Transorbital Penetrating Brain Injury with a Large Foreign Body

A 30-year-old man presented with forward protrusion of the left globe one hour after falling in a ditch of wooden sticks. Except for a minor headache, no other neurological abnormality was reported. The patient was well oriented in time, place and person without any neurological deficit. Glasgow coma scale (GCS) score was 15 and all vital signs were within normal limits. Ophthalmic examination revealed visual acuity of no light perception in the left eye while the left globe was proptotic and displaced temporally. Movements of the left eye were restricted in all directions and eyelid closure was inadequate. A 1.5 cm laceration was present in the medial part of the left upper eyelid, yet no foreign body was detected. Upon presentation, the left ocular surface was covered with blood clots which disclosed conjunctival congestion and chemosis after cleaning. The left pupil and fundus were not visible because of hyphema and consensual light reflex was absent in the right eye (Fig. 1). Ocular examination was normal in the fellow eye. A diagnosis of post-traumatic retrobulbar hemorrhage was made based on the clinical presentation, and orbital and cranial CT scans were requested accordingly. CT scan demonstrated an elongated, well-defined and extremely low-attenuation area within a thin rim of high density in the medial aspect of the left orbit, passing through the superior orbital fissure into the ipsilateral temporal lobe lateral to the sellar region and almost juxtaposing the brainstem posteriorly. The above-mentioned features were suggestive of an orbitocranial foreign body which appeared to be a bamboo stick measuring 11x0.8 cm. A bone fragment was noted at the superior orbital fissure which was consistent with fracture of the greater sphenoid wing. Moreover, intracerebral hemorrhage was present in the left temporal lobe (Fig. 2). With a diagnosis of orbitocranial penetrating injury through the superior orbital fissure the patient was further observed and followed by neurosurgeons.