AUTHOR COMMUNICATION  
Persistent Lower Lid Swelling in an Infant –  
Impacted Foreign Body!  
Javeria Nasir1, Anum Javed2, Mohammad Owais Arshad3, Mohammad Hanif Chatni4  
1-4Department of ophthalmology patel Hospital, Karachi  
ABSTRACT  
Ophthalmologists, including general practitioners definitely encounter ocular foreign bodies in their clinics. The  
conjunctival fornices are potential sites of impaction. We report a case of a 9-month infant boy who was referred  
to us for a persistent lower lid swelling for one month. He had already been to an eye specialist before presenting  
to us. Upon examination, a round, pink coloured, toy cart-wheel came out of his lower eye lid of the right eye.  
Surprisingly, there was no associated conjunctival or adnexal damage. The authors wish to emphasize the  
importance of taking a thorough history and adequate general physical examination. A missing part of a toy,  
elucidated on history, should always raise the suspicion among parents and/or care givers for a probable foreign  
body in infants and children.  
Key Words: Foreign body, ocular trauma, eyelid.  
How to Cite this Article: Nasir J, Javed A, Arshad MO, Chatni MH. Persistent Lower Lid Swelling in an Infant –  
Impacted Foreign Body! Pak J Ophthalmol. 2020; 36 (3): 305-307.  
Doi: 10.36351/pjo.v36i3.1052  
evaluation of lower eyelid swelling that had been there  
for the past one month.  
INTRODUCTION  
Ophthalmologists, including general practitioners  
definitely encounter ocular foreign bodies in their  
clinics. In most instances, a detailed history about the  
nature of injury is sufficient to elucidate the presence  
of a foreign body, however many times they may be  
missed even by the experts.  
CASE PRESENTATION  
A 9 month old male infant was referred to the eye  
department from the peadiatric unit where he was  
admitted for community acquired pneumonia. His  
mother complained of noticing right lower eyelid  
swelling of one-month duration. On further history and  
examination, the mother informed that he got hurt in  
his right eye by a plastic toy while he was playing with  
his elder sibling around a month ago. The baby  
developed lower lid swelling without any redness or  
sticky discharge (Picture 1). Over the course of  
previous one month, the swelling did not reduce or  
increase in size.  
The conjunctival fornices (upper and lower) are  
known to be notorious for harboring foreign bodies for  
considerably longer period of time1,2,3. They may be  
organic or inorganic, commonly include plant  
material, metallic fragments, silica/sand particles, and  
even lost contact lenses. Here we report a case of an  
infant who was referred to us in eye clinic for  
Correspondence to: Dr. Javeria Nasir  
Department of ophthalmology Patel Hospital, Karachi  
Email: i_m_jav@hotmail.com  
He was then taken to an eye specialist, a week  
after the injury, where the swelling was diagnosed as a  
hordoelum of the right eye and was prescribed topical  
antibiotic eye drops along with steroid ointment.  
Despite topical treatment for two weeks, the swelling  
did not regress.  
Received: April 21, 2020  
Accepted: May 4, 2020  
Revised: May 4, 2020  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 305-307  
305  
Javeria Nasir, et al  
the mother informed us that she had been looking for  
that wheel since one wheel of the toy cart had been  
missing from the day the boy developed the swelling.  
Picture 1(a): (Right) Persistent lid swelling.  
Picture 2: Measurement of the extracted foreign body.  
Picture 1(b): (Right) After foreign body removal.  
Conjunctiva showed no sign of granulation and/or  
inflammation. Cornea was lustrous and clear without  
any epithelial defects. Rest of the anterior segment  
Two weeks after injury, the child developed cough  
and runny nose along with three episodes of high fever  
and febrile fits. He was rushed to the emergency  
department, where he was admitted under the care of  
pediatric department and was diagnosed as community  
acquired pneumonia (CAP) based on clinical  
examination and chest x-ray findings. He was on  
intravenous ceftriaxone and vancomycin. Fever  
subsided after 48 hours of starting the treatment. Other  
symptoms also improved gradually with the exception  
of lower lid swelling which persisted despite three  
days of IV antibiotics. Opinion of an ophthalmologist  
was sought before discharge. At the eye clinic, on  
general physical examination he was a healthy  
looking, smiling, active child, slightly irritable in his  
mother’s lap with obvious right eye lower lid swelling.  
He was a febrile with no lymphadenopathy. Gross  
visual acuity was intact in both eyes and child was  
following and fixating normally. Upon palpation the  
swelling was non-tender and mobile with no  
associated skin changes. On right lower lid retraction,  
by the examining doctor, a bright, circular, pink  
coloured 1.1 cm × 1.1 cm (Picture 2), plastic foreign  
body popped out and fell on the floor. This foreign  
body was a wheel of a four-wheeled toy cart with  
which the baby was playing one month back. Later,  
examination  
along  
with  
fundoscopy  
was  
unremarkable. Written informed consent was obtained  
from the patient’s parents for purpose of reporting the  
case.  
DISCUSSION  
Ocular foreign bodies are a common finding in  
patients of all age group presenting in outpatient  
department with or without history of trauma. In  
children, however, due to the difficult examination and  
insufficient history of associated symptoms,  
conjunctival foreign particles are easily over-looked4.  
Reflex tearing and blinking are the inherent protective  
ways that usually wash out any foreign body inside the  
conjunctival fornices5. Initially when there is any  
foreign body in the fornix there is acute inflammatory  
response causing fibrinous exudate formation in an  
attempt to dislodge the foreign body, however, if there  
is a large surface area to the foreign body this  
mechanism is minimal causing granuloma formation  
around foreign body6,7. Granuloma tissue formation  
around foreign body as a means of its mechanical  
stabilization is another protective phenomenon  
observed in some case reports as well. Hence, once  
stable, the simultaneous damage to cornea and  
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Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 305-307  
Persistent Lower Lid Swelling in an Infant – Impacted Foreign Body!  
conjunctiva is avoided leading to prolonged tolerance  
and minimal irritation8. However, in our case, we did  
not find any evidence of granuloma formation, except  
for mild hyperemia.  
Mohammad Owais Arshad; Senior Registrar: Critical  
analysis, Acquisition of Data, final review.  
Mohammad Hanif Chatni; Head of Department:  
Concept, final review.  
There are cases in literature in which unusual  
subconjunctival foreign bodies are reported. Park et al  
have described a foreign body which was confused  
with uveal prolapse9. Similarly, subconjunctival insect  
wings are also reported10.  
REFERENCES  
1. Balakrishnan E, Abraham JE, Naim-ud-Din M.  
Unusual foreign body in the conjunctiva. Br J  
Ophthalmol. 1963; 47: 250–2.  
With this author communication, the authors wish  
to highlight the importance of a thorough yet proactive  
history and clinical examination, which are often  
neglected due to poor co-operation in children, and  
lack of awareness among parents too. In our case the  
foreign body had been there for one month. It was  
missed at three levels, i.e. by the parents, by the  
ophthalmologist and by the pediatrician. A missing  
part of a toy, elucidated on history, should always raise  
the suspicion among parents and/or care givers for a  
probable foreign body in children. The concept of a  
“holistic” approach towards the patient tops the list  
when providing medical care.  
2. Sakata, C., Hiraoka, T., & Oshika, T. Unusually  
Large Plastic Toy as a Persisting Conjunctival Foreign  
Body. Japan J Ophthalmol. 2007; 51 (3): 232234.  
Doi: 10.1007/s10384-007-0434-5.  
3. Gerding H. Unusually long foreign body of the  
conjunctival fornix in a child overlooked by 3  
ophthalmologists.  
Klinische  
Monatsblätterfür  
Augenheilkunde. 2013; 230 (04): 390-1.  
Doi: 10.1055/s-0032-1328391.  
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profile of pediatric ocular trauma in a tertiary hospital  
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5. Giuliano EA. Diseases of the adnexa and nasolacrimal  
system. Equine Ophthalmology. 2016; 27: 197.  
6. Weinberg JC, Eagle Jr RC, Font RL, Streeten BW,  
Hidayat A, Morris DA. Conjunctival Synthetic Fiver  
Granuloma: A Lesion that Resembles Conjunctivitis  
Nodosa. Ophthalmology. 1984; 91 (7): 867-72.  
7. Sowmya V, Nazareth NE, Kamath VB. Foreign-body  
conjunctival granuloma secondary to finger-nail  
trauma. Asian J Ophthalmol. 2015; 14; 14 (2): 73-6.  
8. Alabi EB, Simpson TL. Conjunctival Redness  
Response to Corneal Stimulation. Optometry and  
Vision Science. 2019 Jul 1; 96 (7): 507-12.  
Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
Conflict of Interest  
Authors declared no conflict of interest.  
Authors’ Designation and Contribution  
Doi: 10.1097/OPX.0000000000001398.  
Javeria Nasir; Registrar: Concept, data collection,  
manuscript writing.  
9. Park YM, Jeon HS, Yu HS, Lee JS.  
A
subconjunctival foreign body confused with uveal  
prolapse. Indian J Ophthalmol. 2014 Jun; 62 (6): 730–  
731.  
Anum Javed; Resident: Manuscript writing, final  
review.  
10. Fogla R, Rao SK, Anand AR, Madhavan HN. Insect  
wing case: Unusual foreign body. Cornea. 2001; 20:  
119–21.  
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