Ophthalmology & social media were abuzz last month as a patient in the U.K. was found to have 27 contact lenses “in the eye,” or under the upper eyelid.  The lenses were found as the asymptomatic patient was about to undergo cataract surgery.  See my previous blog here.

Retained contact lenses (Morjaria R, BMJ 2017; 358)

A new case from the BMJ Case Reports tells of a 30-year old patient who had braces removed 10 years previously and was found to have brace wire in the stomach.  The case is titled, “Orthodontic braces come back to bite: a novel presentation of a small bowel volvulus” (BMJ Case Reports 2017; doi:10.1136/bcr-2017-221152)  

CT image (coronal) of orthodontic wire at the root of the small bowel volvulus.

At first, I thought there might be a foreign body crisis in the U.K. National Health Service (NHS) but the dental patient is in Australia.

The authors give an excellent & scholarly description of a patient who presents with abdominal pain for a second time to an emergency department.  On the second trip, the CT scan finds the foreign body.  (And without seeking to offend any colleagues worldwide — and given the cost of care in the US — I’d wager a standard protocol in the US would be to get a diagnostic study before the patient was even evaluated by an emergency department physician in the US.)

The authors conclude, “Most inert ingested objects, if they pass the cricopharyngeal sphincter, will pass spontaneously.1The most common site for perforation or obstruction is the ileocaecal valve.1 The case we describe here is therefore novel in the decade delay in presentation and the clinical sequelae.”  (Layman’s translation: “If you swallow an object it’s most likely to pass naturally through the bowel.  The most common site of perforation or obstruction (ie. a bad thing) is at the junction between the small intestine and colon (ileocaecal valve).  This case was a 10-year delayed diagnosis in a patient who was otherwise asymptomatic.”  They forgot to mention “Do not try at home!”)

BracesinBowelResection2017.gif

The clinical pearl is that contact lenses and braces are among numerous “medical devices” which can be retained in parts of the human body for many years and without incident.

It’ll be interesting to see if this causes mass hysteria among parents who will now worry if their child has retained braces wire. Or whether they really should have just invested in the Invisalign (which likely has a plastic foreign body risk).

Cases which hit the mainstream media are usually the zebras and not the horses.  As stated in the 1940s by Dr. Theodore Woodward, professor at the University of Maryland School of Medicine, who instructed his medical interns: “When you hear hoofbeats, think of horses not zebras”.[2] (The medical slang explanation for “Zebras in medicine” has a Wikipedia page here).

In any event, good luck to orthodontic & GI colleagues in the days (or Warhol’s 15 minutes) ahead.

Ravi D. Goel M.D. is a cataract surgeon & comprehensive ophthalmologist at Regional Eye Associates in Cherry Hill, NJ.  He is also a clinical instructor at Wills Eye Hospital.  His patient-friendly YouTube cataract surgery educational videos are here.