Ophthal Plast Reconstr Surg, Vol. 32, No. 4, 2016
REFERENCES 1. Collins MD, Lawson PA. The genus Abiotrophia (Kawamura et al.) is not monophyletic: proposal of Granulicatella gen. nov., Granulicatella adiacens comb. nov., Granulicatella elegans comb. nov. and Granulicatella balaenopterae comb. nov. Int J Syst Evol Microbiol 2000;50(pt 1):365–9. 2. Cargill JS, Scott KS, Gascoyne-Binzi D, et al. Granulicatella infection: diagnosis and management. J Med Microbiol 2012;61(pt 6):755–61. 3. Teo L, Looi A, Seah LL. An unusual causative agent for an orbital abscess: Granulicatella adiacens. Orbit 2011;30:162–4. 4. Christensen JJ, Facklam RR. Granulicatella and Abiotrophia species from human clinical specimens. J Clin Microbiol 2001;39:3520–3. 5. Okada Y, Kitada K, Takagaki M, et al. Endocardiac infectivity and binding to extracellular matrix proteins of oral Abiotrophia species. FEMS Immunol Med Microbiol 2000;27:257–61. 6. Ohara-Nemoto Y, Kishi K, Satho M, et al. Infective endocarditis caused by Granulicatella elegans originating in the oral cavity. J Clin Microbiol 2005;43:1405–7. 7. del Pozo JL, Garcia-Quetglas E, Hernaez S, et al. Granulicatella adiacens breast implant-associated infection. Diagn Microbiol Infect Dis 2008;61:58–60.
Localization and Retrieval of an Eyelid Metallic Foreign Body With an Oscillating Magnet and High-Resolution Ultrasonography Sylvia H. Yoo, M.D., Dan B. Rootman, M.D., Alice Goh, M.B.B.S., Aaron Savar, M.D., and Robert A. Goldberg, M.D. Abstract: A patient was found to have a metallic foreign body in the left anterior orbit on CT imaging, but the foreign body was not evident on clinical examination. On high-resolution ultrasonography, an object was identified in the left upper eyelid; however, the typical shadow with metallic foreign bodies was not seen. A high-power oscillating magnet was then applied to the eyelid, which revealed a subcutaneous metallic foreign body in the left upper eyelid. When used in conjunction, the high-resolution ultrasound and oscillating magnet successfully localized and facilitated retrieval of the metallic foreign body from the left upper eyelid.
Case Reports
time of injury. However, he continued to complain of periodic sharp pain in the medial left orbit. During a subsequent evaluation of long-term back pain, a CT scan was performed to investigate residual metallic objects used in preparation of MRI examination. The CT revealed a metallic foreign body in the superficial soft tissues of the medial left orbit (Fig. A). It was localized to the canalicular system, conjunctiva or eyelid. Despite careful examination by multiple ophthalmologists and oculoplastic surgeons, including lacrimal probing, the foreign body was not visualized or palpated. Further studies with A-scan ultrasound were unable to identify the foreign body, and B-scan ultrasonography by a retina specialist confirmed that the object was not localized to the sclera or intraocular space. The remainder of his ophthalmologic examination was normal, with the exception of a corneal scar in the OD from prior metallic foreign body removal. To investigate the periocular soft tissues further, static and dynamic high-resolution ultrasound (Logiq P6, GE Healthcare, Waukesha, WA, U.S.A.) was performed with a 15-MHz probe. A hyperechoic mass in the medial aspect of the left upper eyelid was identified (Fig. B). The mass moved dynamically with eyelid excursion (see Video 1, Supplemental Digital Content 1, available at: http://links.lww.com/IOP/ A97). An oscillating electromagnet (Scientronics Series 10K Eye Magnet; IMC Magnetics Corp, Jericho, NY) was then brought into the field of ultrasound imaging (Fig. C). The periodic application of an electromagnetic field caused the metallic body to oscillate in a regular pattern, confirming its identity (see Video 2, Supplemental Digital Content 2, available at: http://links.lww.com/IOP/A98). The position of the pulsating skin below the magnet was then marked (see Video 3, Supplemental Digital Content 3, available at: http:// links.lww.com/IOP/A99) and, after application of 2% lidocaine with 1:100,000 epinephrine, the skin was opened. By repeatedly applying the magnetic field, followed by sharp and blunt dissection, the metallic foreign body was identified and excised. (Fig. D; see Video 4, Supplemental Digital Content 4, http://links.lww.com/IOP/A100). The foreign body measured approximately 3 mm × 4 mm. The pathology report confirmed a firm black object, consistent with foreign body, with soft tissue showing foreign body reaction and brown pigment suggestive of hemosiderin. The patient reported improved pain symptoms and no complications since the procedure. The patient was subsequently able to undergo MRI that revealed pathology in his lumbosacral spine.
CASE REPORT This report conformed to the requirements of the United States Health Insurance Portability and Accountability Act. A 50-year-old man presented with periodic pain in the medial aspect of the left upper eyelid following trauma to OU in a work-related explosion 7 years before. The event had resulted in the embedding of multiple periocular metallic foreign bodies. The majority of these materials were removed manually at the
Jules Stein Eye Institute, UCLA, Los Angeles, California, U.S.A. Accepted for publication June 11, 2014. Presented at the European Society of Oculoplastic and Reconstructive Surgery on September 19–21, 2013 in Barcelona, Spain. The authors have no financial or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.op-rs.com.). Address correspondence and reprint requests to Sylvia H. Yoo, M.D., 100 Stein Plaza, Los Angeles, CA 90095. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000257
DISCUSSION CT imaging of the orbit in this case demonstrated a superficial left periocular metallic foreign body many years after an explosive work-related trauma. Although it was clearly identifiable on imaging, multiple examinations of the eyelid, orbit, and globe were unable to localize the object. Such cases can be surgically frustrating, as wide dissection and surgical exploration can increase collateral tissue damage and lead to unwanted structural and/or functional consequences. For this reason, small metallic orbital foreign bodies are often not removed unless there is a compelling reason to do so, such as infection or functional deficit. In a chart review by Ho et al.,1 retained intraorbital metallic foreign bodies were overall found to be well tolerated, leading the authors to recommend conservative management. They did, however, discuss indications for removal including problematic location or particular metallic composition. Copper foreign bodies may produce a significant inflammatory response, requiring removal, while copper alloys may be better
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e83
Ophthal Plast Reconstr Surg, Vol. 32, No. 4, 2016
Case Reports
A, Axial CT image demonstrating a metallic foreign body (arrow) in the left anterior orbit. B, Hyperechoic foreign body (arrow) detected on sagittal high-resolution ultrasonography in the medial left upper eyelid. C, Colocalization with high-power oscillating magnet and high-resolution ultrasound imaging. D, Foreign body shown after retrieval from the left upper eyelid.
tolerated.1,2 In addition, lead shot or pellets may lead to systemic toxicity, although this is less likely with modern manufacturing. Iron foreign bodies near the scleral wall have also been shown to cause siderosis in rabbit models; thus, iron found in contact with the globe may be an indication for removal as well. Conservative management was effective for many years in the authors’ case; however, his persistent intermittent pain and need for MRI evaluation of back pain provided eventual indications for removal of the foreign body. Image guidance using radiographs, fluoroscopy, sonography, and other advanced techniques have proven to be useful for many clinical applications, especially when the precision of an instrument or anatomic landmark is necessary.3,4 The use of high-resolution ultrasound imaging to localize structures and foreign substances in the periocular soft tissues has long been established.5 This technology offers the advantage of being able to dynamically assess tissues in vivo with excellent spatial resolution. It has been extensively utilized to guide percutaneous therapy of subcutaneous pathologies such as cysts, abscesses, and blood vessels, among others. Ultrasound is, however, a 2-dimensional technology and is significantly operator dependent. There can be ambiguity as to the identity and localization of subcutaneous structures, especially if typical cues are absent. In the case of metallic foreign bodies, one would expect to see shadowing and/or ring artifact.6,7 In the current case, these signs were not clearly evident, possibly due to encasement in fibrous scar, thus making it difficult to firmly determine the identity of the material. Augmenting the ultrasound imaging with the use of highpower, oscillating magnetic field can significantly assist in discriminating metallic objects from surrounding normal tissues.
e84
The in-step oscillation of the object with the alternating magnetic field viewed on ultrasound offers confirmatory evidence of its ferromagnetic identity. Essentially, the 2 technologies interact dynamically to definitively localize the object for surgical planning. Intraoperative application of the magnet can be of further assistance. As more superficial tissues are dissected, the magnet can be used in a serial fashion to direct dissection and thus minimize the area of surgical exploration. Ideally, nonmagnetic instruments could be utilized in these circumstances to allow for simultaneous dissection within the magnetic field.
REFERENCES 1. Ho VH, Wilson MW, Fleming JC, et al. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20:232–6. 2. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494–500. 3. Shiels WE 2nd, Babcock DS, Wilson JL, et al. Localization and guided removal of soft-tissue foreign bodies with sonography. AJR Am J Roentgenol 1990;155:1277–81. 4. Wang X, Lin Y, Yu H, et al. Image-guided navigation in optimizing surgical management of craniomaxillofacial fibrous dysplasia. J Craniofac Surg 2011;22:1552–6. 5. Close JK, Shiels WE 2nd, Foster JA, et al. Percutaneous ultrasoundguided intraorbital foreign body removal. Ophthal Plast Reconstr Surg 2009;25:335–7. 6. Guthoff, RL, Labriola LT, Stachs O. Diagnostic ophthalmic ultrasound. In: Ryan SJ, ed. Retina, 5th ed. Vol. 1. Saint Louis, MO: Elsevier Saunders, 2013:227–84. 7. Prakash G, Venkatesh P, Garg S. Unusual cause for non-detection of retained metallic foreign body on ocular ultrasonography. Clin Experiment Ophthalmol 2005;33:333–4.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
REFERENCES 1. Collins MD, Lawson PA. The genus Abiotrophia (Kawamura et al.) is not monophyletic: proposal of Granulicatella gen. nov., Granulicatella adiacens comb. nov., Granulicatella elegans comb. nov. and Granulicatella balaenopterae comb. nov. Int J Syst Evol Microbiol 2000;50(pt 1):365–9. 2. Cargill JS, Scott KS, Gascoyne-Binzi D, et al. Granulicatella infection: diagnosis and management. J Med Microbiol 2012;61(pt 6):755–61. 3. Teo L, Looi A, Seah LL. An unusual causative agent for an orbital abscess: Granulicatella adiacens. Orbit 2011;30:162–4. 4. Christensen JJ, Facklam RR. Granulicatella and Abiotrophia species from human clinical specimens. J Clin Microbiol 2001;39:3520–3. 5. Okada Y, Kitada K, Takagaki M, et al. Endocardiac infectivity and binding to extracellular matrix proteins of oral Abiotrophia species. FEMS Immunol Med Microbiol 2000;27:257–61. 6. Ohara-Nemoto Y, Kishi K, Satho M, et al. Infective endocarditis caused by Granulicatella elegans originating in the oral cavity. J Clin Microbiol 2005;43:1405–7. 7. del Pozo JL, Garcia-Quetglas E, Hernaez S, et al. Granulicatella adiacens breast implant-associated infection. Diagn Microbiol Infect Dis 2008;61:58–60.
Localization and Retrieval of an Eyelid Metallic Foreign Body With an Oscillating Magnet and High-Resolution Ultrasonography Sylvia H. Yoo, M.D., Dan B. Rootman, M.D., Alice Goh, M.B.B.S., Aaron Savar, M.D., and Robert A. Goldberg, M.D. Abstract: A patient was found to have a metallic foreign body in the left anterior orbit on CT imaging, but the foreign body was not evident on clinical examination. On high-resolution ultrasonography, an object was identified in the left upper eyelid; however, the typical shadow with metallic foreign bodies was not seen. A high-power oscillating magnet was then applied to the eyelid, which revealed a subcutaneous metallic foreign body in the left upper eyelid. When used in conjunction, the high-resolution ultrasound and oscillating magnet successfully localized and facilitated retrieval of the metallic foreign body from the left upper eyelid.
Case Reports
time of injury. However, he continued to complain of periodic sharp pain in the medial left orbit. During a subsequent evaluation of long-term back pain, a CT scan was performed to investigate residual metallic objects used in preparation of MRI examination. The CT revealed a metallic foreign body in the superficial soft tissues of the medial left orbit (Fig. A). It was localized to the canalicular system, conjunctiva or eyelid. Despite careful examination by multiple ophthalmologists and oculoplastic surgeons, including lacrimal probing, the foreign body was not visualized or palpated. Further studies with A-scan ultrasound were unable to identify the foreign body, and B-scan ultrasonography by a retina specialist confirmed that the object was not localized to the sclera or intraocular space. The remainder of his ophthalmologic examination was normal, with the exception of a corneal scar in the OD from prior metallic foreign body removal. To investigate the periocular soft tissues further, static and dynamic high-resolution ultrasound (Logiq P6, GE Healthcare, Waukesha, WA, U.S.A.) was performed with a 15-MHz probe. A hyperechoic mass in the medial aspect of the left upper eyelid was identified (Fig. B). The mass moved dynamically with eyelid excursion (see Video 1, Supplemental Digital Content 1, available at: http://links.lww.com/IOP/ A97). An oscillating electromagnet (Scientronics Series 10K Eye Magnet; IMC Magnetics Corp, Jericho, NY) was then brought into the field of ultrasound imaging (Fig. C). The periodic application of an electromagnetic field caused the metallic body to oscillate in a regular pattern, confirming its identity (see Video 2, Supplemental Digital Content 2, available at: http://links.lww.com/IOP/A98). The position of the pulsating skin below the magnet was then marked (see Video 3, Supplemental Digital Content 3, available at: http:// links.lww.com/IOP/A99) and, after application of 2% lidocaine with 1:100,000 epinephrine, the skin was opened. By repeatedly applying the magnetic field, followed by sharp and blunt dissection, the metallic foreign body was identified and excised. (Fig. D; see Video 4, Supplemental Digital Content 4, http://links.lww.com/IOP/A100). The foreign body measured approximately 3 mm × 4 mm. The pathology report confirmed a firm black object, consistent with foreign body, with soft tissue showing foreign body reaction and brown pigment suggestive of hemosiderin. The patient reported improved pain symptoms and no complications since the procedure. The patient was subsequently able to undergo MRI that revealed pathology in his lumbosacral spine.
CASE REPORT This report conformed to the requirements of the United States Health Insurance Portability and Accountability Act. A 50-year-old man presented with periodic pain in the medial aspect of the left upper eyelid following trauma to OU in a work-related explosion 7 years before. The event had resulted in the embedding of multiple periocular metallic foreign bodies. The majority of these materials were removed manually at the
Jules Stein Eye Institute, UCLA, Los Angeles, California, U.S.A. Accepted for publication June 11, 2014. Presented at the European Society of Oculoplastic and Reconstructive Surgery on September 19–21, 2013 in Barcelona, Spain. The authors have no financial or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.op-rs.com.). Address correspondence and reprint requests to Sylvia H. Yoo, M.D., 100 Stein Plaza, Los Angeles, CA 90095. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000257
DISCUSSION CT imaging of the orbit in this case demonstrated a superficial left periocular metallic foreign body many years after an explosive work-related trauma. Although it was clearly identifiable on imaging, multiple examinations of the eyelid, orbit, and globe were unable to localize the object. Such cases can be surgically frustrating, as wide dissection and surgical exploration can increase collateral tissue damage and lead to unwanted structural and/or functional consequences. For this reason, small metallic orbital foreign bodies are often not removed unless there is a compelling reason to do so, such as infection or functional deficit. In a chart review by Ho et al.,1 retained intraorbital metallic foreign bodies were overall found to be well tolerated, leading the authors to recommend conservative management. They did, however, discuss indications for removal including problematic location or particular metallic composition. Copper foreign bodies may produce a significant inflammatory response, requiring removal, while copper alloys may be better
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e83
Ophthal Plast Reconstr Surg, Vol. 32, No. 4, 2016
Case Reports
A, Axial CT image demonstrating a metallic foreign body (arrow) in the left anterior orbit. B, Hyperechoic foreign body (arrow) detected on sagittal high-resolution ultrasonography in the medial left upper eyelid. C, Colocalization with high-power oscillating magnet and high-resolution ultrasound imaging. D, Foreign body shown after retrieval from the left upper eyelid.
tolerated.1,2 In addition, lead shot or pellets may lead to systemic toxicity, although this is less likely with modern manufacturing. Iron foreign bodies near the scleral wall have also been shown to cause siderosis in rabbit models; thus, iron found in contact with the globe may be an indication for removal as well. Conservative management was effective for many years in the authors’ case; however, his persistent intermittent pain and need for MRI evaluation of back pain provided eventual indications for removal of the foreign body. Image guidance using radiographs, fluoroscopy, sonography, and other advanced techniques have proven to be useful for many clinical applications, especially when the precision of an instrument or anatomic landmark is necessary.3,4 The use of high-resolution ultrasound imaging to localize structures and foreign substances in the periocular soft tissues has long been established.5 This technology offers the advantage of being able to dynamically assess tissues in vivo with excellent spatial resolution. It has been extensively utilized to guide percutaneous therapy of subcutaneous pathologies such as cysts, abscesses, and blood vessels, among others. Ultrasound is, however, a 2-dimensional technology and is significantly operator dependent. There can be ambiguity as to the identity and localization of subcutaneous structures, especially if typical cues are absent. In the case of metallic foreign bodies, one would expect to see shadowing and/or ring artifact.6,7 In the current case, these signs were not clearly evident, possibly due to encasement in fibrous scar, thus making it difficult to firmly determine the identity of the material. Augmenting the ultrasound imaging with the use of highpower, oscillating magnetic field can significantly assist in discriminating metallic objects from surrounding normal tissues.
e84
The in-step oscillation of the object with the alternating magnetic field viewed on ultrasound offers confirmatory evidence of its ferromagnetic identity. Essentially, the 2 technologies interact dynamically to definitively localize the object for surgical planning. Intraoperative application of the magnet can be of further assistance. As more superficial tissues are dissected, the magnet can be used in a serial fashion to direct dissection and thus minimize the area of surgical exploration. Ideally, nonmagnetic instruments could be utilized in these circumstances to allow for simultaneous dissection within the magnetic field.
REFERENCES 1. Ho VH, Wilson MW, Fleming JC, et al. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20:232–6. 2. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494–500. 3. Shiels WE 2nd, Babcock DS, Wilson JL, et al. Localization and guided removal of soft-tissue foreign bodies with sonography. AJR Am J Roentgenol 1990;155:1277–81. 4. Wang X, Lin Y, Yu H, et al. Image-guided navigation in optimizing surgical management of craniomaxillofacial fibrous dysplasia. J Craniofac Surg 2011;22:1552–6. 5. Close JK, Shiels WE 2nd, Foster JA, et al. Percutaneous ultrasoundguided intraorbital foreign body removal. Ophthal Plast Reconstr Surg 2009;25:335–7. 6. Guthoff, RL, Labriola LT, Stachs O. Diagnostic ophthalmic ultrasound. In: Ryan SJ, ed. Retina, 5th ed. Vol. 1. Saint Louis, MO: Elsevier Saunders, 2013:227–84. 7. Prakash G, Venkatesh P, Garg S. Unusual cause for non-detection of retained metallic foreign body on ocular ultrasonography. Clin Experiment Ophthalmol 2005;33:333–4.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
