Microsoft Word - 24. Javeria Nasir - MM Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 305-307 305 AUTHOR COMMUNICATION Persistent Lower Lid Swelling in an Infant – Impacted Foreign Body! Javeria Nasir1, Anum Javed2, Mohammad Owais Arshad3, Mohammad Hanif Chatni4 1-4Department of ophthalmology patel Hospital, Karachi ABSTRACT Ophthalmologists, including general practitioners definitely encounter ocular foreign bodies in their clinics. The conjunctival fornices are potential sites of impaction. We report a case of a 9-month infant boy who was referred to us for a persistent lower lid swelling for one month. He had already been to an eye specialist before presenting to us. Upon examination, a round, pink coloured, toy cart-wheel came out of his lower eye lid of the right eye. Surprisingly, there was no associated conjunctival or adnexal damage. The authors wish to emphasize the importance of taking a thorough history and adequate general physical examination. A missing part of a toy, elucidated on history, should always raise the suspicion among parents and/or care givers for a probable foreign body in infants and children. Key Words: Foreign body, ocular trauma, eyelid. How to Cite this Article: Nasir J, Javed A, Arshad MO, Chatni MH. Persistent Lower Lid Swelling in an Infant – Impacted Foreign Body! Pak J Ophthalmol. 2020; 36 (3): 305-307. Doi: 10.36351/pjo.v36i3.1052 INTRODUCTION Ophthalmologists, including general practitioners definitely encounter ocular foreign bodies in their clinics. In most instances, a detailed history about the nature of injury is sufficient to elucidate the presence of a foreign body, however many times they may be missed even by the experts. The conjunctival fornices (upper and lower) are known to be notorious for harboring foreign bodies for considerably longer period of time1,2,3. They may be organic or inorganic, commonly include plant material, metallic fragments, silica/sand particles, and even lost contact lenses. Here we report a case of an infant who was referred to us in eye clinic for Correspondence to: Dr. Javeria Nasir Department of ophthalmology Patel Hospital, Karachi Email: i_m_jav@hotmail.com Received: April 21, 2020 Revised: May 4, 2020 Accepted: May 4, 2020 evaluation of lower eyelid swelling that had been there for the past one month. CASE PRESENTATION A 9 month old male infant was referred to the eye department from the peadiatric unit where he was admitted for community acquired pneumonia. His mother complained of noticing right lower eyelid swelling of one-month duration. On further history and examination, the mother informed that he got hurt in his right eye by a plastic toy while he was playing with his elder sibling around a month ago. The baby developed lower lid swelling without any redness or sticky discharge (Picture 1). Over the course of previous one month, the swelling did not reduce or increase in size. He was then taken to an eye specialist, a week after the injury, where the swelling was diagnosed as a hordoelum of the right eye and was prescribed topical antibiotic eye drops along with steroid ointment. Despite topical treatment for two weeks, the swelling did not regress. Javeria Nasir, et al 306 Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 305-307 Picture 1(a): (Right) Persistent lid swelling. Picture 1(b): (Right) After foreign body removal. Two weeks after injury, the child developed cough and runny nose along with three episodes of high fever and febrile fits. He was rushed to the emergency department, where he was admitted under the care of pediatric department and was diagnosed as community acquired pneumonia (CAP) based on clinical examination and chest x-ray findings. He was on intravenous ceftriaxone and vancomycin. Fever subsided after 48 hours of starting the treatment. Other symptoms also improved gradually with the exception of lower lid swelling which persisted despite three days of IV antibiotics. Opinion of an ophthalmologist was sought before discharge. At the eye clinic, on general physical examination he was a healthy looking, smiling, active child, slightly irritable in his mother’s lap with obvious right eye lower lid swelling. He was a febrile with no lymphadenopathy. Gross visual acuity was intact in both eyes and child was following and fixating normally. Upon palpation the swelling was non-tender and mobile with no associated skin changes. On right lower lid retraction, by the examining doctor, a bright, circular, pink coloured 1.1 cm × 1.1 cm (Picture 2), plastic foreign body popped out and fell on the floor. This foreign body was a wheel of a four-wheeled toy cart with which the baby was playing one month back. Later, the mother informed us that she had been looking for that wheel since one wheel of the toy cart had been missing from the day the boy developed the swelling. Picture 2: Measurement of the extracted foreign body. Conjunctiva showed no sign of granulation and/or inflammation. Cornea was lustrous and clear without any epithelial defects. Rest of the anterior segment examination along with fundoscopy was unremarkable. Written informed consent was obtained from the patient’s parents for purpose of reporting the case. DISCUSSION Ocular foreign bodies are a common finding in patients of all age group presenting in outpatient department with or without history of trauma. In children, however, due to the difficult examination and insufficient history of associated symptoms, conjunctival foreign particles are easily over-looked4. Reflex tearing and blinking are the inherent protective ways that usually wash out any foreign body inside the conjunctival fornices5. Initially when there is any foreign body in the fornix there is acute inflammatory response causing fibrinous exudate formation in an attempt to dislodge the foreign body, however, if there is a large surface area to the foreign body this mechanism is minimal causing granuloma formation around foreign body6,7. Granuloma tissue formation around foreign body as a means of its mechanical stabilization is another protective phenomenon observed in some case reports as well. Hence, once stable, the simultaneous damage to cornea and Persistent Lower Lid Swelling in an Infant – Impacted Foreign Body! Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 305-307 307 conjunctiva is avoided leading to prolonged tolerance and minimal irritation8. However, in our case, we did not find any evidence of granuloma formation, except for mild hyperemia. There are cases in literature in which unusual subconjunctival foreign bodies are reported. Park et al have described a foreign body which was confused with uveal prolapse9. Similarly, subconjunctival insect wings are also reported10. With this author communication, the authors wish to highlight the importance of a thorough yet proactive history and clinical examination, which are often neglected due to poor co-operation in children, and lack of awareness among parents too. In our case the foreign body had been there for one month. It was missed at three levels, i.e. by the parents, by the ophthalmologist and by the pediatrician. A missing part of a toy, elucidated on history, should always raise the suspicion among parents and/or care givers for a probable foreign body in children. The concept of a “holistic” approach towards the patient tops the list when providing medical care. Ethical Approval The study was approved by the Institutional review board/Ethical review board. Conflict of Interest Authors declared no conflict of interest. Authors’ Designation and Contribution Javeria Nasir; Registrar: Concept, data collection, manuscript writing. Anum Javed; Resident: Manuscript writing, final review. Mohammad Owais Arshad; Senior Registrar: Critical analysis, Acquisition of Data, final review. Mohammad Hanif Chatni; Head of Department: Concept, final review. REFERENCES 1. Balakrishnan E, Abraham JE, Naim-ud-Din M. Unusual foreign body in the conjunctiva. Br J Ophthalmol. 1963; 47: 250–2. 2. Sakata, C., Hiraoka, T., & Oshika, T. Unusually Large Plastic Toy as a Persisting Conjunctival Foreign Body. Japan J Ophthalmol. 2007; 51 (3): 232234. Doi: 10.1007/s10384-007-0434-5. 3. Gerding H. Unusually long foreign body of the conjunctival fornix in a child overlooked by 3 ophthalmologists. Klinische Monatsblätterfür Augenheilkunde. 2013; 230 (04): 390-1. Doi: 10.1055/s-0032-1328391. 4. Qayum S, Anjum R, Rather S. Epidemiological profile of pediatric ocular trauma in a tertiary hospital of northern India. Chinese journal of traumatology. 2018; 1; 21 (2): 100-3. 5. Giuliano EA. Diseases of the adnexa and nasolacrimal system. Equine Ophthalmology. 2016; 27: 197. 6. Weinberg JC, Eagle Jr RC, Font RL, Streeten BW, Hidayat A, Morris DA. Conjunctival Synthetic Fiver Granuloma: A Lesion that Resembles Conjunctivitis Nodosa. Ophthalmology. 1984; 91 (7): 867-72. 7. Sowmya V, Nazareth NE, Kamath VB. Foreign-body conjunctival granuloma secondary to finger-nail trauma. Asian J Ophthalmol. 2015; 14; 14 (2): 73-6. 8. Alabi EB, Simpson TL. Conjunctival Redness Response to Corneal Stimulation. Optometry and Vision Science. 2019 Jul 1; 96 (7): 507-12. Doi: 10.1097/OPX.0000000000001398. 9. Park YM, Jeon HS, Yu HS, Lee JS. A subconjunctival foreign body confused with uveal prolapse. Indian J Ophthalmol. 2014 Jun; 62 (6): 730– 731. 10. Fogla R, Rao SK, Anand AR, Madhavan HN. Insect wing case: Unusual foreign body. Cornea. 2001; 20: 119–21. .…….