A 12-year old boy presented to the emergency room for evaluation of a small wound on the right upper eyelid. Earlier that day at school as the bell rang, the patient bent down to pick up his backpack. As he returned to the standing position, another child holding a pencil ran past him and briefly collided with him, the pencil hitting the area of concern.
The patient experienced little pain and bleeding and went to the nurse’s station for evaluation. The nurse determined everything was fine and sent him home. Later, the patient presented to our ER for further evaluation.
His ocular examination was within normal limits for the most part. Ocular motility was full. Dilated fundus examination was within normal limits. He demonstrated right upper eyelid ptosis with edema involving his right lower eyelid, as well as a small laceration on the right upper eyelid as seen in Figure 1 below.
Figure 1
A CT scan was obtained for further evaluation, which showed an opaque object surrounded by a translucent area in the right superior orbit (Figure 2 below). A decision was made at that time to perform an orbital exploration looking for potential foreign bodies.
Figure 2
The wound was opened and the original track was carefully followed. Two large pieces of the pencil were removed from the right orbit (Figures 3 and 4), including the wood and the lead. After removal of the large foreign body, irrigation was performed, hemostasis was ensured and the wound was closed in a layered fashion.
Figure 3
Figure 4
This case demonstrates how very small entry wounds can be misleading and harbor relatively large foreign bodies beneath. Obtaining an accurate history and performing a thorough clinical exam is key to establishing the diagnosis.
Many times patients are sent home because of low suspicion and lack of initial clinical findings, when in fact they warrant further management because larger problems can exist beyond what may be seen on the surface. Take caution with these traumatic injuries and always be suspicious of lingering foreign bodies, especially if the patient exhibits ptosis and eyelid edema.