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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 220-222

Spontaneous migration of periocular glass foreign body: An interesting case


Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Padma B Prabhu
19/2313, “Swathi”, Chempaka Housing Colony, Pottammal, Kozhikode - 673 016, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_106_17

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  Abstract 


The occurrence of soft-tissue foreign bodies (FBs) in and around the orbit is often seen after trauma. Wound exploration and removal of the embedded materials is the standard of care. Relevant investigations help to detect retained FBs in suspected cases. However, hidden FB and their migration, both early and late, has been reported often and associated with morbidity and mortality. Here, we report a case of spontaneous migration of sharp-edged glass splinter retained in the periocular area in a young female who had sustained trauma in the past. Evaluation of the splinter under high-power magnification will help to identify the morphology and source of injury in such cases.

Keywords: Glass foreign body, migration, periocular, spontaneous


How to cite this article:
Prabhu PB, Vellarikkal D, Valiayaveettil B. Spontaneous migration of periocular glass foreign body: An interesting case. Kerala J Ophthalmol 2017;29:220-2

How to cite this URL:
Prabhu PB, Vellarikkal D, Valiayaveettil B. Spontaneous migration of periocular glass foreign body: An interesting case. Kerala J Ophthalmol [serial online] 2017 [cited 2018 Sep 19];29:220-2. Available from: http://www.kjophthal.com/text.asp?2017/29/3/220/224285




  Introduction Top


The reaction of the body to alien materials such as retained foreign bodies (FBs) varies based on their chemical nature and associated contamination. Nonorganic materials can be inert or toxic. Toxic substances elicit a local irritative response, suppuration, or specific degenerative effects. Local irritation leads to fibrous tissue proliferation and encapsulation of the foreign body. Inert particles include glass, plastics, porcelain, and metals such as gold, platinum, silver, and titanium. Organic materials tend to produce proliferative reaction characterized by formation of granulation tissue. They can also cause infections, especially of fungal etiology.


  Case Report Top


A 40-year-old female presented with pain over the forehead and foreign body sensation in the left upper eyelid. She gave a history of road traffic accident (RTA) 2 months back. She had injured herself following a head-on collision of the vehicle she traveled, with another automotive. She sustained linear lacerated wound on her forehead and left upper lid. There were minute abrasions all over the forehead and root of nose. The external wound was explored, multiple glass particles were removed, and wound sutured in layers. She was asymptomatic for the next 2 months. Subsequently, she started developing pricking pain at certain points in her forehead and upper lip, both away from the primary wound, especially on rubbing her face. On examination, there was a healed scar over the left side of the forehead and left upper lid. Multiple vesicles were seen near the scar. Anterior segment was normal both eyes; best-corrected visual acuity was 6/6 BE and fundus within normal limits (WNL). Sharp FBs were palpable in the subcutaneous plane at multiple sites where vesicles were located. X-ray Paranasal sinuses (PNS) with orbit did not reveal any abnormalities. Ultrasonography (USG) B-scan was WNL. Under local anesthesia, these areas were explored and four pieces of glass FBs' size ranging from 0.5 to 3 mm [Figure 1] were removed. The glass pieces were examined under high magnification, and the sharp edges were noted [Figure 2]. The patient became asymptomatic after the removal of the FBs. However, the possibility of retained FBs with subsequent migration in future was explained and reassured.
Figure 1: Glass foreign body 3 mm × 1 mm retrieved from the wound

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Figure 2: High-power magnified view of the retrieved glass foreign body

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  Discussion Top


Glass is an inert nonorganic substance. It does not elicit any inflammatory reaction. Encapsulation or fibrous capsule formation around glass has not been reported. Many often, they are asymptomatic and remain undetected for months or years. Tissue restitution, effect of gravity, and rotation or movement of the retained particle due to its intrinsic property or sharpness are suggested as the possible mechanism behind migration. Several cases of migration have been reported in literature. Migration can vary from months to years.[1],[2] The rate and pattern of movement are not predictable. Late migration is associated with high morbidity and mortality especially if internal organs are affected. Ozsarac et al. report the removal of paraspinal glass splinter following late migration from the initial site of injury.[1] The patient had intractable neuralgic pain due to nerve damage. Han et al. describe a case of progressive median neuropathy caused by the proximal migration of a retained glass splinter.[3] Yang et al. report late flexor pollicis longus rupture after traumatic implantation of a glass fragment. The foreign body had migrated distally a distance of 4.5 cm from the site of the original injury over a period of 30 years.[4] Lincoln comments in his series of cases with retained FBs that linear sharp objects tend to move even if inert. This was also observed in our case.

Detection and localization of suspected foreign body is a challenge. The various modalities of choice are plain X-ray, USG, and computed tomography (CT) scan. The detection depends on the size, composition, site of lodgment, and dimensions. Glass of all types is opaque on radiographs.[5] Anderson et al. observed that 96% of retained glass FBs were detected by plain X-rays. Customizing the soft-tissue algorithms, especially in the new digital radiography, has improved the detection rate of even smaller and low radiopacity materials.[6] Conventional X-rays help to pick up the location and proximity of such materials near vital organs and are used as a screening modality.[7],[8] Metallic artifacts can affect the quality of images in CT.[8] Dass et al. consider 3-mm cuts as sensitive as 1-mm cuts (spiral CT) for detecting small glass intraocular foreign bodies.In vitro studies in porcine eyes showed a sensitivity of 100% with 0.5-mm glass FBs.[9] The use of magnetic resonance imaging as the initial investigation of choice in cases with suspected foreign particle of unknown consistency is limited. B-scan can easily detect FBs in the superficial plane but is not useful in deep-seated cases or located in the air-filled cavity, for example, sinuses. USG provides real-time imaging, is less expensive, and has no radiation risk. It is easily available and can be done at bedside. However, B-scan cannot detect glass particles embedded in the muscle.[10]

Examination of the isolated particle under high magnification can help in detecting the texture and type of the glass. This has medicolegal implication in a case of RTA. Modern windshield is generally made up of laminated safety glass. A plastic layer commonly polyvinyl butyral or ethylene vinyl acetate is placed between two or more layers of glass. This layer keeps the glass layers bonded together. It provides high strength and prevents shattering even on high impact.[11] However, automotive mirrors, vanity mirror, window glasses, or spectacles are not made of laminated glass, hence splinter and add on to the damage due to the sharp edges. Such FBs are likely to migrate as well. Hence, identifying the potential sources of glass in any injury will help to tailor the investigation of choice. Examining the glass particles removed during primary repair may help to predict the chance of migration in such cases. The injured person can be sensitized to such a possibility in the future which can prevent litigations.


  Conclusion Top


Spontaneous migration of hidden periocular FBs can result in surprises for the patient and treating ophthalmologist. High index of suspicion, use of appropriate investigative modalities, and detailed evaluation of the removed specimens in any case of open injuries can help to sensitize the injured person about such possibilities. Examination of the glass splinters under high-power magnification may have medicolegal implications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ozsarac M, Demircan A, Sener S. Glass foreign body in soft tissue: Possibility of high morbidity due to delayed migration. J Emerg Med 2011;41:e125-8.  Back to cited text no. 1
    
2.
Vargas B, Wildhaber B, La Scala G. Late migration of a foreign body in the foot 5 years after initial trauma. Pediatr Emerg Care 2011;27:535-6.  Back to cited text no. 2
    
3.
Han KJ, Lee YS, Kim JH. Progressive median neuropathy caused by the proximal migration of a retained foreign body (a glass splinter). J Hand Surg Eur Vol 2011;36:608-9.  Back to cited text no. 3
    
4.
Yang SS, Bear BJ, Weiland AJ. Rupture of the flexor pollicis longus tendon after 30 years due to migration of a retained foreign body. J Hand Surg Br 1995;20:803-5.  Back to cited text no. 4
    
5.
Anderson MA, Newmeyer WL 3rd, Kilgore ES Jr. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg 1982;144:63-7.  Back to cited text no. 5
    
6.
Javadrashid R, Golamian M, Shahrzad M, Hajalioghli P, Shahmorady Z, Fouladi DF, et al. Visibility of different intraorbital foreign bodies using plain radiography, computed tomography, magnetic resonance imaging, and cone-beam computed tomography: An in vitro study. Can Assoc Radiol J 2017;68:194-201.  Back to cited text no. 6
    
7.
Horton LK, Jacobson JA, Powell A, Fessell DP, Hayes CW. Sonography and radiography of soft-tissue foreign bodies. AJR Am J Roentgenol 2001;176:1155-9.  Back to cited text no. 7
    
8.
Lakits A, Steiner E, Scholda C, Kontrus M. Evaluation of intraocular foreign bodies by spiral computed tomography and multiplanar reconstruction. Ophthalmology 1998;105:307-12.  Back to cited text no. 8
    
9.
Dass AB, Ferrone PJ, Chu YR, Esposito M, Gray L. Sensitivity of spiral computed tomography scanning for detecting intraocular foreign bodies. Ophthalmology 2001;108:2326-8.  Back to cited text no. 9
    
10.
Yolcu S. Ultrasonography for foreign bodies in the soft tissue. Am J Emerg Med 2015;33:977-8.  Back to cited text no. 10
    
11.
Peng Y, Yang J, Deck C, Willinger R. Finite element modeling of crash test behavior for windshield laminated glass. Int J Impact Eng 2013;57:27-35.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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