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 Table of Contents  
BRIEF COMMUNICATION
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 34-37

Rare foreign bodies encountered in ophthalmic practice


Department of Ophthalmology, Kasturba Medical College, Manipal, Karnataka, India

Date of Submission28-Feb-2020
Date of Decision25-Nov-2020
Date of Acceptance10-Dec-2020
Date of Web Publication10-Apr-2021

Correspondence Address:
Sudha Menon
Department of Ophthalmology, Kasturba Medical College, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_14_20

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  Abstract 


Ocular trauma and retained foreign bodies in the eye form a common occurrence in ophthalmic practice. Mild trauma may often be overlooked and patients, quite often, present late with serious complications. The clinical presentations and management of three patients who presented with a FB in the anterior chamber, within the lens, and within the orbit, respectively, are discussed. The diagnostic and management issues are highlighted along with a brief review of relevant literature.

Keywords: Foreign body, intralenticular, intraocular, intraorbital, ocular trauma, orbit


How to cite this article:
Menon S, Kumar PS, Pai H V. Rare foreign bodies encountered in ophthalmic practice. J Clin Ophthalmol Res 2021;9:34-7

How to cite this URL:
Menon S, Kumar PS, Pai H V. Rare foreign bodies encountered in ophthalmic practice. J Clin Ophthalmol Res [serial online] 2021 [cited 2021 Jun 22];9:34-7. Available from: https://www.jcor.in/text.asp?2021/9/1/34/313469



Ocular trauma and retained foreign bodies (FBs) in and around the eye form a common occurrence in ophthalmic practice. Retained intraocular FBs account for 18%–41% of ophthalmic trauma emergencies and are seen following road traffic accidents, injuries at workplaces, or due to sports injuries.[1],[2] Intraocular FBs maybe in the anterior chamber (AC), intralenticular or may be intraorbital.[3],[4],[5] Since a positive history of trauma is seldom elicited, a strong suspicion of retained FB is important while managing patients with recurrent ocular infections, persistent inflammation, or nonhealing discharging sinuses.[5],[6] We present three rare cases of ocular FBs encountered in our practice and discuss the diagnostic and management dilemmas involved.


  Case Reports Top


Case 1

A 43-year-old female presented with complaints of mild blurring of vision and intermittent pain in the right eye for 1 week. She did not give any history of injury to the eye. Slit-lamp examination revealed multiple nebular opacities on the cornea temporally and a linear FB lying horizontally in the AC [Figure 1]. An iris defect was present at 5 o'clock position and occasional cells were present in the AC. The pupil was round, regular, and reactive. Intraocular pressure (IOP) was 12 mmHg and gonioscopy revealed the position of tip of the FB in the angle [Figure 2].
Figure 1: Anterior segment photo showing a splinter (red arrow) lying horizontally in the anterior chamber

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Figure 2: Gonioscopic image depicting the sharp end of the foreign body (red arrow) in the angle

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The FB removal was done under peribulbar anesthesia. A clear corneal incision was made at 8 o'clock position in the periphery. Viscoelastic substance was injected into the AC and one end of the FB was then grasped using a pair of forceps and gently pulled out in toto. AC wash was done and wound closed with two interrupted sutures using 10-0 Nylon. Examination of the FB showed it to be a thin linear piece of wood, measuring 2 mm × 7 mm in size (probably a splinter from a broom).

Case 2

A 44-year-old male construction worker presented to the outpatient department with the complaints of diminution of vision in his left eye for the past 2 months. He gave a history of a small stone hitting his left eye 6 months back. On slit-lamp examination, a small corneal opacity was noted close to the limbus at 1 o' clock position and an iris defect immediately beneath. The AC was normal and a dense cataract was present. On pupillary dilation, the anterior capsule revealed a break at 1 o'clock position. There was no fundus view due to the cataract. B scan did not reveal any abnormality. An X-ray of the orbit revealed a small intraocular FB [Figure 3].
Figure 3: X-ray shows small opacity in the left orbit (white dot in the center of the red circle)

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The patient was taken up for cataract surgery under guarded visual prognosis. During phacoemulsification, a round, during hydro dissection, a pellet-like FB was noted within the lens matter [Figure 4] and it was removed using McPherson forceps. The posterior capsule was found to be intact. A posterior chamber intraocular lenses was implanted in the bag and wound closed using 10-0 Nylon. Examination of the FB showed a circular metallic pellet, 3 mm in diameter. He was prescribed topical steroids with antibiotics for a month postoperative period was uneventful and vision improved to 6/6 unaided and a near vision of N6 with an addition of +2.00DS.
Figure 4: Intraoperative visualization of the intralenticular foreign body (red arrow)

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Case 3

A 41-year-old man who sustained trauma to his left eye with a wooden stick, presented to the emergency after 1 day. He complained of being unable to open his left eye with mild pain and watering. His visual acuity was normal, he had complete ptosis of the left upper eyelid and extraocular movements were severely restricted in all gazes except adduction. IOP was measured to be 16 mmHg. The pupil was 6 mm dilated, round, and nonreacting. There was bullous subconjunctival hemorrhage, the cornea and lens were clear and AC showed no reaction. Fundus examination revealed no abnormality. Computerized tomography (CT) scans [Figure 5] and magnetic resonance imaging (MRI) [Figure 6] demonstrated a FB in the intraconal compartment of the left orbit lateral to the medial rectus muscle impinging the optic nerve. After 1 day of admission, his pain worsened and visual acuity dropped to 2/60. Under general anesthesia, the wound tract in the upper lid was explored and 2–3 slender wooden fragments were pulled out. Conjunctival peritomy was done from 12 o'clock to 6 o' clock medially and the medial rectus muscle was hooked. A 6 0'double armed Vikryl suture was passed through the tendon and the muscle was disinserted. As the entire FB could not be retrieved completely he underwent a neurosurgical left frontal craniotomy and orbital roof approach for removal a wooden FB measuring 3 mm × 5 mm in size [Figure 7]. On follow-up at 5 months, his vision and the extraocular movements improved to near normal.
Figure 5: Computerized tomography orbit showing a linear hypodensity suggestive of a foreign body measuring 1.0 cm × 0.3 cm × 2.2 cm in the intraconal compartment of the left orbit lateral to the medial rectus muscle impinging the optic nerve (red arrow)

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Figure 6: Magnetic resonance imaging demonstrating a well-defined linear T2 hypointensity measuring 2.5 cm × 1.0 cm of the left orbit adjacent to the medial rectus and indenting on the optic nerve (red arrow)

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Figure 7: Wooden foreign body measuring approximately 5 mm in length and 3 mm in width that was removed through orbital roof approach

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  Discussion Top


The common causes for ocular trauma are road traffic accidents, sports injuries, agricultural injuries, power-driven tools, dynamite blasts, gunshots, etc., Retained intraorbital FBs usually occur following high-velocity injuries such as gunshot injuries or industrial accidents, both of which are more common in young males.[7],[8]

Intraocular Foreign bodies are seen either in the anterior chamber, or in the orbit or they maybe intralenticular. AC FBs are rare accounting for only 15% of all intraocular FBs.[9],[10],[11] Common AC FBs include metallic iron, lead, copper, and nonmetallic FBs such as glass, plastic, cilia, wood, or other vegetative matter. The nonmetallic FBs often have a lower velocity and tend to remain in the AC. The reaction to wood and other vegetative matter depends on the concurrent introduction of microorganisms into the eye. Occasionally, the FB may remain stable in the eye for years, but more often they cause adverse effects such as endophthalmitis, the formation of granulomatous inflammatory masses.[12] Hence, removal of the AC FB is indicated irrespective of its size, inertness, and location.

Intralenticular FBs account for 7%–10% of all intraocular FB.[2],[3] They can be metallic or nonmetallic (cilia, glass, stone, vegetable matter, and coal). Cataract formation is the most common complication of retained intralenticular FB.[2] In addition to cataract formation, uveitis, glaucoma, endophthalmitis, retinal detachment, and intraocular metallosis (chalcosis/siderosis bulbi) have been occasionally reported.[2],[3],[12] Management of intralenticular metallic FBs is often conservative until intraocular inflammation or cataracts develop. Kuhn et al. recommend removing the lens if a cataract is present as happened in our patient.[10] Intraocular magnet for the removal of metallic FB is currently not recommended.[2]

History of penetrating eyelid or orbital injury should raise the suspicion of an intraorbital retained FB. It may remain asymptomatic or present with features of complications such as orbital cellulitis, orbital abscess, granulomas, ocular motility deficits, periostitis, or fistula formation.[13],[14] Wooden FBs may resemble air on CT or MRI, appearing hypodense on CT and hypointense on T2-weighted MRI. However, wooden FBs and very small FBs may be missed on CT scan.[15] Inert FBs such as glass, stone, and most metals are often well tolerated but copper and its alloys are exceptions. Organic matter such as wood often elicit a granulomatous reaction.[14] Indications for removal include the presence of inflammation, proptosis, restricted motility, optic nerve compression, and fistula formation. Failure to localize the FB, fragmentation of the FB, injury to other orbital structures as optic nerve damage, and ocular motility defects are possible complications of the procedure.[12]


  Conclusion Top


Timely detection of intraocular and intraorbital FBs and their removal is a must to improve the visual outcome and to prevent the occurrence of complications. Obtaining an accurate and detailed history is absolutely essential. We wish to reiterate the importance of a careful slit-lamp examination with appropriate radiographic modalities for diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Parver LM, Dannenberg AL, Blacklow B, Fowler CJ, Brechner RJ, Tielsch JM, et al. Characteristics and causes of penetrating eye injuries reported to the national eye trauma system registry, 1985-91. Public Health Rep 1993;108:625-32.  Back to cited text no. 1
    
2.
Zhang Y, Zhang M, Jiang C, Qiu HY. Intraocular foreign bodies in china: Clinical characteristics, prognostic factors, and visual outcomes in 1,421 eyes. Am J Ophthalmol 2011;152:66-730.  Back to cited text no. 2
    
3.
Dhir SP, Mohan K, Munjal VP, Jain IS. Perforating ocular injuries with retained intra-ocular foreign bodies. Indian J Ophthalmol 1984;32:289-92.  Back to cited text no. 3
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Arora R, Sanga L, Kumar M, Taneja M. Intralenticular foreign bodies: Report of eight cases and review of management. Indian J Ophthalmol 2000;48:119-22.  Back to cited text no. 4
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5.
Reddy SC. Intralenticular metallic foreign body: A case report. Int J Ophthalmol 2011;4:326-8.  Back to cited text no. 5
    
6.
Sinha AK, Sinha A. Intra-orbital foreign bodies and their management. Indian J Ophthalmol 1987;35:126-8.  Back to cited text no. 6
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7.
Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: A retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology 1997;104:96-103.  Back to cited text no. 7
    
8.
Jonas JB, Knorr HL, Budde WM. Prognostic factors in ocular injuries caused by intraocular or retrobulbar foreign bodies. Ophthalmology 2000;107:823-8.  Back to cited text no. 8
    
9.
Lit ES, Young LH. Anterior and posterior segment intraocular foreign bodies. Int Ophthalmol Clin 2002;42:107-20.  Back to cited text no. 9
    
10.
Kuhn F, Pieramici DJ. Endophthalmitis. In: Ocular Trauma: Principles and Practice. Thieme New York 2002. p. 293-300 TNY ISBN 1-58890-075-4.  Back to cited text no. 10
    
11.
Saar I, Raniel J, Neumann E. Recurrent corneal oedema following late migration of intraocular glass. Br J Ophthalmol 1991;75:188-9.  Back to cited text no. 11
    
12.
Loporchio D, Mukkamala L, Gorukanti K, Zarbin M, Langer P, Bhagat N, et al. Intraocular foreign bodies: A review. Surv Ophthalmol 2016;61:582-96.  Back to cited text no. 12
    
13.
Azad R, Sharma YR, Mitra S, Pai A. Triple procedure in posterior segment intraocular foreign body. Indian J Ophthalmol 1998;46:91-2.  Back to cited text no. 13
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14.
Al-Mujaini A, Al-Senawi R, Ganesh A, Al-Zuhaibi S, Al-Dhuhli H. Intraorbital foreign body: Clinical presentation, radiological appearance and management. Sultan Qaboos Univ Med J 2008;8:69-74.  Back to cited text no. 14
    
15.
Ho VT, McGuckin JF Jr. Smergel EM. Intraorbital wooden foreign body: CT and MR appearance. AJNR Am J Neuroradiol 1996;17:134-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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