges), and animal or human feces.
It is difficult to differentiate easily from other members of this family,
such as, Enterobacter, Klebsiella, and Serratia species.

41. CLOSTRIDIUM PERFRINGENS
Clostridium perfringens (Welchii), a gram-positive anaerobic bacillus, may cause
gas gangrene following penetrating wounds.
Reported cases of C. perfringens endophthalmitis to more than sixty nine.
The Presentation:
• rapid development of a fulminating panophthalmitis
• severe pain
• early rise of ocular tension
• the appearance of blood or of a thin coffee-colored discharge
• the eventual formation of gas bubbles in the anterior chamber
• the rapid development of total amaurosis
The patient may be managed successfully by early therapeutic vitrectomy and
intravitreal and systemic antibiotic therapy.
Documenta Ophthalmologica 87: 177-182, 1994.

42. Bacteriological studies of gas gangrene
and related infections
Indian Journal of Medical Microbiology. 2003 |
Volume : 21 | Issue : 3 | Page : 202-204

43. Penetrating Orbital Injury with Organic Foreign Bodies.
Ophthalmology 1999;106:523–532
Ophthalmology 1999;106:523–532

44. MICROBIOLOGY
Microbiologic studies during surgery were performed on 13
patients:
• Staphylococcus aureus - 5
• Escherichia coli - 2
• Clostridium subterminale 1
• Haemophilus influenzae 1
• Cultures failed to reveal any causative organism 4
• No fungal infection was detected in this series.