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Extraction of an intraorbital foreign body with the help of an ocular external electromagnet: Instruments of the past still have a place in the present
Extracción de cuerpo extraño orbitario con ayuda de electroimán ocular externo: instrumentos del pasado tienen cabida en el presente
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A) Presurgery image of the orbital implant of patient 1, with abundant secretion and positive culture for <span class="elsevierStyleItalic">S. pneumoniae</span>. B) Patient<span class="elsevierStyleHsp" style=""></span>2, with smaller exposure and negative culture. C) Patient 3, with conjunctival granuloma in exposure area and negative culture. D, E, F) Post-surgery image of the cavities of patients 1, 2 and 3, respectively.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Toribio, M.A. Ferrero, L. Rodríguez-Aparicio, H. Martínez-Blanco" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Toribio" ] 1 => array:2 [ "nombre" => "M.A." "apellidos" => "Ferrero" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Rodríguez-Aparicio" ] 3 => array:2 [ "nombre" => "H." 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Rocha de Lossada, F. Zamorano Martín, M. Rodríguez Calvo de Mora, M. Jódar Márquez, C. Hernando Ayala, L.W. Lu" "autores" => array:6 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Rocha de Lossada" "email" => array:1 [ 0 => "carlosrochadelossada5@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Zamorano Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Rodríguez Calvo de Mora" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Jódar Márquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "C." "apellidos" => "Hernando Ayala" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "L.W." "apellidos" => "Lu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Arizona State University, Arizona, United States" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Extracción de cuerpo extraño orbitario con ayuda de electroimán ocular externo: instrumentos del pasado tienen cabida en el presente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 732 "Ancho" => 1740 "Tamanyo" => 114555 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">a) Sagittal computerized tomography showing the intra-orbit location of the foreign body between the ocular globe and the upper rectus and upper oblique muscles, without compromising intraocular structures; b) coronal 3D reconstruction with foreign body image in the upper medial angle of the right orbit.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Intraorbital foreign bodies (IOFB) are objects located in the orbit, outside of the ocular globe, which can produce severe structural and functional damages to the eyes and to orbit content. In up to 90% of cases, IOFB are well tolerated.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Management and prognosis depends on IOFB composition and location as well as the possible presence of secondary infections. IOFB can be classified as metallic, non-metallic organic (for instance, wood) and nonmetallic inorganic (for instance, plastic). Metallic IOFB has been found in the majority of cases, with a frequency between 55 and 91%.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Location in the orbit could be the anterior or posterior orbital compartment and intraconal or extraconal.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The case is presented of a patient with a metallic IOFB after suffering traumatism while cutting with a radial saw, which was extracted with the help of a currently uncommon device, a Livingston-Mansfield ocular external electromagnet (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) due to its anterior location, to the fact of being metallic and with the objective of avoiding subsequent belated complications.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinic case</span><p id="par0015" class="elsevierStylePara elsevierViewall">Male, 28, without remarkable personal antecedents, who visited the Emergency Department after suffering right orbit traumatism while working with a radial saw without wearing protective goggles. The patient referred that the fragment was metallic but could not specify its nature.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Examination showed upper right palpebral edema with hemorrhagic chemosis. Palpebral eversion showed an orifice, presumably the entry orifice measuring approximately 2 mm long, 2 mm wide located in the upper palpebral conjunctiva at the medial level (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a). However, said examination did not show any foreign body. Visual acuity was 20/20, in both eyes, anterior, posterior segment of the right eye within normality as well as, ocular movements, pupil reaction. Suspecting IOFB, an orbital computerized tomography without contrast was requested, (CT), which showed the presence of a single IOFB measuring 5 mm long, 4 mm wide at the level of the upper-inner orbital angle in the anterior orbit compartment, adjacent to the upper rectus (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>a and b) which did not compromise intraocular contents or produced ocular globe deformity. After consulting the case with maxillofacial surgery due to the anterior location of the IOFB, b), possible subsequent complications due to the indefinite nature of the material, to the lack of availability of endoscopic devices, the absence of an orbit ophthalmology specialty in the Dept. of the authors, it was decided to attempt the extraction of IOFB by means of external pathway surgery jointly with the maxillofacial specialist.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Initially, it was attempted to locate the IOFB through the palpebral skin without success. The localization through palpebral conjunctival dissection through the entry orifice or by means of the dissection of the bulbar conjunctiva and upper tenon capsule were similarly unsuccessful. In these circumstances, a Livingston-Mansfield outer ocular electromagnet was utilized, introducing it through the upper conjunctival dissection, displacing the IOFB to an upper subconjunctival level at approximately 6 mm from the upper limbus (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b). Lastly, the palpebral and conjunctival incisions were sutured, prescribing topical and systemic antibiotic treatment and topical corticoids.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">IOFB are generally well tolerated and do not require extraction, particularly if located posteriorly in the orbit or do not give rise to visual or orbital complications. However, certain circumstances such as the type or shape of material could cause severe complications.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among IOFBs, the metallic type accounts for the majority of cases. The test of choice to identify their location is orbit CT without contrast, with orbit magnetic resonance being contraindicated with the slightest suspicion of metallic IOFB. The limitations of this technique include foreign bodies of ceramic, plastic and wood that could remain unnoticed, in which cases orbit magnetic resonance could be useful.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In what concerns structural as well as functional complications that could be caused by IOFBs, the literature describes abscesses, cellulite, diplopia, ocular globe protrusion, ocular movement restriction, ptosis, afferent relative pupil defect and loss of vision.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4–7</span></a> Depending on the composition of the foreign object, specific complications have also been described, the main being orbit and/or intraocular infection caused by organic IOFB, <span class="elsevierStyleItalic">siderosis bulbi</span> caused by iron objects lodged within the eye and could express with iris heterocromia, early development of cataracts, secondary glaucoma and retinal degeneration, as well as chalcosis caused by copper objects within the eye, the main signs of which include the Kayser-Fleischer ring, visualization of the small copper particles in the anterior chamber or iris, typically sunflower-shaped cataract and retinal degeneration.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4–7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The best time for removing IOFB depends on several factors including the condition of the patient’s health, the nature of the object (metallic objects penetrating the eye at high speed are generally sterile and exhibit lower infection risk) or the form of the object (for example an IOFB with sharp edges could damage the ocular globe). It is recommended to extract IOFBs as early as possible and repairing the ocular globe to diminish the risk of endophthalmitis when intraocular contents are compromised.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a> However, if the ophthalmologist and the surgery staff who will take part in the surgery to not have sufficient experience or adequate surgical materials are not available, it could be convenient to postpone surgery and administer topical and systemic antibiotic therapy.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The most frequently used instruments for extracting IOFB are the external ocular electromagnet, tweezers and intraocular electromagnet. Tweezers are used preferably for non-metallic foreign bodies and electromagnets for metallic bodies. Due to the force of attraction of the external ocular electromagnets, the use of this device is not recommended for removing intraocular foreign bodies due to the possibility of producing vitreous hemorrhage and other iatrogenic damages. Said device is typically used for surgeries with orbital approach externally to the ocular globe.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8–10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is important to prescribe antibiotic therapy to ensure adequate coverage of the pathogens that are typically involved in infections or secondary to IOFB such as <span class="elsevierStyleItalic">Bacillus cereus, Clostridium</span> and coagulase-negative staphylococci.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0055" class="elsevierStylePara elsevierViewall">IOFBs are an infrequent emergency in the authors’ environment and this fact, added to the lack of adequate material and an orbital ophthalmology subspecialty in the authors’ Dept. led to the use of an instrument which is rarely utilized these days. We believe that, despite the technological development and scientific progress, some instruments that could be considered to be outdated could still have a place in our environment in certain emergencies as well as due to the lack of said new technology which is not always available at all hospitals.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In addition, even though IOFBs are well tolerated and generally do not require extraction, in cases characterized by being anteriorly located and with demonstrated location externally to the ocular globe the use of on external electromagnet is useful and supported by scientific literature.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">No conflict of interests has been declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1275451" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1179873" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1275452" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1179872" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case" ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-11" "fechaAceptado" => "2019-09-09" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1179873" "palabras" => array:4 [ 0 => "Intraorbital foreign body" 1 => "Ocular external electromagnet" 2 => "Emergency room" 3 => "Surgery" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Intraorbital Foreign Bodies (IOFB) are objects, usually of metallic nature, located outside the orbit cavity, and can potentially cause serious damage to ocular and orbital structures. The case is presented of a patient with an anterior metallic IOFB that was extracted with the aid of a Livingstone-Mansfield ocular external electromagnet. Despite being an instrument “of the past”, we believe that the electromagnet can still be useful in certain circumstances.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los cuerpos extraños intraorbitarios (CEIO) son objetos que se sitúan en la órbita, normalmente metálicos, que pueden llegar a provocar serios daños estructurales y funcionales en el ojo y en el contenido orbitario. Presentamos el caso de un paciente con un CEIO metálico de localización anterior que se extrajo con la ayuda de un electroimán ocular externo tipo Livingstone-Mansfield. A pesar de tratarse de un instrumento que podría considerarse “del pasado”, sigue teniendo cabida en nuestro medio en determinadas circunstancias.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rocha de Lossada C, Zamorano Martín F, Rodríguez Calvo de Mora M, Jódar Márquez M, Hernando Ayala C, Lu LW. Extracción de cuerpo extraño orbitario con ayuda de electroimán ocular externo: instrumentos del pasado tienen cabida en el presente. Arch Soc Esp Oftalmol. 2019;94:605–608.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1139 "Ancho" => 855 "Tamanyo" => 191989 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intra-surgery image of the Livingston-Mansfield external ocular electromagnet.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 923 "Ancho" => 1740 "Tamanyo" => 217557 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">a) Right eye image showing the presumed orifice of entry of the IOFB into the upper palpebral conjunctival at the medial level; b) right eye image showing the foreign body displaced up to the upper subconjunctival level at approximately 6 mm from the upper limbus.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 732 "Ancho" => 1740 "Tamanyo" => 114555 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">a) Sagittal computerized tomography showing the intra-orbit location of the foreign body between the ocular globe and the upper rectus and upper oblique muscles, without compromising intraocular structures; b) coronal 3D reconstruction with foreign body image in the upper medial angle of the right orbit.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Retained intraorbital foreign bodies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V.H. 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