Self-inflicted, trans-optic canal, intracranial penetrating injury with a ballpoint pen


A 60-year-old man was admitted to our medical ward due to aspiration pneumonia. He had a medical history of diabetes mellitus, end-stage renal disease; a tuberculosis bacilli-related thoracic spine infection with paraplegia, and a previous coronary artery bypass graft. During his third day at the hospital, he obtained a ballpoint pen and inserted it into his left eye. On physical examination, the patient appeared to be alert with normal vital signs. The ballpoint pen protruded from his left upper eyelid; it was firmly lodged in his left medial orbit between the globe and nose, causing left eye proptosis (Fig. 1).

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Figure 1. The ballpoint pen was firmly lodged in his left medial orbit between the globe and nose.

Neurologic examinations revealed that the patient was neurologically intact except for complete left ophthalmoplegia. Brain CT scanning revealed a tubular foreign body that was located in the anteroposterior plane extending from the orbital apex and directly into the parasellar region (Fig. 2). The metallic portion of the foreign body was entrapped in left optic canal (Fig. 3). There was no evidence of intracranial hemorrhaging or a rupture in the globe (Fig. 4). The patient was treated with high-dose steroids to protect the optic nerve. The plastic ballpoint pen and metallic tip was withdrawn from the orbit smoothly at bedside, and no craniotomy was required. The ballpoint pen had been inserted to an estimated depth of 7 cm through the eyelid and into the orbit. The patient was then transferred to the ICU for close neuro-observation. We initiated intravenous broad-spectrum antimicrobials and vancomycin therapy and continued these medications for three weeks. A psychiatrist was consulted for a complete psychiatric evaluation and suicide prevention. The follow-up CT scan showed no retained foreign bodies or intracranial hemorrhaging (Fig. 5). At the last follow-up examination 2 months after the injury, the patient presented with complete left ophthalmoplegia and blepharoptosis but intact visual function.

Click to zoom. Figure 2:
CT scan shows the trajectory of the foreign body.
Click to zoom. Figure 3. The ballpoint pen tip reaches into the parasellar region via the optic canal.
Click to zoom. Figure 4. There was no evidence of a rupture in the globe.
Click to zoom. Figure 5. The follow-up CT scan shows residual hematoma in the orbital cavity; no retained foreign bodies or intracranial hemorrhaging.