BritishJournal ofOphthalmology, 1991,75, 374-376

Case of penetrating orbitocranial injury caused bywood

Erkan Mutlukan, Brian W Fleck, James F Cullen, Ian R Whittle

AbstractA case ofretained intraorbital and intracerebralwooden foreign body following an orbitocranialpenetrating injury through the lower lid of anadult is described. Initial failure to recognisethe true nature ofthe injury led to intracerebralabscess formation and monocular blindness.Diagnosis and management of such cases arediscussed.

A fit 41-year-old male presented with a bluntinjury to the right eye, and lacerations of thelower eyelid. He had fallen from a fence intosome wooden foliage, but had not beenconcussed.On examination the visual acuity was 20/30 in

the right eye and 20/20 in the left. Two splintersof wood were removed from small lacerations inthe right lower eyelid. There was a slight ptosis.A 10mm conjunctival laceration was present justinferior to the cornea. The sclera was intact.Abduction of the eye was normal, but all otherocular movements were limited. Corneal hypo-aesthesia and a hyphaema were present, and theintraocular pressure was 50 mmHg. The pupilwas oval, but reacted normally. The fundus wasnormal, as was the visual field to confrontation.The left eye was healthy. A skull x ray did notshow any abnormality.The patient was admitted to an ophthalmology

ward. The conjunctival and cutaneous lacera-tions were sutured, and oral acetazolamide wasgiven to control the intraocular pressure.

Royal Infirmary ofEdinburgh, PrincessAlexandra Eye PavilionE MutlukanBW FleckJ F Cullen

Department of ClinicalNeuro-Sciences,Western GeneralHospital, Edinburgh,ScotlandI R WhittleCorrespondence to:Dr E Mutlukan, PrincessAlexandra Eye Pavilion,Edinburgh EH3 9HA.Accepted for publication13 November 1990

Six hours later the patient became pyrexial,with a temperature of 390C, and his consciouslevel deteriorated to Glasgow Coma Scale 9. Hewas therefore transferred to the regional neuro-surgery department.An extradural haematoma was suspected, and

a CT scan was performed. It showed right sidedfrontal lobe contusions with associated subarach-noid and intracerebral haemorrhage (Fig 1). Airwas evident in the right orbit and adjacent to theintracerebral haematoma. A right frontal burrhole was made, which revealed contused cortexand subarachnoid haemorrhage. A subduralcatheter was therefore inserted to monitor intra-cranial pressure. Microbiological examination ofthe catheter swab identified a Fusobacterium sp.and Leptotrichia buccalis.The patient's pyrexia resolved with antibiotic

treatment and his conscious level gradually im-proved to GCS 15. However, he graduallydeveloped a right proptosis, measuring 25 mm inthe right eye (17 mm in the left) during the nextfive days. His visual acuity was reduced to handmovements, and a right afferent pupil defectdeveloped. A repeat CT scan showed a masssituated superiorly and medially in the rightorbit, thickening of the medial rectus muscle,and an orbital roof fracture (Figs 2, 3, 4). Inaddition a right frontal haematoma with sur-rounding oedema was present (Fig 5).An emergency right frontal craniotomy, right

optic canal decompression, and exploration ofthe right orbit were therefore performed througha superior orbitotomy. This revealed an abscess

Figure I CT scan on the day ofadmission showed rightfrontal contusion with associated subarachnoid and intracerebralhaemorrhage. Air was evident in the right orbit and intracranially.

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Case ofpenetrating orbitocranial injury caused by wood

Figure 2, 3, 4 A repeatCTscan on the fifth day afterinjury showed a rightintraorbital mass extendingsuperiorly and medially inthe right orbit, associatedwith thickening ofthe medialrectus muscle and an orbitalrooffracture.

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IFigure 2

cavity which contained fragments ofwood in theright frontal lobe. Multiple fragments of woodwere also found in the posterior and inferomedialparts ofthe orbit. Pus from the brain abscess grewBacteroides asaccharolyticus and small numbers ofanaerobes.

Postoperatively the patient developed focalseizures, which responded to treatment withphenytoin. Further aspiration ofthe right frontallobe abscess was performed with CT-imagedguided stereotaxy five weeks later. At the time ofmost recent follow-up the ptosis and exophthal-mos had completely resolved, with full ocularmovements, but the visual acuity in the right eyewas no perception of light and optic atrophy haddeveloped. There was no other neurologicaldeficit.

DiscussionThis case serves as a reminder that seeminglytrivial injuries of the eyelids can be associatedwith severe lesions in the orbital region andshows the need to suspect intracranial penetra-tion in orbital injuries.1-'Figure 3

rtgure 4

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Mutlukan, Fleck, Cullen, Whittle

IFigureS The rightfrontalintracerebral haematoma hasprominent surroundingoedema five days after theinjury. I

Transorbital intracranial penetration by awooden foreign body is unusual. Previous caseswith entry sites at the upper lid, inner or outercanthus, and without any ocular damage, as wellas other types of orbitocranial injuries have beenreported."'I2 We are unaware of any previousreport of wooden foreign body penetration intothe cranial cavity through the lower lid andorbital roof in the absence of perforation of theglobe. Wood is not detected on plain x rays andvery difficult to detect on CT scans, as it has adensity very similar to that of intracranial andorbital soft tissue, especially after being presentin an aqueous environment for 48 hours, when ithas had time to absorb fluid.""'5 Ultrasoundoften does not detect orbital wood if it is dry andsurrounded by air in the cavity.'6 The value ofmagnetic resonance imaging in detecting intra-orbital wood has recently been reported, andMRI scanning has been advocated when penetra-tion by a wooden foreign body and its retentionare suspected."7

All periorbital puncture wounds should alertthe physician to the possibility of intracranialpenetration. Intensive antibiotic therapy mustbe started immediately after all perforatingorbital wounds by wooden objects even in theabsence ofany systemic and neurological signs, asthe porous organic nature of the wood provides adangerous natural reservoir for micro-organisms,causing a 12-5 - 25% mortality rate secondary tointracranial infection.5" 18 Antibiotics alone maynot suffice, and there is a need for expeditious and

thorough surgical exploration if retention of awooden foreign body is suspected.

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14 Myllyla V, Pyhtinen J, Paivansalo M, et al. CT detection andlocation of intraorbital foreign bodies: experiments withwood and glass. ROFO 1987; 146: 639-43.

15 Kuhns LR, Borlaza GS, Seigel RS, et al. An in-vitro com-parison of computed tomography, xero-radiography andradiography in the detection of soft-tissue foreign bodies.Radiology 1979; 132: 218-9.

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17 Green BF, Kraft SP, Carter KD, et al. Intraorbital wooddetection by magnetic resonance imaging. Ophthalmology1990; 97:608-11.

18 Miller CF II, Brodkey JS, Colombi BJ. The danger ofintracranial wood. Surg Neurol 1977; 7: 95-103.

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