An unusual case of globe-sparing penetrating orbital injury by a nail.

We describe a case of a 28-month-old boy who presented to our emergency department with a right orbital penetration by an iron nail. At presentation, no pain or functional loss were noted. Plain head radiographs and computed tomography were performed and demonstrated a two centimeters long nail penetrating the right orbit. The foreign body was extracted carefully in the operating room. No complications were observed upon follow-up. Rarely, orbital penetration by an iron-nail can present without functional disturbances or pain and is not necessarily accompanied by sequelae.

Introduction

A 28-month-old boy presented to our emergency department after his caregivers had noticed an iron nail head protruding from the nasal part of his right eye [Figure 1a]. The caregivers denied possessing a nail-gun and could not explain this unusual phenomenon. At admission, the patient was calm, and his behavior did not indicate any ocular or systemic injury. A thorough ophthalmic examination was normal, including eye movement, without any signs of a ruptured globe. Plain head radiographs followed by orbital computed tomography revealed a two centimeters long nail almost fully embedded in the inferior nasal aspect of the right orbit, between the medial wall of the orbit and the globe. No fractures were detected [Figure 1b–d]. The patient was taken to the operating room. Under general anesthesia, forced duction test was negative and lacrimal drainage irrigation revealed intact fluid passage. Following these procedures, we gently extracted the nail without any complications. We cleaned the wound with iodine and applied gentamicin into the wound with a 23 gauge cannula mounted on a syringe. We closed the laceration with a single 5-0 vicryl suture and administered a tetanus vaccine. After uneventful observation in our department overnight, we discharged the patient with systemic antibiotics for seven days. At one week follow-up, the ophthalmic examination was unremarkable.

Figure 1

(a) External photograph of the injured eye at presentation, (b) sagittal computed tomography image showing the location and depth of the nail's penetration in the right orbit, (c) coronal, and (d) sagittal head radiograph depicting the location of the nail

Discussion

Ocular nail trauma is a fairly common cause of penetrating ocular injuries.[12] The majority of such injuries are attributed to automatic nail guns and are associated with sharp pain and decrease in visual acuity. Other penetrating ocular nail trauma is otherwise rare. To the best of our knowledge, this is the first description of a nail-related orbital penetration that presented without pain or functional disturbance. As described above, promptly and methodically addressed, this impressive clinical picture is not necessarily accompanied by sequelae.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.