Description

A 14-year-old man presented to the emergency services following trauma to his left eye (LE) sustained during a battery explosion. The patient was conscious, and oriented in time, space and person, and higher mental functions were preserved. The patient had visual acuity of light perception in his left eye. Head of a metallic screw could be seen on ocular examination and the screw appeared to penetrate the left superior orbit through the upper eyelid (figure 1A). Details of the eyeball could not be visualised, though the cornea appeared opacified. Intraocular pressure could not be assessed on digital palpation due to severe lid oedema. The fellow eye was within normal limits. Ultrasound was avoided in view of suspected open globe injury. An urgent CT scan was advised which revealed the extension of the foreign body (FB) into the basi-frontal lobe of the left cerebral hemisphere (figure 1B). Open-globe injury was presumed and an urgent surgery was planned along with a neurosurgeon for extraction of the FB with globe and eyelid repair.

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Figure 1

(A) Clinical photograph of the left eye showing the presence of head of a metallic screw in the superior-medial orbit. (B) Sagittal section CT image of the head depicting the extension of the metallic screw towards the basi-frontal lobe of the left cerebral hemisphere. (C) Image shows the successfully removed metallic screw during surgery (D) postoperative clinical photograph of the left eye showing repaired lid laceration, necrotic conjunctiva and dense corneal oedema.

During surgery, left frontal craniotomy was done and the cranial tissue was retracted by the neurosurgeon. The screw was then isolated from the surrounding structures and was pulled out from the penetration site in the superior orbit (figure 1C). During its extraction, the FB had to be gripped with forceps and slowly ‘unscrewed’ as it was tightly stuck in the orbital roof. The breach in the orbital roof and the dura mater was repaired by the neurosurgeon. Surprisingly, the globe was found to be intact, though corneal oedema precluded detailed examination of the anterior segment. The conjunctiva appeared to be necrotic possibly due to acidic chemical injury. The upper lid entry wound was sutured in multiple layers. Ultrasound done the following day revealed no abnormality in the posterior segment of the LE. The corneal oedema was persistent though digital ocular pressure seemed normal (figure 1D). The patient was counselled for need of future ocular surface reconstruction followed by keratoplasty, and was immediately referred to corneal surgeon for urgent management of chemical injury. Confidentiality was maintained and only the surgical team had access to patient’s details. All unauthorised access to information was prohibited throughout the treatment period.

Penetrating injuries of skull and brain are life threatening and they constitute about 0.4% of head injuries.1 In cases of transorbital intracranial injuries, the orbital roof is the most frequent penetration site owing to its thin wall.2 Vertically directed objects may pierce the roof of the orbit and cause frontal lobe damage. A high frequency of vertically oriented injuries has been postulated to be a resultant of an instinctive human tendency to extend the neck backwards as a defensive motion at the moment of trauma. Battery explosion-related ocular injury is from multiple mechanisms. Each mechanism, whether thermal due to heat or mechanical due to solid fragments or chemical due to acid, has the potential to cause irreversible ocular damage and often staged interventions are necessary for optimal results.3