Intraorbital foreign body projectile as a consideration for unilateral pupillary defect

Research has shown that 3% of all visits to the Emergency Department (ED) in the US are related to ocular trauma [1]. Rapid assessment and evaluation are imperative to preserve maximal visual function. However, close attention must also be paid to obtaining a detailed history from the patient, family member, or witness to the precipitating event. Intraorbital foreign body (IFB) is a term that refers to any foreign material within the bony orbit but outside of the globe [2]. Injuries involving IFBs are associated with high levels of ocular and orbital morbidity [3]. The majority of injuries involve young males, tool-related mechanisms, and metallic, non-organic materials [3,4]. Computed tomography (CT) is the best option for initial evaluation of an IFB; however, if metallic material is suspected a plane film may be of value [2,5,6].Pupillary irregularity resulting from orbital trauma can be ocular or orbital in nature. Blunt or penetrating trauma to the globe can result in iris sphincter muscle disruption or disintertion of the iris from its origin [7]. Partial or complete disruption of cranial nerve III can also occur. The intraorbital anatomy of cranial nerve III contains a superior and inferior division. The superior division is responsible for innervation of the levator and superior rectus muscles. The inferior division supplies the medial and inferior rectus and inferior oblique muscles, as well as the parasympathetic fibers to the sphincter pupillae and ciliary muscles. Disruption of the inferior division can lead to a dilated pupil and/or decreased adduction and globe depression. Interruption of both divisions can lead to ptosis, mydriasis, and ophthalmoplegia. Slight compression of the pial blood vessels and the superficially located pupillary fibers could result in dilation of the pupil [8]. In a non-traumatic setting approximately 25% of cases of a unilateral dilated pupil are idiopathic [9].A 39-year-old Caucasian male lumber mill saw operator presented t