Thinking outside the pencil box: unwitnessed orbital trauma in a child

Abstract

A 19-month-old boy presented with 3 days of increasing right periorbital edema after an unwitnessed fall in a playground 4 days earlier. He was admitted to an outside hospital for presumed preseptal cellulitis but failed to improve on broad-spectrum intravenous antibiotics. On presentation at Massachusetts Eye and Ear Infirmary, he had right upper lid edema and erythema with a partially healed 5 mm laceration beneath the brow (Figure A). Computed tomography imaging showed a foreign body in the superomedial orbit with a density appearing similar to that of the adjacent bone (Figure B). The radiodensity of foreign body was 398.22 Hounsfield units (HU) and that of the adjacent ethmoid bone was 516 HU. Orbital exploration was undertaken through the laceration, which tracked to the superomedial orbit. A bright green, foreign body was removed from the end of the tract (Figure C), but there was no evidence of infection. Further questioning of the boy's family revealed that he had been playing with a green crayon pencil prior to the time of injury, and this was thought the most likely cause of the foreign body.