Review of 555 cases of intra-ocular foreign body with special reference to prognosis

High risk and low prevalence diseases: Open globe injury

INTRODUCTION

Open globe injury (OGI) is a rare but serious condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of OGI, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

OGI refers to full-thickness injury to the layers of the eye. OGI can be caused by blunt or sharp trauma, and subtypes include penetration, perforation, intraocular foreign body (IOFB), globe rupture, or mixed types. OGI is more common in males and usually secondary to work-related injury, but in women it is most commonly associated with falls. Emergency clinicians should first assess for and manage other critical, life-threatening injuries. Following this assessment, a thorough eye examination is necessary. Computed tomography (CT) may suggest the disease, but it cannot definitively exclude the diagnosis. While point-of-care ultrasound (POCUS) is highly sensitive and specific for some findings in OGI, its use is controversial due to potential globe content extrusion. Management includes protecting the affected eye from further injury, preventing Valsalva maneuvers that could extrude ocular contents, updating tetanus vaccination status, administering broad-spectrum antibiotics, and ophthalmology consultation for surgical intervention to prevent the sequelae of blindness and endophthalmitis.

CONCLUSION

An understanding of OGI can assist emergency clinicians in diagnosing and managing this sight-threatening traumatic process.

Be careful where you aim: craniomaxillofacial trauma from the utility of metal hammers

PURPOSE

A hammer is a popular tool among the "do it yourself" (DIY) population who pursue home-improvement projects. While we are aware that hammers have health hazards, no study has yet to explore the craniomaxillofacial injuries that could arise from the use of hammers. The purpose of this study is to describe the characteristics of craniomaxillofacial injuries from hammers.

MATERIALS AND METHODS

This is a 20-year cross-sectional study conducted using the National Electronic Injury Surveillance System (NEISS). Injuries from hammers were included in this study if they involved the head, face, eyeball, mouth, or ear. The study predictor was the mechanism of injury. The study outcome was the admission rate from the emergency department (ED) and anatomical site injured. Patient and injury characteristics were compared using chi-squared and independent sample tests.

RESULTS

Our final sample had a total of 2967 hammer-induced injuries. Most of the sample consisted of white (55.3%) males (80.2%). Summer was the most injury-congested season (30.1%). The majority of the patients were over the age of 18 (65.6%). Laceration (47.3%) was the most common primary diagnosis, followed by contusion/abrasion (21.9%). The head (42.9%) was the most commonly injured craniomaxillofacial region followed by the face (29.0%). Craniomaxillofacial injury most frequently transpired at the patient's home (63.6%). Concerning the mechanism of injury, accidentally self-induced injuries with a hammer were the most common (32.4%). Patients who were injured from the debris were more likely (P < 0.01) to be admitted (7.6%) relative to patients who were not (2.5%). The head was most likely to get injured from a falling hammer (P < 0.01). The face was most likely to get injured through accidental self-injury (P < 0.01). The eyeball was most likely to get injured from debris (P < 0.01). The mouth was, similar to the face, most likely to get injured through accidental self-injury (P < 0.01).

CONCLUSIONS

Craniomaxillofacial injuries secondary to hammers illustrated a predilection to the head. Hammer falling from a height was most likely to injure the head. Debris from hammer strikes was the most dangerous mechanism of injury and was most likely to injure the eyeball. Hence, the authors urge the use of protective gear for the head (i.e., helmet) and eyeball (i.e., glasses) when handling hammers for constructive purposes.

Intraocular foreign bodies extracted by pars plana vitrectomy: clinical characteristics, management, outcomes and prognostic factors

Background

Intraocular foreign bodies (IOFBs) are an important cause of visual loss within the group of working age population. We aim to present the clinical features and the algorithm according to which we manage the foreign bodies that are located in the posterior segment of the eye. We define the outcomes and the prognostic factors that influenced the final visual acuity and globe survival in patients with IOFBs that we extracted by pars plana vitrectomy (PPV) over a 5-year period.

Methods

We reviewed the medical records of all the cases with IOFBs that we removed by PPV, over 5 years (2009–2013). We extracted the following parameters: age, gender, wound anatomy, IOFB characteristics, ocular lesions, initial and final visual acuities. We used the program SPSS version 20.0.0. for the statistical analysis of our data.

Results

During 5 years, we treated 21 IOFBs by PPV, representing 12.20 % of all the open globe injuries. All the patients were males with the median age of 36 years. The foreign body was located in the vitreous - 11 cases (52.38 %), retina - seven cases (33.33 %) and perforating - three cases (14.28 %). Retinal detachment (RD) at presentation was identified in eight cases (38.09 %) and endophthalmitis, in six cases (28.57 %). The visual outcome was significantly worse in patients with RD at presentation (p = 0.012) and with IOFBs larger than 3 mm (p = 0.042). Endophthalmitis did not influence the visual outcome.

Conclusions

The worse prognostic factors were: RD at presentation and large foreign body.

Trial registration number

IRCT2015040418966N3 / Apr. 9/2015

Corneal and anterior segment foreign body trauma in dogs: a review of 218 cases

OBJECTIVES

To review clinical data on dogs that suffered a corneal and anterior segment foreign body (CASFB) trauma and to determine the risk factors for foreign body (FB) trauma and subsequent enucleation.

ANIMALS STUDIED

Dogs with CASFB presented to the Animal Health Trust (AHT) from January 2000 to December 2012.

PROCEDURES

Clinical data for CASFB cases were compared to those available for the remaining AHT ophthalmic population over the same period. The depth of the FB trauma was divided into five categories. The type of FB and method of removal were described for each category. The degree of secondary uveitis and lens involvement was graded and correlated with subsequent enucleation.

RESULTS

The mean age (standard deviation) of 218 identified CASFB cases was 3.96 (2.95) years. Risk factors for CASFB trauma were dogs younger than 5 years, English Springer Spaniels, Labrador Retrievers, and working dogs. Most dogs required general anesthesia for FB removal, and hypodermic needles were the most commonly used instrument. The lens was involved in some cases with a full-thickness CASFB trauma (n = 49, 45%), but most suffered a minor lens trauma (n = 37, 76%). The lens trauma and phacoclastic uveitis were managed medically in most dogs (n = 37, 76%), and phacoemulsification was only elected as initial treatment in some dogs (n = 10, 20%). Enucleation was required overall in 6% of dogs. Statistically significant associations were found between enucleation and depth of FB trauma, degree of uveitis, and severity of lens trauma (P < 0.001).

CONCLUSIONS

Young dogs, English Springer Spaniels, Labrador Retrievers, and working dogs had an increased risk of CASFB trauma. Risk factors for enucleation were full-thickness FB penetration, severe lens trauma, and severe uveitis.

Metallic intraocular foreign bodies: characteristics, interventions, and prognostic factors for visual outcome and globe survival

PURPOSE

To describe metallic intraocular foreign body (IOFB) injuries and identify prognostic factors for visual outcome and globe survival.

DESIGN

Interventional, consecutive, retrospective case series.

METHODS

setting: Wills Eye Hospital. study population: Ninety-six eyes of 96 patients with metallic intraocular foreign bodies. procedures: Metallic IOFB injuries between January 1991 to June 2002 were reviewed for clinical characteristics, surgical intervention, and outcome. Univariate and multivariate analyses were performed to identify prognostic variables. main outcome measures: Final visual acuity and globe survival.

RESULTS

The average patient age was 33.0 years with a male predominance (94%). Forty percent of eyes had a presenting vision of 20/50 or better. Following IOFB removal, 40% of patients required additional interventions. Thirty-one percent of eyes had a final acuity of 20/50 or better. Eight percent of patients ultimately required enucleation or evisceration. Excellent visual outcome (defined as > or =20/50) was associated with multiple variables, including normal lens at presentation and anterior segment IOFB (P< .003). Factors associated with poor visual outcome (defined as <20/200) included uveal prolapse and posterior segment IOFB (P < .0003). Globe loss was associated with younger age, presenting light perception (LP) or no light perception (NLP) vision, BB/pellet injury, and the presence of an afferent pupillary defect (P < .01).

CONCLUSIONS

Multiple prognostic factors were identified in this large analysis of metallic IOFB injuries, which may help predict visual outcome and globe survival. Most of these variables were independent of intervention and can be identified at the time of initial presentation.

Incidence and visual outcome of endophthalmitis associated with intraocular foreign bodies

PURPOSE

To determine the risk factors and visual outcome of endophthalmitis associated with traumatic intraocular foreign body (IOFB) removal and its allied management.

METHODS

A retrospective review was conducted of patients with penetrating eye trauma and retained IOFB with associated endophthalmitis managed at King Khaled Eye Specialist Hospital over a 22 year period (1983 to 2004).

RESULTS

There were 589 eyes of 565 patients (90.3% male; 9.7% female) which sustained ocular trauma and had retained IOFB that required management. Forty-four eyes (7.5%) developed clinical evidence of endophthalmitis at some point after trauma. From these 44 eyes, initial presenting visual acuity (VA) of 20/200 or better was recorded in 8 eyes (18.1%) and the remaining 36 eyes (81.9%) had VA ranging from 20/400 to light perception. Eleven eyes (25%) underwent IOFB removal and repair within 24 hours after trauma while 33 eyes (75%) had similar procedures done 24 hours or more after trauma. Thirty-one eyes (70%) underwent primary pars plana vitrectomy (PPV) at the time of removal of posteriorly located IOFBs. Definite positive cultures were obtained from 17 eyes (38.6%). Over a mean follow-up of 24.8 months, 21 eyes (47.7%) had improved VA, 6 eyes (13.6%) maintained presenting VA while 17 eyes (38.7%) had deterioration of their VA, including 10 eyes (22.7%) that were left with no light perception (NLP) vision. After the treatment of endophthalmitis, 20 eyes (45.4%) had VA of 20/200 or better at their last follow-up. Four eyes (12.9%) from the vitrectomy group (31 eyes) and 5 eyes (45.4%) from non-vitrectomy (11 eyes) group had final VA of NLP. Predictive factors for the good visual outcome included good initial presenting VA, early surgical intervention to remove IOFB (within 24 hours), and PPV. Predictors of poor visual outcome included IOFB removal 48 hours or later, posterior location and no PPV for the posteriorly located IOFB.

CONCLUSIONS

Delayed removal of IOFB following trauma may result in a significant increase in the development of clinical endophthalmitis. Other risk factors for poor visual outcome may include poor initial presenting VA, posterior location of IOFB and no vitrectomy at the time of IOFB removal.

Ferrous intraocular foreign bodies retained in the posterior segment: management options and results

PURPOSE

Analysis of traditional versus comprehensive management techniques for eyes with ferrous IOFBs in the posterior segment.

PATIENTS AND METHODS

Retrospective review of 30 eyes undergoing IOFB removal by EM and of 34 eyes managed by PPV techniques.

RESULTS

Vitreous hemorrhage occurred commonly (EM group: 40%, PPV group: 50%). Only in the EM group did the intervention cause iatrogenic vitreous hemorrhage (23%) and has postextraction endophthalmitis developed (10%). Vision improved in 23% of eyes, deteriorated in 53%; >0.5 vision was achieved in 20%. Five EM eyes (17%) were anatomically lost; PVR developed in 48% of the remaining eyes. In the PPV group, no eye was anatomically lost and PVR developed in 12%. Vision improved in 68% of eyes, deteriorated in 15%; >0.5 vision was achieved in 68%. A single retinal impact site occurred in 71%, < or =2 impact sites in 21% of eyes.

CONCLUSIONS

Approximately one of two eyes with posterior segment IOFB develops vitreous hemorrhage, over two-thirds sustain at least one retinal lesion, and one-fifth of eyes suffer multiple retinal injuries. Both the anatomical (p = 0, 003) and the functional (p = 0, 005) prognoses are significantly better in eyes undergoing PPV compared to eyes with EM use. Timely PPV appears to markedly reduce the risk of endophthalmitis development. These results confirm the need to abandon the EM and perform PPV for eyes with posterior segment IOFBs.

Controversies in the management of open-globe injuries involving the posterior segment

There are numerous unresolved issues and controversies regarding the management of open-globe injuries involving the posterior segment. These areas include, but are not limited to, the following issues. Although vitrectomy has been shown to improve visual outcomes and allow retention of the eye in many cases, the extent of visual improvement is often limited because of the nature of the injury. Timing of vitrectomy surgery has been and will continue to be debated by proponents of early versus delayed intervention. The multiple features of acute ocular injury make it very difficult to interpret retrospective data regarding the most appropriate timing for surgical intervention. The use of prophylactic cryotherapy, in the setting of a scleral laceration with possible retinal damage, is not as controversial at present, as there is now sufficient data indicating that cryotherapy may actually exacerbate intraocular proliferation and worsen the situation. The role and benefit of a prophylactic scleral buckle is very widely contested, and it is not known if it truly decreases the risk of subsequent retinal detachment. Another area of debate centers on the use of antibiotics. When there is a known clinical infection, intravitreal antibiotics are the mainstays of therapy. However, in the absence of clinical infection, the use of prophylactic antibiotics and their routes of administration are quite controversial. Although there are significant data regarding the use of antibiotics in the postoperative setting, this information cannot be extrapolated into the setting of open-globe injuries, as organisms and virulence factors differ. Similarly, the use of vitrectomy versus vitreous tap in the setting of traumatic endophthalmitis is not fully resolved, although vitrectomy is used in most cases to repair concurrent damage from the injury itself. Finally, the placement of intraocular lenses in the acute trauma setting is controversial, as the risk of complications is quite high. Prospective, controlled clinical studies have not been done. This article reviews pertinent data regarding these management issues and controversies, and provides recommendations for treatment based on the available published data and the authors' personal experience.

Visual outcome and prognostic factors after magnetic extraction of posterior segment foreign bodies in 40 cases

AIMS

To evaluate the clinical features as well as the visual and anatomical outcome in eyes with magnetic posterior segment foreign bodies, to identify prognostic factors after removal using an electromagnet.

METHODS

The records of 40 patients with posterior segment foreign bodies were retrospectively reviewed for 6 years (1989-94). Post-traumatic cataracts and secondary retinal detachments were treated using conventional surgical techniques. Pars plana vitrectomy was used only for late complications. The mean follow up was 30 months (6-71). Clinical factors were studied using univariate analysis.

RESULTS

The most common findings before treatment of these 40 eyes were lens wound, hyphaema, vitreous haemorrhage, and retinal impairment. The foreign body was in the vitreous (85%) or minimally embedded in the retina (15%). Initial visual acuity was worse or equal to 20/40 in 70% of the cases. Subsequent to surgical treatment, a cataract was reported in 60% of the patients. Postoperative complications included retinal detachment (15%) and phthysis (5%). The prognosis was worse in cases with intraocular foreign body of largest diameter > or = 3 mm, an initial visual acuity less than 20/200, or the presence of post-traumatic retinal detachment. Presence of initial intravitreous haemorrhage, hyphaema, or intraocular tissue prolapse did not appear to affect the prognosis.

CONCLUSION

The long term visual acuity results indicated that wound repair associated with conventional magnet extraction in an emergency is a viable treatment for posterior segment magnetic foreign bodies in this selected group. At the time of diagnosis, size of foreign body (< 3 mm) and initial visual acuity > or = 20/200 were predictors of good visual outcome after primary magnetic extraction.

The management of intraocular foreign bodies

This study of 69 cases of retained intraocular foreign body confirms that eyes with anterior segment foreign bodies fare better than those with posterior segment foreign bodies, that eyes with smaller foreign bodies fare better than those with larger, and that the magnet is the safest method of removal. There is no evidence to support primary vitrectomy in every case of posterior segment foreign body. Computerised tomography is the best method of localisation, but a foreign body can be missed on computerised tomography, and a plain x-ray is still the best method of detection.

Results and prognostic factors in penetrating ocular injuries with retained intraocular foreign bodies

Of 105 eyes with ocular injuries involving retained intraocular foreign bodies, 63 (60%) had a final visual acuity of 20/40 or better; 20 (19%) were 20/50 to 5/200; and 15 (14%) were worse than 5/200. Six eyes (6%) were enucleated. The extent of visual recovery was limited in selected cases by the characteristics of the initial injury. Multivariate analysis was used to identify prognostic factors. Predictive of a good visual outcome (greater than or equal to 20/40) were: (1) initial visual acuity better than 20/40 and (2) the need for only one or two operations in the treatment of the injury. Predictive of a poor visual outcome (less than 5/200) were: (1) initial visual acuity worse than 5/200 and (2) a wound 4 mm or longer in length, independent of wound location. The visual outcome in this series of patients was compared with other large series of intraocular foreign bodies reported before the development of vitreous microsurgical techniques. The percentage of patients with a visual outcome of 20/40 or better has remained the same, whereas the incidence of enucleation has diminished.

The hazards of hammers

Fifty-five patients who had received an intraocular foreign body as a result of using a hammer were identified during a 4-year period. Of these, 36 had suffered the injury while at work and 19 while undertaking do-it-yourself activities at home. None had been wearing suitable protection. Seven patients were bystanders and not actually wielding the hammer. Twenty-three patients had a final visual acuity in the affected eye of 6/24 or worse.

On the recovery of the electroretinogram of rats after removal of intravitreal lead particles

Lead particles (1.4 mm2) were implanted into the vitreous body of rats (16 animals) for 10 days and the recovery rate of the ERG was measured over an observation time of 190 days. After extraction of the lead particles the a- and b-wave amplitudes show a recovery from about 60% to 87% in comparison to those of the intact fellow eyes between the 60th and 90th day of observation. In earlier experiments the mechanical damage was measured using glass splinters. The differences between these values and the above mentioned recovery rate after lead extraction correspond to the irreversible component of the metal intoxication. In another group of rats (16 animals) the lead particle was not removed before the end of the observation time of 190 days. Subtracting these ERG values from those of the first group of rats after lead extraction one gets small differences which correspond to the reversible component of the metal intoxication. The irreversible lead intoxication is much less than that of intravitreal iron particles as we found under the same conditions. The lead particles we used, are larger than those we have to handle in clinical cases taking the relation of surface area size of the particle to the total bulbus weight. The ophthalmoscopical findings are described.

Vitrectomy in double perforating eye injuries

The results of 41 consecutive cases of double perforating eye injuries, operated with vitrectomy between December 1975 and December 1982, are reported. Fourteen eyes (34%) obtained a visual acuity of 5/10 or better, and 23 eyes (56%) obtained 5/200 or better. Twenty-eight (68%) developed retinal detachment, and 12 of these were attached by surgery. In this series the pre-operative visual function and the type of injury had a significant effect on the final result. No beneficial effect from early (within 14 days) vitrectomy could be shown.

The pathophysiology of the ocular microenvironment. I. Preliminary report on the possible involvement of copper in ocular inflammation

The concentration of copper [( Cu]) in the extracellular fluid compartments of rabbit eyes was found to increase approximately 30-fold during experimental uveitis, generally paralleling increases in [protein]. However, during the recovery phase the decrease in [Cu] lags behind the decrease in [protein] in some rabbits, suggesting the presence of abnormally high levels of non-protein-associated Cu. Intravitreal injection of CuSO4 (6 micrograms of Cu/eye) causes an inflammatory response and evidence of tissue damage. A better understanding of trace element metabolism is clearly required to further elucidate the mechanism of ocular inflammation and associated tissue damage.

A 10-year survey of eye injuries in Northern Ireland, 1967-76

Ocular injuries of sufficient severity to necessitate admission to the Eye and Ear Clinic, Royal Victoria Hospital, Belfast, were sustained by 1707 male patients and 325 female patients. Blunt injury occurred in 1063 eyes (49.2%), perforating injury in 1037 (48%), and intraocular or intraorbital foreign bodies in 181 eyes (8.4%). More than three-quarters of the patients (77.4%) were less than 36 years of age and 84% of all injuries occurred in males. Normal visual acuity (6/6 or better) was regained by 41.2% of the patients in whom the final visual outcome was known. The benefit of wearing seat belts in road vehicles and protective goggles in industry and sport should receive more publicity on radio and television and via poster campaigns. Compulsory fitting of laminated windscreens in all road vehicles is recommended. The vulnerability of children to ocular injury should be highlighted through the mass media, schools, and health centres.

Two remarkable events in the field of intraocular foreign body: (1) The reversal of siderosis bulbi. (2) The spontaneous extrusion of an intraocular copper foreign body

Two unusual events concerning intraocular foreign bodies are presented. The first patient had an occult or unsuspected intraocular foreign body. He showed iridoplegia with mydriasis, siderosis iridis, and an intraocular piece of iron lying posteriorly near the retina. The foreign body was removed and the patient regained normal iris color and pupillary activity. His vision remains 20/15 six years postoperatively dispite ensuing retinal detachment one year after removal of the foreign body. The second patient was a young boy injured by a blasting cap explosion. He lost one eye from the injury and had a piece of intraocular brass in his left eye. In spite of the development of chalcosis and a mature cataract the lens gradually shrank in the pupillary space permitting a clear aphakic area and 20/25 vision. The brass fragment migrated forward and inferiorly and was finally extruded under the conjunctiva five years later, where it was removed and chemically analyzed by x-ray diffraction.

Forty-seven consecutive cases of intra-ocular foreign body

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