6 Occult foreign bodies which penetrate the orbit are only detected with secondary complications, including visual loss, severe orbital inflammation, selleck compound meningitis, orbital cellulitis, osteomyelitis, ptosis, and brain abscess.7�C9 Orbitocranial injuries can prove fatal. Death in a child from transhemispheric brain injury after intraorbital penetration with a pencil has been reported1; in another incident, a schizophrenic patient committed suicide by piercing his orbit with a plastic ballpoint pen, which entered the cerebellum.10 Orbitocranial injuries with foreign bodies can be silent at presentation. Thus even a minor injury should be assessed properly to rule-out severe comorbidities. These cases require imaging studies including CT and MRI; however, MRI should only be performed after a metallic foreign body has been ruled out.

If vascular injury is suspected, angiography may be required. Trauma to the cerebrovascular system (both penetrating and nonpenetrating) can cause injuries such as arterial dissection, pseudo-aneurysm, arterial or venous rupture or thrombosis, and arteriovenous fistula. A vascular injury should be suspected from frank hemorrhage or neurological deficits such as numbness, weakness, and paralysis of the face, upper or lower extremity, or entire side of the body. There may also be a loss of consciousness, facial drooping, slurred speech, aphasia, confusion, blurred vision, and impaired breathing or swallowing. Nausea and vomiting may also occur. If a vascular injury is detected on angiography, measures must be taken preoperatively to control any intraoperative bleeding.

Orbital injuries can lead to enophthalmos or proptosis, ecchymosis, restricted ocular movements, diplopia, chemosis, and crepitus. The presence of such symptoms and signs warrants detailed radiological investigations to assess the severity of the injury. Resolution of orbitocranial penetrating injury usually requires a multidisciplinary approach, involving neurosurgical and vascular specialists; postoperatively psychiatric evaluation and counseling may be advisable. In children it is also essential to rule out abuse. Removing a long foreign body through an anterior approach appears to be a simple procedure; however, there is a risk of orbital hemorrhage and lethal intracranial bleeding.

Craniotomy and/or an endovascular approach needs to be performed for those presenting with symptoms of vascular involvement or if the foreign body has no extracranial extension. Such cases should be undertaken with neurosurgical and vascular surgical support. In conclusion, a case of ��trivial�� eyelid trauma might be associated with a more serious occult Cilengitide problem. In cases involving children, where history taking can be especially challenging, a high index of suspicion, thorough evaluation of the patient, and proper imaging studies can prevent clinical catastrophes.