a 19-year - old male presented to the casualty with a history of 
 injury to his left eye by a palm leaf , which fell from a height of 
 about 10 meters
. a piece of the stalk had been removed from the 
 wound at a local hospital earlier in the day . on examination ,
his 
 vision was 20/20 , the globe was intact and ocular movements 
 were full .
the 
 wound was dressed and the patient was asked to review in the 
 outpatient department .
the patient returned 18 months later with a swelling at the 
 same site . on examination ,
there was 
 a non - axial proptosis of the left eye with limitation of elevation . 

the globe was pushed 3 mm forwards and 2 mm upwards . a 
 2  1 cm firm , non - tender mass was present at the infraorbital 
 margin
computed 
 tomography ( ct ) scan of the orbit obtained in axial and coronal 
 planes depicted a medium - sized soft tissue density mass in 
 the inferomedial aspect of the left orbit .
the mass involved the 
 retrobulbar , intra and extraconal spaces , abutting and slightly 
 displacing the optic nerve superiorly [ fig .
2a , b ] . as the results of the investigations did not suggest the presence 
 of a retained intraorbital foreign body , we considered other 
 possible diagnoses like tuberculosis , sarcoidosis and idiopathic 
 orbital inflammation .
however , systemic examination did not 
 reveal any clinical evidence of tuberculosis or sarcoidosis . 

complete blood count , esr , mantoux test and chest x - ray were 
 within normal limits .
as the patient was not very symptomatic 
 at the time , we decided to keep him under observation for some 
 time .
he presented two years later with a discharging sinus at 
 the site . at this point
, we strongly suspected the presence of 
 a residual foreign body and advised a magnetic resonance 
 imaging ( mri ) scan of the orbit .
it grew 
 enterobacter species , sensitive to ciprofloxacin , norfloxacin , 
 lomefloxacin and gentamicin .
ciprofloxacin 500 mg twice daily ) 
 and daily dressing of the sinus was continued .
one week 
 later , a foreign body , measuring 1.2 cm , was seen in the gauze 
 when the dressing was removed . on follow - up
so further active intervention 
 was deferred at that point and the patient was advised regular 
 follow - up .
he 
 said that he had been having recurrent discharge from the 
 sinus , which was being dressed at a local hospital .
another 
 piece of the wooden foreign body was seen on the gauze when 
 the dressing was removed that day .
3 ] . on follow - up , 
 the swelling resolved and the sinus healed completely .
we repeated a ct scan of the orbit a 
 year later , which showed complete resolution of the mass 
 [ fig .
most metallic foreign bodies remain 
 quiescent for a long period of time without causing any 
 problems .
so the general recommendation is to leave them 
 alone in the absence of specific indications for removal.4 
 however , organic foreign bodies like wood have a much 
 higher incidence of potentially sight - threatening and life- 
 threatening complications.5 they may remain dormant for 
 a variable period of time and manifest with delayed - onset 
 orbital granuloma , cellulitis , abscess or chronic draining sinus.1 
 hence , surgical removal of organic intraorbital foreign bodies 
 is recommended.5 in our case , a piece of the foreign body had been removed 
 after the initial trauma .
when seen in our casualty on the 
 evening of the same day , the wound looked superficial and there 
 was no clinical evidence of a residual foreign body .
it is 
 important to remember that wooden foreign bodies often 
 break during attempted removal.1 the associated wound may 
 be small and self - sealing.6 therefore , if there is recurrence of 
 clinical symptoms , especially , if there is a discharging sinus , the 
 possibility of a retained foreign body should be considered .
imaging and prompt exploration of the sinus may help 
 in localizing and removing the foreign body .
a ct scan is 
 the standard diagnostic test , because it demonstrates most 
 intraorbital foreign bodies and is safe in the presence of metallic 
 foreign bodies.5 in our case , however , the ct scan did not show 
 any evidence of the foreign body .
review of previous reports 
 suggests that wood is often not detected on ct scan.7 computed 
 tomographic imaging relies on the differing radiodensities of 
 tissues for their differentiation .
the radiodensity of wood is 
 variable and may be similar to that of the orbital tissues , which 
 may account for the potential difficulty of recognition .
the 
 ct appearances seem related to the interval between injury 
 and examination.8 in the acute stage , the very low density of 
 wood can be confusing with low window settings , mimicking 
 air bubbles . in the subacute stage , wood assumes a moderate 
 density and may be difficult to distinguish from surrounding 
 orbital fat . in the chronic stage , the density of wood can become 
 higher than that of orbital muscle . it may be associated with a 
 foreign - body reaction , which appears as a homogenous mass 
 surrounding the dense wooden foreign body , with a density 
 similar to the adjacent extraocular muscles .
spiral ct scanners 
 have improved resolution and faster speed of acquisition of 
 images.9 the fast image capture allows the scanning to occur 
 with minimal motion artifact . in spite of these advantages , 
 wooden intraocular foreign bodies could only be described as 
 probable intraocular foreign bodies by neuroradiologists in 
 a pilot study using a spiral ct scanner.9 the mri scans are better at demonstrating wooden foreign 
 bodies .
magnetic resonance imaging depends on the density of 
 protons in the tissue and their different relaxation times .
these 
 properties of wood are dissimilar enough from those of the soft 
 tissue to allow differentiation.7 therefore , it is recommended 
 that mri scan should be performed after a negative ct scan 
 if there is a possibility of a wooden intraorbital foreign body . 

an mri scan may be performed as the primary imaging 
 modality if there is a definite history of a wooden intraorbital 
 foreign body.5 several aspects of this case are interesting . the long latent 
 period between injury and development of the orbital mass 
 and sinus , the apparent removal of the foreign body from the 
 wound after the initial trauma , the spontaneous extrusion of 
 pieces of the foreign body twice with an interval of 18 months 
 and complete resolution of the orbital mass on ct scan are 
 distinctive features of this case . the entire sequence of events 
 spanned over five years .
this was partly due to the frequent 
 defaulting on the part of the patient . in conclusion
, we would like to emphasize that intraorbital 
 foreign bodies may often present a confusing clinical picture . 

it is important for the ophthalmologist , radiologist and 
 pathologist to include foreign body granuloma among the 
 differentials of an intraorbital mass .
it is imperative to seek 
 past and recent history of trauma and maintain a high index of 
 suspicion in all such cases , regardless of the interval between 
 the trauma and current presentation .
 intraorbital foreign bodies often present a confusing clinical 
 picture . 
 wooden foreign bodies are notorious for remaining 
 quiescent for a long time , before presenting with a variety of 
 complications . 
 the wound of entry may often be small and 
 self - sealing . 
 wooden foreign bodies also show a propensity 
 to break during attempted removal . 
 intraorbital wood is often 
 not detected by standard diagnostic tests like the computed 
 tomography scan , adding to the diagnostic dilemma . 
 the 
 presence of an intraorbital mass with a discharging sinus should 
 evoke suspicion of a retained organic foreign body , regardless of 
 the time interval between the trauma and current presentation . 
 it 
 is imperative to maintain a high index of suspicion in such cases 
 to avoid misdiagnosis . 
 we report an unusual case of a missed 
 wooden intraorbital foreign body , which spontaneously extruded 
 after five years . 