ThucAnh T. Ho,
Mathew MacCumber
Worldwide, approximately 55 million eye injuries are believed to occur each year, leaving 1.6 million blind from injuries.[1] One to 2.5 million of these eye injuries are believed to occur in the United States eah year.[2,3] Globally, there are approximately 200,000 open globe injuries each year with an estimate of 3.5/100,000/year of perforating eye injuries.[1] Intraocular foreign bodies (IOFBs), particularly those in the posterior segment, challenge the ophthalmologist's diagnostic, therapeutic, and judgmental skills. Experience, refied imaging studies, and improved vitrectomy techniques are responsible for more effective management of intraocular foreign bodies and better outcome.
HISTORY
Risk factors for ocular trauma include age, gender, occupation, and recreational pursuits. The risk pattern by age peaks in the two extremes of life: 5-25 years of age and the over 70 age group.[4] Tielsch et al reviewed 9373 cases and found sports injuries to have the youngest peak incidence (10-19 years.) This provides the opportunity for intervention through regulations.[4] Males are 2 to 8 times more likely to sustain ocular injuries, especially children. Up to 25% of all serious ocular traumas occur in the workplace.[5] During a motor vehicle accident, up to 85% of ocular injuries of ocular injuries are sustained by unrestrained drivers or front seat passengers. Schrader looked at 1026 open globe injuries between 1981 and 1999 and found a decreased incidence of injuries sustained at work and in traffic accidents, with a decrease incidence of associated blindness and enucleations. Unfortunately, the incidence of injuries related to hobbies has risen during the same time period.[6]
The successful management of IOFBs begins with a detailed history. Once the patient is deemed systemically stable, a thorough history of the precipitating event and clinical examination to determine the size, composition, and location of the IOFB are essential in guiding surgical management. The time and circumstances of injury have medicolegal ramifications. Most states have a legal requirement to report firearms-related injuries. Suspected cases of child abuse need appropriate pediatric intervention. The interval from the time of injury to the time that medical attention is sought may be a determinant of treatment and prognosis. Infection, organization of the vitreous, cicatrization, and metallosis are all time-dependent. If the patient is referred from a colleague, information obtained from previous examinations, such as baseline visual acuity, diagnostic studies, and treatment is of great value in maximizing the prognosis and avoiding unnecessary repetition. Knowledge of prior examination is critical in cases when the media opacifies quickly, providing valuable information such as IOFB appearance, size, location, and associated retinal fidings. History of tetanus vaccination and drug allergies should also be determined.
Assiduous attempts should be made to determine the material composing the IOFB. Determining whether goggles or glasses were worn at the time of injury may prove valuable in ascertaining the nature of the foreign body. Glass, stone, plastic, and precious metals are inert, rarely causes a reaction, and can be tolerated for many years.[7] Iron containing materials, including steel, can induce a significant inflammatory response and possible siderosis. Copper can be particularly devastating through induction of a prominent inflammatory response, while alloys containing 80% copper or less can cause chalcosis.[8] Vegetable matter such as thorns, wood, and soil also produces a severe inflammatory reaction and is associated with the most devastating cases of endophthalmitis.
Very rarely do metal-on-metal injuries cause infection, perhaps because of the heat and speed of the missile; but unless the metallic foreign body is removed, iron-containing IOFBs may cause siderosis to develop. Copper foreign bodies often are associated with the use of wire cutters. The severity of inflammation and the rapidity with which chalcosis occurs are dependent on the location and the size of the copper fragment inside the eye. Rare cases of small copper IOFB located peripherally may cause little, if any, complication. Explosives and firearms, usually consisting of copper and lead, are associated with binocular damage, multiple foreign bodies, and double perforations.
EXAMINATION
Examination of the patient with an IOFB must be tailored to the clinical presentation and the extent of injury. A severely damaged open globe, with uveal prolapse and total hyphema, may require little more than a pen light examination. Determining at least the presence of light perception provides a basis for discussion with the patient and family regarding surgical intervention and prognosis. For most cases, however, determination of visual acuity, the presence of an afferent papillary defect, biomicroscopy, and ophthalmoscopy of both eyes is paramount in directing management and gauging prognosis. Predictors of fial visual outcome include initial visual acuity of 20/200 or better, anterior wounds, small wounds (?10 mm), and sharp injuries.[9] Self-sealing corneal wounds may permit gentle gonioscopy when anterior segment IOFB is suspected (Fig. 187.1), however gonioscopy may be more safely performed intraoperatively after wound stabilization. Not infrequently, the diagnosis is delayed or missed in cases where small, high-speed projectile penetrates the eye, causing minimal discomfort and little initial damage (Fig. 187.2). Only later will the patient present with persistent inflammation, visual blurring, iris discoloration, or an abnormal pupil. Even in retrospect, the patient seldom recollects the causative incident.[10,11] Consequently, all patients presenting with conjunctival or corneal foreign bodies or ocular irritation in association with high risk activities such as hammering metal-on-metal or use of power tools warrant a thorough ophthalmoscopic examination, even when an entry wound or anterior segment trauma is imperceptible. Subtle anterior chamber reaction, pupillary irregularity or defect, and lens changes may become apparent on closer inspection. If media opacities in the form of hyphema, cataract, or vitreous hemorrhage preclude adequate visualization to exclude an IOFB, imaging is necessary.
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FIGURE 187.1 Thirty-four-year-old man presented with foreign body sensation in the right eye after an automobile accident involving a shattered windshield. (a) Pie-shaped area of corneal edema. (b) Gonioscopy shows a small foreign body (arrow) in the angle. After surgical removal, visual acuity improved from 20/30 to 20/20. |
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FIGURE 187.2 Subtle sclera foreign body in a quiet eye, easily overlooked without careful inspection. The depth of the foreign body needs to be ascertained. |
IMAGING STUDIES
In general, eyes with suspected IOFB require imaging to determine the presence, location and number of IOFBs. Non-contrast computerized tomography (CT) scanning has replaced conventional radiography (Fig. 187.3) as the diagnostic study of choice for all forms of ocular trauma. Computed tomography provides much more reliable information on size, shape, and localization of the foreign body, whether in the anterior or the posterior segment (Fig. 187.4).[12-15] Drawbacks of conventional CT include separate scanning in axial and coronal planes leading to prolonged scanning time and radiation exposure. Reconstruction is limited by stair-step artifact, compromising detection and localization of small and multiple foreign bodies, especially those adjacent to the sclera or optic nerve. Volume averaging also hinders detection and localization of small and multiple foreign bodies.[16] Current spiral CT scanning with both 1-mm and 3-mm cuts can detect metallic IOFB as small as 0.5-mm with nearly 100% sensitivity.[17] Spiral CT allows continuous scanning in less time with volumetric, overlapping data acquisition, providing multiplanar reconstruction of high-quality coronal and sagittal images. Thinner slices mean less volume averaging and better detection and localization of small and multiple foreign bodies. Size and location of IOFB detected on helical CT corresponded with what was found during surgical and clinical follow-ups.[16]
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FIGURE 187.3 Lateral x-ray view demonstrates multiple facial and intraocular foreign bodies. |
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FIGURE 187.4 (a) Computed tomography scan of a foreign body in the retina at the nasal equator. (b) Entry site. (c) Scleral buckle at the site of the transscleral posterior extraction. (d) Normal posterior pole-20/20 vision. |
In eyes with small stable wounds, judicious use of B-scan ultrasonography over closed eyelids (Fig. 187.5) has proved useful in determining the extent of intraocular damage, retinal detachment, and double perforation, as well as in detecting foreign bodies not seen on CT, such as vegetative IOFBs.[18,19,20] Using high-frequency (50 MHz) sound waves, ultrasound biomicroscopy (UBM) is able to creat high-resolution, 2-dimensional cross-sectional anterior segment images to a depth of 5 mm. It has proven to be a useful adjunct in the detec-tion of small foreign bodies, including those of nonmetallic composition, not otherwise detected by CT and/or B-scan ultrasonography.[21,22] Magnetic resonance imaging are only occasionally useful in the setting of ocular trauma, such in the detection of radioopaque IOFBs in large unstable wounds and it must be avoided when iron-containing, i.e. metallic, IOFBs are suspected.[23-28]
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FIGURE 187.5 (a) Ultrasonogram of an intraocular foreign body. (b) Ultrasonogram shows an intraocular foreign body perforating the posterior wall of the globe. |
COMPLICATIONS
The extent of the initial injury is predictive of the fial outcome with the entry site, size, number, and composition of the foreign body determining factors. Loss of media clarity, hemorrhage, and infection make up the spectrum of complications from visual diminution to loss of the eye.
METAL-INDUCED TOXICITY
More insidious are the complications in an eye harboring a copper- or iron-containing foreign body. Occult entry or difficulties attendant on removal, which was a problem especially with copper and other nonmagnetic foreign bodies before the advent of vitrectomy, most commonly explain the prolonged presence of such a foreign body in the eye. In the case of iron, siderosis may develop within weeks, but the course is variable depending on the iron content in the foreign body and its location. Virtually all ocular structures are involved in the siderotic process-corneal opacities, glaucoma, cataract, iris color changes, mydriasis, retinal function destruction, and optic nerve atrophy. The effects of copper are also dependent on size, composition, and location. A small particle near the pars plana that becomes quickly and totally encapsulated may cause no reaction, whereas a fragment of pure copper induces acutely destructive, violent inflammation.[31] In contrast, the reaction to an alloy is more gradual. Chalcosis develops as copper diffuses from the foreign body and deposits in the peripheral cornea, iris, vitreous, retinal surface, and zonules. The sunflower cataract is the result of deposition of copper ions in the lens. Nickel, aluminum, mercury and zinc may produce milder inflammatory reactions.
In the case of a suspected longstanding iron-containing IOFB, anisocoria, abnormal pupillary reaction, and heterochromia may be present (Fig. 187.6). Rust-colored precipitates may form on the corneal endothelium as well as iron lines at the level of the corneal epithelium. Cataractous changes may vary from brown dust-like accumulations on the anterior capsule to a mature partially or totally dislocated cataract. Posterior segment fidings include rusty vitreous fibers, blunted retinal reflex, arteriole narrowing, and disc pallor.[32] Electroretinography (Fig. 187.7) is invaluable in providing information of a diagnostic as well as a prognostic nature. When a difficult decision regarding removal of a longstanding intraocular foreign body is held in abeyance, close follow-up with periodic full-field electroretinograms can provide clear documentation of the progression of toxic changes and indications for intervention.[33]
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FIGURE 187.6 Iris color change in an eye harboring an occult ferrous foreign body. (a) Normal right eye. (b) Darker iris of the siderotic eye. |
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FIGURE 187.7 (a) Electroretinogram of an eye with siderosis from a retained ferrous intraocular foreign body. (b) Electroretinogram 4 months after removal of the foreign body. Note the return to normal evidenced by increased b-wave amplitude and decreased implicit time. |
Studies of the pathologic features of eyes with siderosis have revealed iron deposits accumulated in the regions of ocular pumps such as corneal endothelium and Descemet's membrane, trabecular meshwork, pupillary constrictor muscles, ciliary epithelium, lens epithelium, retinal pigment epithelium, and internal limiting membrane.[34] In chalcosis, marked inflammation has been found around the copper foreign body along with copper deposits in the peripheral corneal stroma, Descemet's membrane, lens, vitreous, and surface of the retina.[35]
ENDOPHTHALMITIS AND OTHER COMPLICATIONS
The introduction of virulent infectious organisms such as from vegetable material can destroy the eye in a matter of hours (Fig. 187.8). Appropriate, timely, and successful intervention will minimize but not eliminate complications.[36-39] Endophthalmitis remains a main concern, although the incidence has been reduced by antibiotics and prompt intervention.[40] It can be a particularly vexing problem in farming communities.
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FIGURE 187.8 Anterior segment findings in a patient with IOFB-related endophthalmitis, including hypopyon, corneal edema, and conjunctival injection. |
Intraoperative bleeding continues to be a significant cause of failure, as does rhegmatogenous retinal detachment with proliferative vitreoretinopathy that does not respond to treatment (Fig. 187.9).[42]Delayed vitreous organization, fibrous proliferation, subretinal neovascularization,[43] retinal detachment, and epiretinal membranes (Fig. 187.10) add to the uncertainty of the prognosis.[44,45] Sympathetic ophthalmia is a rare but potentially devastating complication of intraocular foreign bodies and of vitrectomy. The difficulty of postoperative visual rehabilitation is increased by the often-present corneal scarring and aphakic status.
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FIGURE 187.9 (a) Clinical photo of an IOFB-associated retinal detachment with proliferative vitreoretinopathy. (b) Gross pathological specimen of a similar case. |
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FIGURE 187.10 Evolution of epimacular fibrosis from a scar at the untreated impact site of a foreign body. (a) Impact site amidst small retinal and vitreous hemorrhage. (b) Slight clearing 1 month later. (c) Cicatrization with epimacular fibrosis 7 months later. (d) Causative foreign body. Final vision was 20/200. |
MANAGEMENT
INITIAL INTERVENTION
The initial management of all IOFBs is similar to that of other cases of open-globe injury. Perhaps the most important role of the ophthalmologist in all eye trauma cases is to ensure that the patient is first cleared by the trauma team of any serious systemic injuries before the patient is transferred to the ophthalmologist's care (Fig. 187.11). Not infrequently, the referring physician is alarmed with the appearance of the eye and overlooks or rushes the systemic evaluation to expedite ocular management. The trauma team should be reassured that a rushed systemic clearance rarely improves ophthalmic outcome.
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FIGURE 187.11 Systemically unstable patient with multiple intraocular and facial foreign bodies. |
Patients without recent immunization should receive tetanus prophylaxis. All patients should be given systemic antibiotics such as a fourth generation fluoroquinolone and, if necessary, antiemetics. In cases of vegetable matter, coverage against Bacillus species with systemic clindamycin or vancomycin should also be considered. All protruding foreign material should be left undisturbed and a shield should be place over every eye with a suspected open-globe injury (Fig. 187.12). Preoperative topical medication is seldom necessary and risks disrupting the wound, especially in the hands of individuals unfamiliar with the management of eye trauma. Occasionally, a carefully placed antibiotic-soaked bandage contact may aid in reforming or maintaining an anterior chamber in smaller, well-opposed corneal laceration when surgery is unavoidably delayed.
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FIGURE 187.12 Protruding intraocular foreign body should be shielded, e.g. with a plastic cup, and removed in a controlled fashion in the operating room. |
Timing of surgical IOFB removal remains controversial, however, most recommend early removal to minimize complications such as infectious endophthalmitis, fibrous encapsulation of the IOFB, and proliferative vitreoretinopathy.[46] Delayed surgery, on the other hand, allows for improved visualization and the possible development of a spontaneous vitreous detachment to facilitate surgical removal. Because of the high rate of devastating endophthalmitis, intraocular copper as well as IOFBs contaminated with organic matter should be removed immediately. Magnetic elements such as aluminum, zinc, iron, steel, mercury and nickel should be removed within 24 hours. Inert elements such as glass, gold, silver, and platinum can be observed if there is no evidence of infection or structural disruption.[7] If early surgical intervention is not possible, particularly if there is evidence of infectious endophthalmitis, injection of intravitreal antibiotics prior to surgical removal of the IOFB has been advocated.[47]
SURGICAL TECHNIQUE
Traditionally, general anesthesia is utilized in the management of ocular trauma. However, this is contraindicated in high-risk patients and is associated with a longer recovery. Recently, some surgeons have investigated the use of intravenous sedation with local, or even topical, anesthesia in selected patients. Scott, et al looked at 220 patients with open globe injuries managed at Bascom Palmer Eye Institute between 1995 and 1999. Sixty-four percent of these cases were performed under intravenous sedation and local anesthesia, in the form of retrobulbar or peribulbar blocks with augmentation after conjunctival cut-down. Patients managed under local anesthesia and intravenous sedation were more likely to have better presenting visual acuity, IOFBs, more anteriorly located and shorter wounds.[48] In addition to the well-known complications of retrobulbar blocks, care must be taken to prevent expulsion of intraocular content in the presence of larger wounds. Boscia, et al looked at the use on topical anesthesia and intravenous sedation in 10 open globe cases and found it to be a reasonable alternative in less severe injuries.[49]
Careful preoperative preparation of the globe as well as lid speculum placement is necessary to limit the extent of the injury and minimize introduction of toxic agents into the open eye. Stabilization of the globe is necessary before the IOFB is addressed. The peritomy should be extensive, starting several millimeters from the wound, to allow adequate exposure. Corneoscleral lacerations should initially be stabilized with a 9-0 nylon suture at the limbus. The cornea is then closed with 10-0 nylon while 8-0 or 9-0 nylon is used to close the scleral extension of the wound (Fig. 187.13). Disinserting a rectus muscle may be necessary to improve visualization and reduce pressure on the open globe (Fig. 187.14). Prolapsed uveal tissue is reposited if clean and viable; it is excised if necrotic or contaminated. When the corneal penetration results in disruption of the anterior chamber, a limbal paracentesis opposite the wound is useful to reform the anterior chamber, evacuate blood or debris, introduce a spatula to release the iris from the wound, or irrigate to test the wound closure. After reestablishing the integrity of the globe, it is best to proceed with removal of the foreign body at the time of the primary repair.
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FIGURE 187.13 Corneoscleral lacerations should initially be stabilized with a 9-0 nylon suture at the limbus (a). The cornea is then closed with 10-0 nylon (b) while 8-0 or 9-0 nylon is used to close the scleral extension of the wound (c). |
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FIGURE 187.14 Disinserting a rectus muscle may be necessary to improve visualization and reduce pressure on the open globe. |
REMOVAL OF IOFB VIA EXTERNAL MAGNET
Because the majority of intraocular foreign bodies are magnetic, the role of magnets continues to be very important in the treatment of intraocular foreign bodies. A myriad of magnets have been employed over the years (Fig. 187.15).[50-54] Although vitrectomy with use of a rare earth intraocular magnet is increasingly applied for IOFB removal, the external electromagnet (is still occasionally necessary, particularly when vitrectomy machinery is unavailable. Although somewhat unwieldy because of its weight, the later is capable of creating a strong magnetic field via a blunt conical tip using short bursts of electrical application to avoid heat generation. Additional important considerations in the magnetic extraction of intraocular foreign bodies are:
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FIGURE 187.15 Commonly used magnets. (a) Electromagnet. (b) Rare earth magnet. (c) Pencil magnet. |
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The magnetism of a metallic foreign body is directly related to its iron content. |
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A magnetic foreign body orients itself longitudinally to the magnet, a change of orientation that can be damaging if it occurs near the retina. |
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The strength of the magnet decreases as its distance from the foreign body increases, the magnetic force being inversely proportional to the cube of the distance. |
Williams, et al found the entrance wound to be 65% corneal, 25% scleral, and 10% corneoscleral with its fial location 61% vitreous, 23% anterior chamber/lens and 19% retinal.[44] The external magnet is employed through the existing ocular wound, or through another incision after the entrance wound is stabilized and the anterior chamber is reformed with balanced salt solution or viscoelastic. Well-visualized, intravitreal, magnetic IOFB can safely be extracted through a pars plana sclerotomy utilizing an external electromagnet. Care is made to ensure that the sclerotomy is sufficiently large to allow easy passage of the IOFB without tissue incarceration. Preplaced sutures will expedite closure and minimize risks of hypotony after removal of a large IOFB. Occasionally, a shelved limbal incision may be necessary if the IOFB is sufficiently large.
REMOVAL OF IOFB VIA FORCEPS
The approach to a foreign body located in the anterior chamber or superficially embedded in the lens usually involves reformation of the anterior chamber with viscoelastic and closure of the corneoscleral wound first. The IOFB can then be removed in controlled fashion through a shelved limbal or corneal incision via either IOFB forceps if it is nonmagnetic or adherence to an intraocular magnet followed by transferal to a foreign body forceps for removal (Fig. 187.16). If the anterior lens capsule has been violated, consideration should be made to remove of the lens by phacoemulsification or extracapsular extraction, especially if there is extrusion of lenticular material, to avoid complications of phacogenic uveitis and glaucoma. (Fig. 187.17). In some cases, small intralenticular IOFBs can be left in place and followed for the development of cataract. If there is posterior capsular disruption or zonular instability, a pars plana lensectomy may be necessary. The placement of a primary intraocular lens is reasonable if there is adequate support and no evidence of endophthalmitis. When performed, the lens calculations can be derived from the keratometry and axial length measurements of the fellow eye preoperatively. In general, the results of foreign body extraction from the anterior chamber, iris, or lens are excellent.[55]
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FIGURE 187.16 (a) Foreign body in the anterior chamber. (b) After corneal wound closure, the IOFB can then be removed in controlled fashion through a shelved limbal via IOFB forceps. |
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FIGURE 187.17 Intracapsular cataract extraction performed to remove an intraocular foreign body deeply embedded in a cataractous lens. |
Posterior segment IOFBs are often more problematic because they are may be difficult to see, reach, and remove due to associated ocular damage. The route of removal of an IOFB from the posterior segment is determined by its location, its size, its magnetic property, and the clarity of the media.[56] Attempts to remove the foreign body blindly or through the entry site are too dangerous and are not recommended. Preservation of the lens is occasionally achievable[57] even when it is damaged by the foreign body, but if visibility is compromised, lensectomy becomes unavoidable. Pars plana vitrectomy techniques are usually employed to remove both magnetic as well as nonmagnetic IOFBs, especially in the presence of media opacification due to cataract or blood. Vitrectomy is performed to release vitreous around the IOFB. If magnetic, initial adherence to an intraocular magnet followed by transfer to an IOFB forceps is then performed (Fig. 187.18). If nonmagnetic, forceps alone are used. The sclerotomy should be enlarged to the appropriate size for atraumatic IOFB removal. As complete a removal of vitreous as safely possible is then performed, including consideration of elevation of the posterior hyaloid to avoid late complications. Retinal detachment repair is carried out if required. A prophylactic scleral buckle should be considered in cases of severe injury, especially in association with an anterior wound and vitreous loss.
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FIGURE 187.18 (a) Track of a foreign body through the cornea, iris, and lens. (b) Foreign body in the vitreous with dense hemorrhage. (c) After closure of the corneal wound, pars plana vitrectomy is performed to release vitreous around the intravitreal IOFB. If magnetic, initial adherence to an intraocular magnet followed by transfer to an IOFB forceps is then performed. |
If the magnetic foreign body is impaled in the retina and choroid, the removal approaches are either anteriorly via the pars plana using vitrectomy techniques (Fig. 187.19)[28,58] or via the posterior transscleral route, particularly with magnet foreign bodies in severely traumatized eyes (Fig. 187.20).[59] The latter approach requires localization of the IOFB by indirect ophthalmoscopy with external marking of the sclera, ultrasonography or scleral bulging pulsation induced by the external electromagnet. Scleral flaps are dissected, diathermy is applied in the scleral bed in stepping-stone fashion, and a sclerotomy is made directly over the foreign body. A small incision is made in the bulging choroid, and the foreign body is delivered with the external magnet. The scleral flap is then sutured.
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FIGURE 187.19 Nine-year-old boy with a blasting cap injury of the left eye. (a) Anterior tract through the cornea, iris, and lens. (b) Foreign body on the retinal surface. (c) Lensectomy, vitrectomy, and forceps removal of the copper-containing foreign body were performed. |
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FIGURE 187.20 (a) Magnetic foreign body impaled in the retina. (b) Trap door and diathermy at localization site under disinserted rectus muscle. (c) Foreign body causes a bulge of the choroidal knuckle through the sclerotomy, with approach of the magnet. (d) Delivery of foreign body with a pencil magnet. (e) Silicone implant. (f) Sutured flaps. (g) Internal view of the extraction site and buckle effect. |
For eyes with salvageable vision, IOFBs are usually best managed with pars plana vitrectomy. Extraction of an encapsulated foreign body is facilitated by first clearing the condensed vitreous and capsule surrounding it (Fig. 187.21). Care should be taken to remove the posterior hyaloid and trim the vitreous base to decrease the risk of postoperative formation of proliferative vitreoretinopathy and retinal detachment (Fig. 187.9). If magnetic, initial adherence to an intraocular magnet followed by transfer to a foreign body forcep under direct microscopic illumination is performed. If nonmagnetic, forceps alone are used. Care must be taken to assess the size and shape of the foreign body, to choose the appropriate forceps,[60] and to properly prepare the pars plana extraction site. Removal of subretinal nonmagnetic foreign bodies may require a retinotomy or gentle manipulation to move them to a safer location before making them accessible to the forceps.[61] Retinal or choroidal bleeding should be anticipated and rapidly treated with elevation of intraocular pressure, direct tamponade, or cautery as required. Additionally, liquid perfluorocarbon may be used to protect the macula from inadvertent intraoperatively dropped IOFBs. Retinal tears at the site of impact are treated with laser or cryopexy if the edges are elevated or if early signs of retinal detachment are present (Fig. 187.22). When there is no associated retinal detachment at the impact site, retinopexy may not be necessary.[62]
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FIGURE 187.21 (a&b) Encapsulated foreign body lying on retina. (c) Accessing the retinal IOFB through the surrounding capsule. |
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FIGURE 187.22 (a) Foreign body lying on the retina amidst vitreous hemorrhage, next to a retinal tear at the site of impact. (b) After removal of the foreign body and retinopexy. |
Broad spectrum intravitreal antibiotics such as vancomycin (1-2 mg/0.1 ml), ceftazidime (2 mg/0.1 ml), and/or clindamycin (1 mg/0.1 ml) should be considered intraoperatively in all cases of vegetable matter foreign body, concurrent endophthalmitis, or suspected contaminated IOFBs. Postoperative management includes systemic broad-spectrum antibiotics, topical broad-spectrum antibiotics such as a fourth-generation fluoroquinolone topical steroids, and cycloplegia. The patient should be followed particular closely during the first few days in hospital or on an outpatient basis for development of endophthalmitis or other trauma-related complication.
PREVENTION
Although the incidence of intraocular foreign bodies is small compared with the multitude of problems that affect the eye, their toll (personal and economic) is vastly disproportionate to their number because those afflicted are overwhelmingly young and often in their most productive years.[63] Despite therapeutic advances, a significant number of eyes are lost, and of those that are saved, subnormal vision is a common outcome. Although eyes generally fair better than with other open-globe injuries, the percentage of eyes with excellent vision after intraocular foreign body removal is small.[64] It is obvious, therefore, that in addition to the careful history, examination, ancillary studies, and timely and appropriate intervention, better efforts are necessary. What we learn from retrospective studies is limited by insufficiently detailed data and inadequate classification of the ocular injuries. Closer attention to classifying the extent of injuries caused by intraocular foreign bodies will not only aid in their management but also provide better information on which to base a prognosis and perhaps preventative measures.[65,66] Educating the public to increase the general awareness of the potentially calamitous consequences of seemingly innocuous activities, such as hammering a nail or "playing" with BB guns, is imperative.[67] Equally important is the need to stress the use of protective glasses on the job and in the home when performing tasks involving hammering or other activities that could possibly entail a projectile.[68] Avoiding unnecessary visual loss can best be achieved by pursuing prevention as the paramount goal.[69,70]
ACKNOWLEDGMENT
Many of the figures were collected and generously provided by Kirk H. Packo, MD and Maggie DeAlba, RN. Alexander R Gaudio contributed to the previous edition of this chapter.
REFERENCES
1. Negrel ADTB: The global impact of eye injuries. Ophthalmic Epidemiology 1998; 5(3):143-169.
2. Praver L: Eye trauma: The neglected disorder. Archive of Ophthalmology 1986; 104:1452-1453.
3. White MFJ, Morris R, Fiest RM, Witherspoon CD, Helms Jr. HA, John GR: Eye injury: Prevalence and prognosis by setting. South Med J 1989; 82:151-158.
4. Tielsch JM, P L, Shankar B: Time trends in the incidence of hospitalized ocular trauma. Ophthalmology 1989; 107:519-523.
5. Blindness, N S t P: A guideline for controlling eye injuries in industry. National Society to Prevent Blindness. 1990; New York.
6. Schrader W: Open globe injuries: Epidemiological study of two eye clinics in Germany, 1981-1999. Croatian Medical Journal 2004; 45(3):268-274.
7. Saar I, R J, Neumann E: Recurrent corneal edema following late migration of intraocular glass. Br J Ophthalmol 1991; 75:188-189.
8. Duke-Elder SS, M P: Mechanical Injuries, St Louis, CV Mosby, 1972.
9. Esmaeli B, e a: Visual outcome and ocular survival after penetrating trauma. A clinicopathologic study. Ophthalmology 1994; 102:393-400.
10. Lebowitz AA, C J, Thompson JT, Shields JA: Occult foreign body simulating melanoma with extrascleral extension. Retina 1988; 8:141-144.
11. Duber JSF: Occult plastic intraocular foreign body. Ophthalmic Surg 1989; 20:169-170.
12. Zinreich SJ, M N, Aguayo JB, et al: Computed tomographic three dimensional localization and compositional evaluation of intraocular and orbital foreign bodies. Arch Ophthalmol 1986; 104:1477-1482.
13. Lindahl S: Computed tomography of intraorbital foreign bodies. Acta Radiol 1987; 28:235-240.
14. Etherington RJ, H M: Localization of intraocular and intraorbital foreign bodies using computed tomography. Clin Radiol 1989; 40:610-614.
15. Chacko JG, F R, Johnson MH, et al: Detection and localization of steel intraocular foreign bodies using computed tomography. A comparison of helical and conventional axial scanning. Ophthalmology 1997; 104:319-323.
16. Lakis A, P R, Scholda C, Bankier A: Orbital helical computed tomography in the diagnosis and management of eye trauma. Ophthalmology 1999; 106:2330-2335.
17. Dass AB, F P, Chu RY, et al: Sensitivity of spiral computer tomography in detecting intraocular foreign bodies. Ophthalmology 2001; 108:2326-2328.
18. Fisher Y: Advances in contact ophthalmic ultrasonography: Ocular trauma and intraocular foreign body patients. Dev Ophthalmol 1989; 18:69-74.
19. Bryden FM, P A, Bailey M, McGhee CN: Real time ultrasound in the assessment of intraocular foreign bodies. Eye 1990; 4:727-731.
20. Rubsamen PE, C S, Winward KE, Byrn SF: Diagnostic ultra sound and pars plana vitrectomy in penetrating ocular trauma. Ophthalmology 1994; 101:809-814.
21. Barash D, G-C N, Tzadok D, Lifshitz T, Yassur Y, Weinberger D: Ultrasound biomicroscopic detection of anterior ocular segment foreign body after trauma. American Journal of Ophthalmology 1998; 126:197-202.
22. Deramo V, S G, Baumal CR, Fineman MS, Correa ZM, Benson WE, Rapuano CJ, Cohen EJ, Augsburger JJ: Ultrasound biomicroscopy as a tool for detecting and localizing occult foreign bodies after ocular trauma. Ophthalmology 1999; 106(2):301-305.
23. LoBue TD, D T, Lobick J, Turner DA: Detection and localization of nonmetallic intraocular foreign bodies by magnetic resonance imaging. Arch Ophthalmol 106:260-261.
24. Lagouros PA, L B, Peyman GA, et al: Magnetic resonance imaging and intraocular foreign bodies. Arch Ophthalmol 1987; 105:551-553.
25. Williams S, C D, Dillon WP, et al: Ferrous intraocular foreign bodies and magnetic resonance imaging. Am J Ophthalmol 1988; 105:398-401.
26. Williamson TH, S F, Forrester JV: Magnetic resonance imaging of intraocular foreign bodies. Br J Ophthalmol 1989; 73:555-558.
27. Glatt HJ, C P, Barrett L, Sartor K: Magnetic resonance imaging and computed tomography in a model of wooden foreign bodies in the orbit. Ophthal Plast Reconstr 1990; Surg 6:108-114.
28. Ambler JS, M S: Management of intraretinal metallic foreign bodies without retinopexy in the absence of retinal detachment. Ophthalmology 1991; 98:391-394.
29. Kelsey CA, K J, Keck GM, et al: Ocular hazard of metallic fragments during MR imaging at 0.06 T. Radiology 1991; 180:282-283.
30. Kremmer S, S U, Wilhelm H, Zenner E: Mobilisation intraokularer Fremdkorper durch Magnet Resononz Tomographie. Klin Monatsbl Augenheilkd 1996; 208:201-202.
31. Micovic V, M S, Opric M: Acute aseptic panophthalmitis caused by a copper foreign body. Fortschr Ophthalmol (Germany) 1990; 87:362-363.
32. Sneed S: Ocular siderosis. Arch Ophthalmol 1988; 106:997.
33. Good P, G K: Electrophysiology and metallosis: Support for an oxidative (free radical) mechanism in the human eye. Ophthalmologica 1988; 196:204-209.
34. Bernardino VB, J: 1992.
35. Rosenthal AR, M M, Leuenberger P, Hopkins JL: Chalcosis: A study of natural history. Ophthalmology 1979; 86:1956.
36. Percival S: Late complications from posterior segment intraocular foreign bodies. Br J Ophthalmol 1972; 56:462.
37. Armstrong M: A review of intraocular foreign body injuries and complications in N. Ireland from 1978-1986. aInt Ophthalmol 1988; 12:113-117.
38. Behrens Baumann WPG: Intraocular foreign bodies. 297 consecutive cases. Oftalmologica 1989; 198:84-88.
39. Seal DV, K C: Criteria for intravitreal antibiotics during surgical removal of intraocular foreign bodies. Eye 1992; 6:465-468.
40. Thompson JT, R L, Enger CL, et al: (For the National Eye Trauma System): Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. Ophthalmology 1993; 100:1468-1474.
41. Mieler WF, E M, Williams DF, Han DP: Retained intraocular foreign bodies and endophthalmitis. Ophthalmology 1990; 97:1532-1538.
42. Cardillo JA, S J, LaBree L, et al: Post traumatic proliferative vitreoretinopathy. The epidemiologic profile, onset, risk factors, and visual outcome. Ophthalmology 1997; 104:1166-1173.
43. Trimble SN, S H: Subretinal neovascularization following metallic intraocular foreign body trauma. Arch Ophthalmol 1986; 104:515-519.
44. Williams DF, M W, Abrams GW, Lewis H: Results and prognostic factors in penetrating ocular injuries with retained intraocular foreign bodies. Ophthalmology 1988; 95:911-916.
45. Punnonen E, L L: Prognosis of perforating eye injuries with intraocular foreign bodies. Arch Ophthalmol (Copenh) 1989; 67:483-491.
46. Jonas JB, B W: Early versus late removal of retained intraocular foreign bodies. Retina 1999; 19:193-197.
47. Knox FA, B R, Kinsella F, Mirza K, Sharkey JA, Mulholland D, Altaie R: Management of endophthalmitis with retained intraocular foreign bodies. Eye 2004; 18:179-182.
48. Scott IU, M C, Flynn HW, Lemus DR, Schiffman JC, Reynolds DS, Pereira MB, Belfort A, Gayer S: Local anesthesia with intravenous sedation for surgical repair of selected open globe injuries. American Journal of Ophthalmology 2002; 110:1555-1559.
49. Boscia FLTM, Columbo G, Alessio G, Sborgia C: Combined topical anesthesia and sedation for open-globe injuries in selected patients. Ophthalmology 2003; 110:1555-1559.
50. Crock GW, J P, Reddy P: Intraocular magnet of Parel. Br J Ophthalmol 1986; 70:879-885.
51. Nishi O: Magnetic device for removal of intraocular foreign bodies. Ophthalmic Surg 1987; 18:232-233.
52. Mansour A: New attachment for the ocular magnet. Ann Ophthalmol 1988; 20:239.
53. May DRNF, Munoz R: A 20 gauge intraocular electromagnetic tip for simplified intraocular foreign body extraction. Arch Ophthalmol 1989; 107:281-283.
54. McCuen II BWHD: A new retractable micromagnet for intraocular foreign body removal. Arch Ophthalmol 1989; 107:1819-1820.
55. Hadden OB, W J: The management of intraocular foreign bodies. Aust N Z J Ophthalmol 1990; 18:343-351.
56. Coleman DJ, L B, Rondeau MJ, Chang S: Management of intraocular foreign bodies. Ophthalmology 1987; 94:1647-1653.
57. Pieramici DJCAJ, Rubsamen PE, Roseman RL: Lens preservation after intraocular foreign body injuries. Ophthalmology 1996; 103:1563-1567.
58. Slusher M: Intraretinal foreign bodies. Management and observations. Retina 1990; 10(Suppl 1):S50-S54.
59. Karel I, D P: Management of posterior segment intraocular foreign bodies and long term results. Eur J Ophthalmol 1995; 5:113-118.
60. McCarthy MJ, P J, Soukup B: The use of ureter stone forceps to remove a large intraocular foreign body. Am J Ophthalmol 1990; 110:208-209.
61. Joondeph BC, FHJ : Management of subretinal foreign bodies with a cannulated extrusion needle. Am J Ophthalmol 1990; 110:250-253.
62. Lai WW, M S, Brent GJ, Humayan M, Langston RH: Management of the retinal impact site after intraocular foreign body trauma. Ophthalmology 2000; 107(5):811-812.
63. Khan MD, K N, Mohammed Z, Nazeer AF: A 6½ years' survey of intraocular and intraorbital foreign bodies in the North west Frontier Province, Pakistan. Br J Ophthalmol 1987; 71:716-719.
64. Williams DF, M W, Abrams GW: Intraocular foreign bodies in young people. Retina 1990; 10(Suppl 1):S45-S49.
65. Kuhn F, M R, Witherspoon CD, et al: A standard classification of ocular trauma. Ophthalmology 1996; 103:240-243.
66. Pieramici DJ, SPJ , Aaberg JM, et al: A system for classifying mechanical injuries of the eye. Am J Ophthalmol 1997; 123:820-831.
67. Owen P, K S, Elkington AR: The hazards of hammers. Injury 1987; 18:61-62.
68. Dunn Jr JP, B S, Mondino BJ, Goodwin Jr LT: Ocular trauma caused by exploding glass bottles containing dry ice and water. Ophthalmic Surg 1990; 21:628-631.
69. Jeffers J: The role of organized ophthalmology in preventing ocular injuries. Int Ophthalmol Clin 1988; 28:255-258.
70. Pizzarello L: American Academy of Ophthalmology's commitment to eye safety. [Letter]. Arch Ophthalmol 1989; 107:1565.
