a 6-year - old boy presented with a history of penetrating injury to the upper left eyelid sustained while diving head - first into a pond . on presentation , he could only perceive hand movements very close to his face . since a computed tomography ( ct )
scan done at this time did not reveal the presence of any foreign body , the patient was treated for orbital cellulitis .
one month later , he returned reporting discharge from the eyelid wound , which had formed a fistula .
a repeat ct scan showed an abscess with an empty sinus tract but no distinguishable foreign body [ fig . 1 ] .
the patient subsequently developed septic arthritis of the left hip joint , which was treated separately .
subsequent re - evaluation of the patient 's left eye revealed a queried perception of light , relative afferent pupillary defect , optic disc pallor , and inferotemporal displacement of the globe .
a superonasal quadrant granulation mass was observed from the non - healing wound , but elevation and depression of the globe in adduction were minimally restricted .
re - evaluation of the ct scan showed a single hypodense superomedial lesion corresponding to the previously noted sinus tract .
a superomedial orbitotomy resulted in the removal of 4 wooden foreign bodies , each approximately 1.5 inches in length . by post - operative day 5
, the patient 's edema and proptosis had resolved . at 1-month follow - up ,
the eyelid wound was completely healed , and left eye visual acuity had improved to 20/120 .
axial ( a ) and coronal ( b ) ct of a 6-year - old boy with a history of penetrating injury shows an empty abscess tract without obvious foreign body .
subsequent orbitotomy recovers four wooden fragments ( d ) a 12-year - old boy presented to an outside hospital with fever , vomiting , and a prominent right eye with a painful , swollen lower lid .
he had a history of a penetrating injury sustained while diving head - first into a river 12 days previously .
after 1 week of treatment with systemic antibiotics , the patient presented to our institution with continued swelling at the injury site .
he had an indurated swelling of the lower lid with a discharging sinus , mechanical ptosis , diplopia , eccentric upward displacement of the globe , and 3-mm of proptosis .
repeat ct scan showed a hypodense body surrounded by secondary granulomatous inflammation [ fig . 2 ] .
post - operatively , the patient showed symptomatic improvement with a reduction in proptosis and a visual acuity of 20/30 in the affected eye [ fig . 3 ] .
coronal ( a ) and axial ( b ) ct scans taken one week after initial ct showed no evidence of retained foreign body .
ct now shows a hypodense body surrounded by secondary granulomatous inflammation pre - operative ( a ) and post - operative ( b ) photographs of 12-year - old boy with a history of penetrating injury by a 2 inch wooden foreign body ( c ) sustained while pond - diving
a 6-year - old boy presented with a history of penetrating injury to the upper left eyelid sustained while diving head - first into a pond . on presentation , he could only perceive hand movements very close to his face . since a computed tomography ( ct )
scan done at this time did not reveal the presence of any foreign body , the patient was treated for orbital cellulitis .
one month later , he returned reporting discharge from the eyelid wound , which had formed a fistula .
a repeat ct scan showed an abscess with an empty sinus tract but no distinguishable foreign body [ fig . 1 ] .
the patient subsequently developed septic arthritis of the left hip joint , which was treated separately .
subsequent re - evaluation of the patient 's left eye revealed a queried perception of light , relative afferent pupillary defect , optic disc pallor , and inferotemporal displacement of the globe .
a superonasal quadrant granulation mass was observed from the non - healing wound , but elevation and depression of the globe in adduction were minimally restricted .
re - evaluation of the ct scan showed a single hypodense superomedial lesion corresponding to the previously noted sinus tract .
a superomedial orbitotomy resulted in the removal of 4 wooden foreign bodies , each approximately 1.5 inches in length . by post - operative day 5
, the patient 's edema and proptosis had resolved . at 1-month follow - up ,
the eyelid wound was completely healed , and left eye visual acuity had improved to 20/120 .
axial ( a ) and coronal ( b ) ct of a 6-year - old boy with a history of penetrating injury shows an empty abscess tract without obvious foreign body .
a 12-year - old boy presented to an outside hospital with fever , vomiting , and a prominent right eye with a painful , swollen lower lid .
he had a history of a penetrating injury sustained while diving head - first into a river 12 days previously .
after 1 week of treatment with systemic antibiotics , the patient presented to our institution with continued swelling at the injury site .
he had an indurated swelling of the lower lid with a discharging sinus , mechanical ptosis , diplopia , eccentric upward displacement of the globe , and 3-mm of proptosis .
repeat ct scan showed a hypodense body surrounded by secondary granulomatous inflammation [ fig . 2 ] .
post - operatively , the patient showed symptomatic improvement with a reduction in proptosis and a visual acuity of 20/30 in the affected eye [ fig . 3 ] .
coronal ( a ) and axial ( b ) ct scans taken one week after initial ct showed no evidence of retained foreign body .
ct now shows a hypodense body surrounded by secondary granulomatous inflammation pre - operative ( a ) and post - operative ( b ) photographs of 12-year - old boy with a history of penetrating injury by a 2 inch wooden foreign body ( c ) sustained while pond - diving
the injuries sustained in the cases we present are troubling since swimming and diving in rivers , ponds , and other natural bodies of water is a common pastime of children in rural areas worldwide .
penetration injuries by wooden foreign bodies embedded in shallow riverbeds have not been previously recognized as a risk of outdoor swimming and diving . however , in our experience these types of injuries represent a true threat to vision .
this danger is compounded by the fact that retained organic foreign bodies are not often immediately apparent on imaging studies , making prompt removal difficult .
previous studies report that wood , depending on its level of hydration , can be isodense to either air or orbital fat on ct scan . in our two cases ,
ct scans taken within a few days of injury did not show a distinct foreign body , but only edema and signs of inflammation .
only after the foreign body became infected did a discharging sinus cavity form and become evident on ct scans . while nasr et al .
found magnetic resonance imaging ( mri ) to be slightly better at identifying organic foreign bodies , other studies recommend using ct scans for the initial identification of wooden foreign bodies , so the best imaging method remains controversial . as in our case , serial imaging in patients with a high - risk mechanism of injury may be a useful non - invasive method of identifying a retained wooden orbital foreign body .
unfortunately , orbital exploration does not always identify the presence of a wooden orbital foreign body . as in our two cases ,
these fragments are often not lodged in a tissue , but embedded within orbital fat .
they are thus mobile within the orbital cavity until becoming enclosed within a discharging sinus .
thus , even after a negative orbital exploration , it is important to keep a high index of suspicion for a retained wooden orbital foreign body . in summary
, ophthalmologists attending to cases of penetrating orbital injuries sustained during river and pond diving should maintain a high index of suspicion for a retained wooden orbital foreign body and realize that neither orbital exploration nor imaging may be sufficient for diagnosis .
consideration should be given to serial imaging in the event of a negative initial scan .
a thorough history as to the mechanism of injury , a meticulous exam , and frequent follow - up visits are also of utmost importance .
 diving into lakes and ponds is a common activity of rural children . 
 we present two cases of penetrating orbital injuries from plant matter sustained in this manner . 
 such injuries pose a particular challenge because wooden foreign bodies are often missed during orbital exploration , and current imaging modalities can not reliably identify retained organic material . 
 when a patient presents with orbital penetration after a high - risk mechanism of injury , such as freshwater diving , the clinician must maintain a very high index of suspicion for retained wooden foreign body . 
Case Reports
Case 1
Case 2
Discussion