Case Report

Ophthalmologica 2006;220:397399
DOI: 10.1159/000095868

Received: April 6, 2006

Accepted: May 6, 2006

Corneal Ulcer Caused by a Wooden

Foreign Body in the Upper Eyelid
6 Months after Minor Injury
Martin Baumeister a, b Claudia Kuhli-Hattenbach a Marc Lchtenberg a
a
b

Department of Ophthalmology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany;

College of Optometry, University of Houston, Houston, Tex., USA

Key Words
Corneal ulcer
Wooden foreign body
Minor injury

Ocular infection

Abstract
Purpose: To describe a case of a wooden foreign body in the
upper eyelid that remained asymptomatic for 6 months.
Case Report: A 9-year-old boy was presented with moderate upper lid swelling. Medical history was positive for trauma with a wooden stick 6 months ago. At first, the condition
resolved under local antibiotic treatment. Three weeks later,
the inflammation recurred and a corneal ulcer developed.
Examination under general anesthesia revealed a wooden
foreign body which had remained in the upper eyelid since
the first injury. Conclusion: Organic foreign bodies in the
eyelid can remain asymptomatic for a long period of time
and can play a role in periocular inflammation. In case of
doubt, children and other less cooperative patients should
be examined under general anesthesia.
Copyright 2006 S. Karger AG, Basel

Case Report
A 9-year-old boy was presented to the outpatient department
because of swelling and pressure sensation in the left upper eyelid.
Medical history was positive for trauma with a wooden stick by
another boy 6 months ago on the same eye and he had been treat-

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ed in an external hospital. According to the mother, this attack

had caused a superficial corneal injury and eyelid swelling.
Uncorrected visual acuity in both eyes was 20/20. Upon slitlamp examination, slight preseptal inflammation and swelling of
the left upper lid was noticed. Eversion of the upper lid revealed
moderate tarsal inflammation resembling a pyogenic granuloma.
Apart from these findings, the conjunctiva was not affected, the
corneal epithelium was smooth, ocular motility was normal and
there was no sign of intraocular inflammation. No trace of a foreign body was found. In the right eye, examination was unremarkable. No other medical conditions were reported.
Under local antibiotic treatment with natamycin ointment
(Pima Biciron, S&K Pharma, Perl, Germany) and a combination
of erythomycin and colistin ointment (Ecolicin, Chauvin Ankerpharm, Berlin, Germany) 3 times a day, the symptoms resolved
quickly. After 5 days of treatment, only a slight tarsal redness remained. Three more weeks later, however, the patient presented
again showing markedly increased inflammatory upper eyelid
swelling and pseudoptosis (fig. 1) as well as increasing pain in the
left eye. Visual acuity had dropped to 20/200. The patient did not
report any additional injury to the eye. Because of pain and limited cooperation, the upper eyelid could not be everted. Body temperature, white blood cell count and c-reactive protein serum
concentration were within normal limits. Because of a suspected
preseptal phlegmone, the patient was admitted to the hospital.
Systemic antibiotic therapy with cefuroxime (Zinacef, GlaxoSmithKline, Munich, Germany) 500 mg i.v. 3 times a day was initiated. Local therapy during the day consisted of a combination
of polymyxin B, neomycin and gramicidin eye drops (Polyspectran, Alcon, Freiburg, Germany) every 30 min, atropine eye drops
(Atropin 1% POS, Ursapharm, Saarbrcken, Germany) twice a
day, and nystatin eye drops (100,000 units/ml) 3 times a day. At
night, nystatin ointment and a combination ointment of polymyxin B, bacitracin and neomycin (Polyspectran) were given.

Marc Lchtenberg, MD
Department of Ophthalmology, Johann Wolfgang Goethe University
Theodor-Stern-Kai 7, DE60590 Frankfurt am Main (Germany)
Tel. +49 69 6301 5721, Fax +49 69 6301 7795
E-Mail luechtenberg@em.uni-frankfurt.de

Fig. 1. Photograph of the 9-year-old boy with pseudoptosis and

swelling of the upper eyelid on the left eye due to an intrapalpebral
foreign body.

Fig. 3. A wooden splinter with a length of 2.5 cm, a width of

0.5 cm and a thickness of 0.2 cm which was removed from the left
upper eyelid.

Fig. 2. B-mode ultrasonogram of the left upper eyelid of the pa-

Fig. 4. Photograph of the patient 7 months after removal of the

tient. There is a high-reflective area with a diameter of 3.92 mm

(arrow) surrounded by a mid-reflective zone.

wooden foreign body. A slight ptosis is present, no signs of intraor extraocular inflammation are visible. The left pupil was pharmacologically dilated for fundoscopy.

At first, the pain and swelling decreased under this treatment.

Swab cultures from the conjunctiva showed no growth of bacteria. Two days after admission, however, the pain increased again
and a corneal epithelial defect and infiltrate were found.
B-mode ultrasound examination of the left upper lid showed
an inhomogeneous area with a diameter of approximately 3.9 mm
which raised suspicion of a foreign body (fig. 2). Because the pain
relief with topical anesthesia was not sufficient for opening the
eyelids, the patient was then examined under general anesthesia.
This examination with double eversion of the eyelids showed a
2.5-cm-long splinter of wood (fig. 3) which had been embedded
in the tissue of the upper eyelid 6 months ago when the first injury was inflicted, and had now penetrated the conjunctiva and
caused a corneal ulcer.

Repeated cultures from the eyelid after foreign body removal

showed no growth of bacteria and fungi.
After removal of the foreign body, antibiotic and antimycotic
therapy was continued as described above. Systemic therapy was
continued for 7 days and local therapy was tapered over 6 weeks.
The eyelid and the cornea healed within 6 weeks without further
complications. At the last visit 7 months after removal of the foreign body, no signs of extraocular or intraocular inflammation
were present. There was, however, a mild ptosis of the upper eyelid (fig. 4). Slit-lamp examination showed a slight superficial corneal scar. Visual acuity was 20/20 in both eyes. The patient reported no pain or visual complaints.

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Ophthalmologica 2006;220:397399

Baumeister /Kuhli-Hattenbach /
Lchtenberg

Discussion

Undetected organic foreign bodies can cause severe

infections and strong inflammatory reactions even if
they have been silent for a long period of time [1]. There
are several reports of retention of foreign bodies, especially hard and soft contact lenses which migrated into
the upper eyelid after being trapped in the upper conjunctival fornix. These findings emphasize the importance of a thorough examination and eversion of the eyelids, if necessary double eversion, even in cases of minor
corneal epithelial injuries [28]. When examining superficial eye injuries, it is mandatory to thoroughly check the
fornices of the conjunctiva for foreign bodies. Usually,
wooden foreign bodies cannot be visualized by native Xray imaging [1, 812]. If located in the eyelid, they may be
well detectable using ultrasound by a skilled and experienced examiner. If the foreign body has penetrated deeper into the orbit, a CT or MRI may be necessary. This case
stresses the importance of meticulous clinical examination to detect a foreign body immediately after the injury.

Once the foreign body is embedded in inflammatory mucous tissue, it can become hardly detectable in the clinic.
In cases like this one, when an almost healed inflammation starts to exacerbate without an apparent external
cause, the examination of the fornix must be repeated,
even if previously no foreign body was found. If the patient is unable to cooperate and a foreign body is suspected, an examination under general anesthesia should be
considered.

Conclusion

Organic foreign bodies in the eyelid can remain

asymptomatic for a long period of time and can play a role
in periocular inflammation. In case of doubt, children
and other less cooperative patients should be examined
under general anesthesia. B-mode ultrasound imaging is
useful as a routine procedure for detection of foreign
bodies in the eyelids and anterior orbit.

References
1 Tuppurainen K, Mantyjarvi M, Puranen M:
Wooden foreign particles in the orbit spontaneous recovery. Acta Ophthalmol Scand
1997;75:109111.
2 Benger RS, Frueh BR: An upper eyelid cyst
from migration of a hard corneal contact
lens. Ophthalmic Surg 1986;17:292294.
3 Brinkley JR Jr, Zappia RJ: An eyelid tumor
caused by a migrated hard contact lens. Ophthalmic Surg 1980;11:200202.
4 Friedberg ML, Abedi S: Encysted hard contact lens appearing as an orbital mass. Ophthal Plast Reconstr Surg 1989;5:291293.

Corneal Ulcer Caused by a Wooden

Foreign Body

5 Hammons M, Gayre G, Hammons D, Dutton J: Intrapalpebral migration of a rigid gaspermeable contact lens resulting in an eyelid
mass. Ophthalmology 2003;110:17811783.
6 Hayasaka Y, Hayasaka S, Nagaki Y, Endo Y:
An eyelid mass caused by a migrated hard
contact lens. Eye Contact Lens 2003;29:250
251.
7 Patel NP, Savino PJ, Weinberg DA: Unilateral eyelid ptosis and a red eye. Surv Ophthalmol 1998;43:182187.
8 Hall G, Benger RS: Missed diagnosis of an
intraorbital foreign body of surfboard origin. Ophthal Plast Reconstr Surg 2004; 20:
250252.

9 Brock L, Tanenbaum HL: Retention of wooden foreign bodies in the orbit. Can J Ophthalmol 1980;15:7072.
10 Kiel R, Wiaux C, Atipo-Tsiba PW, Gottrau P:
Wooden spike orbital injury (in German).
Klin Monatsbl Augenheilkd 2005; 222: 252
254.
11 Lee JS, Lee JE, Oum BS, Cha SH: Orbitocranial injury caused by wood. Korean J Ophthalmol 1999;13:128132.
12 Levy J, Monos T, Shelef I, Nash M, Lifshitz T:
Intrasinus wood foreign body causing orbital cellulitis in congenital insensitivity to pain
with anhidrosis syndrome. Ophthal Plast
Reconstr Surg 2004;20:8183.

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