Rate of metallic foreign bodies found on orbital radiographs prior to MRI

OBJECTIVE

The purpose of this research is to more precisely quantify the positivity rate for conventional radiographs (CR) of the orbit performed for the purpose of pre-MR screening in patients at risk of having a radio-opaque orbital foreign body (ROFB).

METHODS

By review of electronic medical records, we identified 47,237 patients who had undergone orbital CR for clearance of ROFB prior to MRI. The reports from these examinations were manually reviewed, and the examinations with positive findings were re-interpreted by a CAQ-certified head and neck radiologist. The rate of ROFB found in these examinations was reported and compared to historical estimates in the literature.

RESULTS

328 of the 47,237 examinations (0.69 %) were originally interpreted as positive for ROFB. Upon re-review, only 39 of the 47,237 examinations (0.083 %, 95 % CI 0.06 %-0.11 %) contained ROFB that were in locations that posed a risk to ocular or vascular structures or were in an equivocal location. Almost all of the patients with false-positive initial interpretations had been denied MRI.

DISCUSSION

The rate of ROFB discovered on clearance CR of the orbits prior to MRI is far less than previously estimated in the radiology literature. More conservative guidelines for MR clearance may be useful to reduce costs, mitigate imaging delays, and avoid unnecessary denial of imaging.

Efficiency of different imaging methods in detecting ocular foreign bodies

BACKGROUND

Ocular foreign bodies (OFBs) are a relatively common occurrence in ocular injuries, and a severe risk factor for vision disorders. They are notoriously challenging to identify and localize precisely to allow surgical removal, even with the most recent technological advancements.

PURPOSE

To compare the efficiency of different imaging methods in detecting and localizing OFBs.

METHODS

We conducted a retrospective analysis of the medical records of patients with OFBs, detected by ultrasound biomicroscopy (UBM) and confirmed during surgery. Patients who presented to our medical center between January 2016 and January 2022 and also underwent computed tomography (CT), X ray, and/or ocular B-scan ultrasonography (B-scans) were selected.

RESULTS

This study included 134 patients with a history of ocular trauma and OFBs (mean age: 47.25 years, range: 8-78). The mean time interval from injury to UBM examination was 36.31 months (range: 0.2-120 months). Most OFBs were metallic (51.82%) or plant-based (25.37%); 22.39% of them were located in the sclera, 26.87% in the anterior chamber, and 23.88% in the ciliary body and iris. OFBs ranged in size from 0.10 to 6.67 mm (mean: 1.15 ± 1.10 mm). B-scans identified OFBs in 37 of the 119 patients examined (31.09%); CT in 52 of 84 patients (61.90%); and radiography in 29 of 50 patients (58.00%). Univariate and multivariate analyses determined that both CT and radiography showed low detection rates for plant-based versus non-plant-based OFBs (CT: p < 0.001; radiography: p = 0.007), small particles (<1.00 mm vs. >1.00 mm; CT: p = 0.001, radiography: p = 0.024), and with eyeball wall locations (vs. intraocular; CT: p < 0.001, radiography: p = 0.021). Similarly, B-scans were less efficient for plant-based and eyeball wall-located OFBs (both p = 0.001), whereas the difference based on dimensions was not significant (p = 0.118).

CONCLUSIONS

CT, radiography, and B-scans showed lower detection rates for plant-based, small, and eyeball wall-located OFBs. Our findings strongly suggest that UBM could be a more adequate imaging modality when such OFBs are suspected.

A case of panuveitis caused by caterpillar setae

INTRODUCTION

Panuveitis is a serious inflammatory disease. Setae are fibers produced by many insects and plants. Many case reports have described caterpillar and spider fibers entering the eye. These hairs are covered with tiny barbs that help them enter and migrate into the eye tissue, leading to severe inflammation. Normally, they are buried mainly in the conjunctiva and cornea. However, in the present case, they entered the posterior segment of the eye, which is very rare.

CASE DESCRIPTION

A female patient presented with a complaint of repeated foreign body sensation, redness, pain, and photophobia in the left eye for 9 years following initial exposure to caterpillars. She visited the doctor in January after aggravation of symptoms. Slit-lamp examination, ultrasound biomicroscopy, ultrasound B-scan, fluorescein angiography, and indocyanine green angiography revealed the presence of a foreign body in the vitreous, which caused discomfort in the patient's left eye and subsequently, panuveitis of the left eye. The symptoms improved significantly after foreign body removal using vitrectomy. Microscopic examination revealed that the foreign body was caterpillar setae.

CONCLUSION

Clinicians should be more vigilant about history of contact with caterpillars while examining uveitis that has recurred for many years. Identification of the root cause of the disease can ensure better treatment.

Comparing forceps and self-assembled intraocular rare earth magnet in removing metallic intraocular foreign bodies in 25-guage vitrectomy

PURPOSE

To compare the efficacy and efficiency of self-assembled intraocular rare earth magnet and forceps in removing intraocular foreign bodies(IOFBs) undergoing 25-gauge(G) pars plana vitrectomy.

METHODS

A total of 30 patients with metallic IOFB underwent 25-G PPV were enrolled into this study. Self-assembled intraocular rare earth magnet were used in 15 patients(bar group), and forceps were used in 15 patients(forceps group). Success rate of removing IOFB, time taken to remove IOFB, incidence of IOFB slippage and fall, iatrogenic retinal damages were compared between the two groups.

RESULTS

There was no significant difference in success rate of removing IOFBs between the groups(93.3% and 100%, P > 0.99). The median time taken of removing FB was significantly shorter in bar group than in forceps group(112 and 295 s, P = 0.001). None of the patients in bar group had IOFB slippage and fall, or related iatrogenic retinal damage in the process of removal. In forceps group, IOFB slippage and fall during removal were observed in 7 of 15(47.6%) patients, related iatrogenic retinal injuries were recorded in 6 of 15(40.0%) patients, both were significantly higher than bar group(P = 0.003 and P = 0.017, respectively).

CONCLUSIONS

Compared with forceps, the assembled intraocular magnet can greatly reduce the possibility of IOFB slippage and fall, prevent related iatrogenic retinal damage, and shorten the time taken to remove IOFB. The assembled intraocular magnet can be an useful tool in removing metallic IOFBs in PPV.

INTRAVITREAL CHOPPING OF DROPPED NUCLEUS WITH A NITINOL INTRAOCULAR FOREIGN BODY FORCEPS: AN ALTERNATIVE TECHNIQUE FOR THE MANAGEMENT OF RETAINED NUCLEUS FRAGMENTS

PURPOSE

To evaluate the efficiency and safety of using an intraocular foreign body forceps with two nitinol loops at its tip to capture and chop dropped nucleus (DN) during vitrectomy as an alternative method and to evaluate the outcomes and complications of this surgical technique.

METHODS

The eyes that underwent 23-gauge vitrectomy with removal of DN using nitinol forceps with a minimum follow-up time of 1 year are included in this study. The efficiency of surgical technique and anatomical and functional results with complications is recorded.

RESULTS

Nine patients with a mean age of 73.11 ± 2.15 years were included in this study. The mean time between DN and vitrectomy was 7.67 ± 3.74 (5-14) days. In all eyes, DN was easily chopped and removed with aspiration. Argon laser photocoagulation was performed in 4 eyes (44.44%) during surgery. All eyes were followed up for a mean time of 21.11 ± 12.36 (12-48) months. The mean preoperative best-corrected visual acuity increased significantly during the postoperative follow-up ( P < 0.001). No complications related to the cataract surgery or DN removal were observed.

CONCLUSION

Surgical removal of DN with the help of these forceps with nitinol loops is found to be safe and effective in this study. This method avoids ultrasonographic energy and enables 23-gauge vitrectomy without a fragmatome.

Mobile battery blast injuries: An emerging ocular health hazard in children

PURPOSE

To assess clinical features, visual outcomes, and setting of mobile battery blast-induced eye injuries in children.

METHODS

Retrospective case sheets of children with mobile battery blast injuries were reviewed at a tertiary eye care center from January 2015 to March 2022. We noted the mode of injury, battery status, and clinical presentation and analyzed the treatment outcomes.

RESULTS

The study included 14 eyes of 11 patients. Three patients (27%) had bilateral ocular injuries. The most common reasons for the blast were wiring a bulb to the battery or charging the battery with a universal mobile charger, seen in four cases each. Three eyes had closed-globe injuries (CGIs), whereas 11 had open-globe injuries (OGIs). Of the 11 eyes with OGI, four also had a retained intraocular foreign body (IOFB). Only four (36%) eyes having OGI could achieve vision better than 6/60. All three eyes with CGIs developed secondary glaucoma, and two underwent trabeculectomy. However, the visual prognosis was better (>6/36) in eyes with CGI. Overall, mean visual acuity at the final follow-up was improved to 1.41 ± 1.14 logMAR from 2.32 ± 0.76 logMAR at presentation. This was also found to be statistically significant with a P value of 0.02.

CONCLUSION

Battery blast-induced ocular injuries, although rare, often lead to poor outcomes. Apart from charging, playing with discarded or damaged batteries was a common reason for battery blasts in our series.

Pediatric Open Globe Injuries Caused by Firecrackers in a Tertiary Eye Care Hospital in Iran

OBJECTIVE

The aim of the study is to determine characteristic features of open globe injuries caused by firecrackers among pediatric population.

METHODS

In this retrospective cross-sectional chart review, medical records of children with ocular trauma who were hospitalized in Isfahan, Iran, during 2013-2017 were reviewed. We analyzed the collected data before and after propensity score (PS) matching.

RESULTS

Of 396 pediatric patients with open globe injury, 22 injuries (5.9%) were caused by firecrackers. Hyphema, iris prolapse, and lens rupture were noted in 15 (68.18%), 10 (45.45%), and 2 (9.09) eyes, respectively. None of patients had endophthalmitis. The mean age of patients in firecracker group was higher and significant (11.86 ± 4.05 in firecracker vs 7.80 ± 4.68 in nonfirecracker, P < 0.001). Furthermore, most boys were in firecracker group (95.5%, P = 0.005). Patients in firecracker group resided more in urban areas (86.4%, P = 0.054) and had more intraocular foreign body (IOFB) in the eyes (40.9%, P < 0.001). After PS matching, patients in firecracker group had higher IOFB ( P = 0.008). In logistic regression models, patients with corneal lacerations had lower odds for long-time admission (≥4 days) than patients with both corneal and scleral lacerations in crude model (odds ratio, 0.35; 95% confidence interval, 0.17-0.69) and adjusted model (odds ratio, 0.37; 95% CI, 0.18 to 0.74). After PS matching, there was no significant association between risk factors and outcomes.

CONCLUSIONS

The present study showed several differences between the pediatric open globe injuries caused by firecrackers and other mechanisms of injuries, including the age, sex, living place, presence of IOFB, and length of hospital stay.

LAWN TRIMMER-RELATED OPEN-GLOBE INJURIES IN TAIWAN

PURPOSE

Work-related ocular trauma remains the leading cause of unilateral visual impairment worldwide. Many preventable work-related ocular injuries continue to occur, even at home. This study describes the characteristics, surgical techniques, and prognostic factors of lawn trimmer-related open-globe injuries in eastern Taiwan.

METHODS

This was a retrospective, consecutive case series study. Slit-lamp biomicroscopy, dilated fundoscopy, and orbital computed tomography (CT) images were collected.

RESULTS

Twenty-six eyes of 26 patients were enrolled in the study. Fifteen patients (57.7%) had an intraocular foreign body (IOFB). The IOFB was metallic in 13 cases and glass and stone in the other 2 cases. Seven IOFBs (46.7%) were retained in the anterior chamber, 7 (46.7%) in the posterior segment, and 1 (6.7%) in the intraconal space. Univariate analysis showed that the presence of IOFB trended toward the development of endophthalmitis; however, this was not statistically significant (hazard ratio, 2.25; 95% confidence interval 0.35-14.61; P = 0.658). Eleven patients had metallic IOFBs noted on CT scans with metal artifacts, whereas two patients had small metallic IOFBs without metal artifacts. One patient had a glass IOFB mimicking metal artifacts on the CT scan. In one case, CT failed to reveal the IOFB, and an intralenticular metallic foreign body was incidentally found intraoperatively.

CONCLUSION

Our study provides a broad characterization of lawn trimmer-related open-globe injuries. The informative and diverse findings of IOFBs on CT scans will help clinicians detect and recognize IOFBs more precisely and perform the surgery without causing further damage.

Ex vivo porcine model for eye, eyelid, and orbit movement analysis of 4-mm ferromagnetic foreign bodies in MRI

PURPOSE

Ferromagnetic foreign bodies (FFB) present during magnetic resonance imaging (MRI) explorations can lead to tissue injury due to movement, especially in and around the eyes. Ferromagnetic foreign bodies located in the intraocular area, eyelids, and orbit are thus prohibited from undergoing MRI. The aim of the study was to analyze movement of 4-mm ferromagnetic foreign bodies in MRI in the eye, eyelid, and orbit using computed tomography (CT) scan.

METHOD

We developed a porcine model using 12 quarters of fresh porcine heads. Each porcine head included one whole orbit with the ocular globe, orbital fat, muscles, and eyelids. Four-millimeter FFB were implanted in the eye within 2 days post-slaughter, and images were acquired within 5 days post-slaughter. Four-millimeter FFB movement was analyzed after 1.5-Tesla (T) MRI. Four locations were tested: intravitreous, suprachoroidal, intraorbital fat, and intrapalpebral. Movement analysis was assessed using computed tomography (CT) scan.

RESULTS

The intravitreous ferromagnetic ball moved 14.0 ± 8.8 mm (p < 0.01), the suprachoroidal ball moved 16.8 ± 5.4 mm (p < 0.01), the intraorbital fat ball moved 5.8 ± 0.9 mm (p > 0.05), and the intrapalpebral ball moved 2.0 ± 0.4 mm (p > 0.05).

CONCLUSION

The ex vivo porcine model was able to study FFB movement. The 4-mm ferromagnetic balls moved in intravitreous and in suprachoroidal locations after MRI.

A rare asymptomatic metallic intraocular foreign body retained in the anterior chamber for 15 years: A case report

RATIONALE

Intraocular foreign bodies (IOFBs) are common in ocular injuries, but asymptomatic metallic IOFBs retained in the anterior chamber for years are rare.

PATIENT CONCERNS

A 31-year-old female presented with blurred vision in her right eye after lumbar magnetic resonance imaging. Her best-corrected vision acuity was 0.6 in the right eye and 1.0 in the left eye. Slit-lamp examination revealed a brown granular foreign body in the anterior chamber and pigmentation of the limbus. Lens and retina examination indicated ocular siderosis. Corneal endothelioscopy revealed decreased endothelial cell density. A detailed history showed ocular globe injury 15 years earlier.

DIAGNOSES

Anterior chamber IOFB with ocular siderosis.

INTERVENTIONS

Anterior chamber foreign body removal was performed with appropriate incision and forceps.

OUTCOMES

The anterior chamber IOFB was successfully removed and examined as a magnetic metal foreign body. The best-corrected vision acuity was 1.0 at 1 day postoperatively. An abnormal electroretinogram with a 12% decrease in the "b" wave and a 91% decrease in the "a" wave was observed 3 months postoperatively. There were no intraoperative or postoperative complications during a 3-month follow-up.

LESSONS

Eye trauma should be examined carefully to exclude IOFBs. Asymptomatic anterior chamber foreign bodies can also cause corneal endothelial injury and ocular siderosis. Careful examination and timely management are needed in such cases.

Large interface particles from LASIK surgery

The presence of interface debris is commonly reported in patients having undergone LASIK refractive surgery. The patient described here had numerous large particles believed to be plastic and metal artefacts from the surgery at the level of the stroma/flap interface, along with a corneal scar consistent with a foreign body injury. The aetiology and possible sequelae of the particles and scar are discussed.

Lead Intraocular Foreign Body Injury Following Ejection

BACKGROUND: Ejection injuries involving the eyes have become uncommon due to effective protection by helmets and visors. We report a unique case of intraocular lead foreign body injury occurring after ejection from a Hawk aircraft in a pilot who had his helmet and visor on.CASE REPORT: A 40-yr-old male pilot sustained facial injuries after ejection from a Hawk aircraft. He had multiple foreign bodies embedded in the skin around his jaw, corneal foreign bodies, and self-sealed corneal and lens entry in left eye, with one foreign body lodged within the lens and two in the vitreous behind the lens. The foreign bodies showed low reflectivity on CT scan suggestive of plastic. However, spectroscopic and electron microscopic analysis of pieces removed from the cornea confirmed the material to be predominantly lead, which came from the miniature detonator cord (MDC). An electroretinogram (ERG) showed reduction of scotopic b wave amplitude in the affected eye. The pilot underwent intravitreal foreign body removal successfully through pars plana vitrectomy. Post-removal vision recovered from 20/60 to 20/20 with ERG also showing recovery of scotopic b wave amplitude from 100 μV to 180 μV.DISCUSSION: Though systemic toxicity due to high blood levels of lead are well known, this case is unique in demonstrating direct retinal toxicity because of intravitreal lead foreign body. It also raises aeromedical concerns about the hazards of MDC splatter despite full protection with helmet and visor.Khan MA, Gaur D, Murthy PC, Pandey A. Lead intraocular foreign body injury following ejection. Aerosp Med Hum Perform. 2020; 91(8):673-677.

Epidemiology and prognostic factors of open globe injuries in a Tunisian pediatric population

INTRODUCTION

Childhood ocular trauma is a preventable cause of visual impairment and blindness worldwide. The purpose of our study was to determine demographic, etiologic, and clinical characteristics, visual outcome, and factors affecting visual prognosis in children with open globe injuries (OGI) and to analyze the predictive value of ocular trauma scoring systems for OGI in children.

METHODS

We conducted a retrospective study enrolling 120 pediatric patients hospitalized for OGI from January 2010 to March 2017. Age, gender, date of trauma, time between trauma and presentation, place and circumstances of injury, etiology, visual acuity (VA), wound location and type of injury based on the Birmingham Eye Trauma Terminology, and the clinical signs were recorded. We recorded the number of surgical procedures performed, complications and visual outcomes.

RESULTS

The mean age was 7.38 years. In all, 62.5% of the patients were male, and 37.5% were female. The gender ratio was observed to decrease with increasing age. The mean time interval between injury and consultation was 22.80±42.68hours. Injuries usually occurred at home (80%) followed by playgrounds and sports venues (8.3%), the street (6.7%) and school (5%). All of the OGI's were accidental, and the main context was play (70%). The most common traumas were penetrating injury (60.8%) and metal (30%) objects. Penetrating trauma accounted for 68.3% of cases, followed by rupture (27.5%) and intraocular foreign body (IOFB) (7.5%). Initial VA was<1/10 in 59.2% of cases, and the point of entry was the cornea in 65.8% of cases. Final VA was<1/10 in 39.69% of all cases. FVA was significantly correlated with BCVA prior to the surgery, mechanism of the trauma, wound location and size, and other associated lesions. The Ocular Trauma Score (OTS) and the Pediatric Ocular Trauma Score (POTS) were significantly correlated with final VA.

CONCLUSION

OGI's in children occurs most frequently in school-age boys. Prognosis is determined by presenting visual acuity, trauma score, and wound severity and location.

Removal of an intraorbital metallic foreign body following double-penetrating ocular injury: A case report

RATIONALE

Open eye injury is one of the commonest ophthalmic emergencies, and when accompanied by intraorbital foreign bodies, the condition carries a poor prognosis.

PATIENT CONCERNS

A 28-year-old man presented to the emergency department of our hospital complaining of sudden painful loss of vision in the left eye after he hammered an iron plate.

DIAGNOSIS

The ocular examination revealed a 4-mm full thickness scleral laceration with prolapsed uveal tissue, a traumatic cataract. Computed tomography (CT) demonstrated an orbital foreign body in the retrobulbar area.

INTERVENTIONS

The patient underwent emergency scleral suturing, severance of medial rectus muscle, and removal of the orbital foreign body. Twelve days after the emergency operation, pars plana lensectomy and pars plana vitrectomy were performed.

OUTCOMES

After 3 months of follow-up, there was no immune response. Visual acuity in the left eye was the perception of hand motion. The retina remained mostly attached with normal intraocular pressure, and good cosmetic appearance. The globe anatomy was maintained, but the vision could not be restored due to the grave nature of the trauma.

LESSONS

Transconjunctival approach extraocular muscle severance may thus be a suitable approach to the removal of intraorbital metallic foreign body.

Vision stolen by a hidden thief: 5-Year retention of a bandage contact lens

An 80 year-old male patient was prescribed a bandage contact lens on the left eye 5 years ago because of an injury on the eye by a wooden stick. He was never followed up to remove the contact lens. Two years ago, he suffered from gradually decreased visual acuity in the left eye. After removing the contact lens, his visual acuity gradually increased to 12/20 and the symptom revealed. Intraocular pressure, corneal endothelium density, corneal curvature, and the anterior chamber depth were within the normal range in the left eye, and were comparable with the right eye. Although no permanent damage was found in the patient, a strict follow-up procedure is strongly recommended for patients who receive a bandage contact lens.

Surgical Treatment of Penetrating Ocular Injuries with Retained Intraocular Foreign Bodies

A total of 40 cases of retained intraocular foreign bodies (IOFB) presenting to the University Eye Clinic of Novi Sad between January 1988 and December 1994 were evaluated and surgically treated. The group most affected were males with a mean age of 33 years, who had been occupationally injured, presenting with either corneal or scleral single laceration. Thirty-seven injuries (92%) were due to metallic foreign bodies. Two eyes presented with initial clinical signs of endophthalmitis (5%). Five eyes (12.5%) were war-injuries, with tremendous destruction of all ocular structures. After an average of 12 months follow-up 70% of total eyes achieved postoperative good or useful vision, 50% of these with visual acuity 0.5 or better.

Retained strabismus suture material masquerading as nonspecific orbital inflammation

We report a case of orbital myositis of the superior rectus muscle-levator complex masquerading as nonspecific orbital inflammation but corresponding in location to a known braided polyester "chicken suture" placed 20 years earlier during strabismus surgery. The orbital inflammation was refractory to oral steroids but resolved promptly on surgical removal of the suture material. Although suture material is known to cause foreign body granulomatous reactions, to our knowledge this is the first reported case of a deep, diffuse orbital inflammation attributable to chicken suture placed during strabismus surgery.

[Foreign Body in the Anterior Chamber 10 Months after Uneventful Cataract Surgery]

PURPOSE

A foreign body detected in the anterior chamber 10 months after uneventful sutureless cataract surgery.

CASE REPORT

Clear corneal phacoemulsification and intraocular lens placement (PEA + IOL) were performed on a 74-year-old man suffering from vision loss caused by senile cataracts. After uneventful surgery, the postoperative course appeared to be problem-free.

OBSERVATION

However, 10 months after the operation, the patient reported blurred vision. Slit-lamp examination revealed an oil droplet, reminiscent of a foreign body, about 1 mm in diameter, on the IOL surface. The visual acuity problem did not become exacerbated and the anterior segment of the eye remained intact. Although we removed the foreign body, qualitative testing was impossible because the body disintegrated.

CONCLUSIONS

A rare case of a foreign body in the anterior chamber 10 months after uneventful PEA + IOL. We are of the view that the body may have been composed of ophthalmic ointment delivered from the conjunctival sac at the end of surgery.

Retained Intraocular Perfluoro-n-octane After Valved Cannula Pars Plana Vitrectomy for Retinal Detachment

BACKGROUND AND OBJECTIVE

To investigate cases of retained intraocular perfluoro-n-octane (PFO) after pars plana vitrectomy (PPV) for retinal detachment (RD).

PATIENTS AND METHODS

Retrospective, noncomparative case series of six eyes with retained intraocular PFO after RD repair. Clinical data were supplemented with an experimental silicone eye model.

RESULTS

A cluster of six cases of retained intraocular PFO after PPV for RD repair were noted shortly after transitioning to valved cannulas. PFO was noted in the anterior chamber (AC) and/or vitreous and removed with AC paracentesis, AC wash-out, and/or PPV. A silicone eye model demonstrated that PFO levels are maintained anterior to cannula insertion with valved cannulas only.

CONCLUSION

The authors hypothesize that anterior PFO fill using valved cannulas can lead to sequestration within the AC, zonules, ciliary sulcus, ciliary teeth, and/or capsular bag. They suggest vigilance in not overfilling PFO, particularly when transitioning to use of valved cannulas, to minimize the risk of intraocular retention.

High-speed cannula detachment into the eye during hydrodissection

Detachment of a hydrodissection cannula during a phacoemulsification procedure appeared to produce no adverse sequelae during surgery. Day 1 postoperatively, two nonpenetrating hemorrhagic retinal lesions were identified; there was no evidence of posterior capsular perforation. Day 6 postoperatively, the pupil was temporally peaked by a fine vitreous strand running to the main-port incision in the superotemporal cornea. This was divided with Nd:YAG laser, and argon laser was applied to encircle the two retinal lesions. Postoperative uncorrected visual acuity remained 6/4 at day 1, day 6, and week 4 (3 weeks after laser application) follow-up visits. Surgeons must accept responsibility for confirming the integrity of the cannula and syringe connection before beginning hydrodissection, which can be highly destructive to intracameral structures.

Spontaneous fracture of an implanted posterior chamber polyimide intraocular lens haptic: a case report

A 57-year-old male patient visited our clinic for decreased visual acuity in the right eye for 10 days. He denied any trauma history, but recalled that the symptom developed after straining. He had undergone uncomplicated phacoemulsification and posterior chamber intraocular lens (IOL) implantation in the bag of the right eye 11 years ago. The IOL was a three-piece silicone polyimide-haptics design. On slit-lamp examination, the IOL optic and proximal part of nasal fractured haptic were found in the anterior chamber. The distal part of fractured haptic was observed in the capsular bag. He underwent IOL exchange. The fracture site of the haptic was near the optic-haptic junction. This is the unique case report of a spontaneous fracture of an implanted posterior chamber polyimide IOL haptic, which implies the possibility of IOL haptic fracture in various haptic materials.

Long-term hypotony because of accidental break of a 23 g microcannula after transconjunctival sutureless vitrectomy

PURPOSE

To report a case of long-lasting hypotony because of accidental break, with scleral tunnel entrapment, of a 23-gauge microcannula during transconjunctival sutureless vitrectomy.

METHODS

Interventional case report. An 80-year-old Spanish woman who underwent 23-gauge transconjunctival sutureless vitrectomy presented at the postoperative ocular examination with irreversible, refractory low intraocular pressure of unknown cause. Two weeks after surgery, a piece of the microcannula was found at the inferotemporal sclerotomy site during a scheduled medical appointment. Surgical intervention was indicated to explore and remove the foreign body.

RESULTS

The day after foreign body extraction, the patient's pressure rose to normal levels. However, her visual acuity did not improve until 3 weeks later.

CONCLUSION

Transient postoperative hypotony is unsurprising after 23-gauge vitrectomy because of leakage of small-diameter open sclerotomies. However, when long-term low intraocular pressure fails to return to normal levels because of an unidentified condition, breaking of the microcannula piece with scleral tunnel entrapment may be contemplated.

[Mason's lacing cord. Potential danger of severe open ocular injuries]

BACKGROUND

Introduction of new working equipment or the modification of established working routines could induce new trauma mechanisms. In all of theses cases ophthalmologists are not only responsible for ocular treatment they also have to act as assessors. This might include legal aspects, e.g. to validate the circumstances of an accident.

METHODS

We present a new trauma mechanism caused by a mason's lacing cord which was fixed with nails. In addition to two case studies we collected experimental data (maximum tension and maximum elongation of various mason's lacing cords) about the triggering event using standard test conditions.

RESULTS

A tensile force of 96.2 N was needed to achieve maximum elongation of mason's lacing cords. With a cord length of 5 m, an elongation of 0.09 m was enough to cause penetrating injuries (for 10 m cord length the critical elongation was 0.13 m). Under these conditions a nail could be accelerated to a velocity of 18 m/s. This may lead to open eyeball injuries with severe visual loss.

CONCLUSIONS

Nails fixed to elastic mason's lacing cords are potential risk factors for occupational ocular injuries and severe loss of vision. Caution labels should be attached to the work equipment and proper eye protection should be used to prevent severe occupational ocular injuries.

BILATERAL ORBITO-OCULAR GUNSHOT INJURY IN A NIGERIAN MALE: CASE REPORT AND REVIEW OF LITERATURE

Orbito-ocular injuries with retained intra-orbital foreign bodies affecting both orbits are uncommon in civilian practice. This case report aims to highlight an unusual presentation of bilateral orbito-ocularinjury with retained intra-orbital foreignbodies following accidental explosion of a locally fabricated dane gun. A 30-year-old male presented with a five day history of bilateral orbito-ocular injury sustained following an explosion of a dane gun he was fabricating. There was immediate loss of vision in both eyes, and initial treatment was sought at a nearby private general medical clinic. Visual acuity at presentation was no perception of light and light perception with inaccurate projection in the right and left eye respectively, and he had an open wound over the left cheek with retained intra-orbital foreign bodies on plain radiographs. He subsequently underwent wound exploration and closure with removal of the foreign bodies. Vision however remained poor and he was lost to follow-up after being referred for vitreo-retinal consultation. The attendant socio-economic impact on the individual and family following severe bilateral orbito-ocular injury could be enormous when it results in bilateral loss of vision in a young adult. Measures should thus be put in place to regulate the handling of firearms so as to possibly reduce the resultant morbidity from such injuries.

Medical malpractice claims related to cataract surgery complicated by retained lens fragments (an American Ophthalmological Society thesis)

PURPOSE

To review malpractice claims associated with retained lens fragments during cataract surgery to identify ways to improve patient outcomes.

METHODS

Retrospective, noncomparative, consecutive case series. Closed claims data related to cataract surgeries complicated by retained lens fragments (1989 through 2009) from an ophthalmic insurance carrier were reviewed. Factors associated with these claims and claims outcomes were analyzed.

RESULTS

During the 21-year period, 117 (12.5%) of 937 closed claims associated with cataract surgery were related to retained lens fragments with 108 unique cataract surgeries, 97% against cataract surgeon and 3% against retinal surgeon. Twelve (11%) of 108 claims were resolved by a trial, 30 (28%) were settled, and 66 (61%) were dismissed. The defendant prevailed in 83% of trials. Indemnity payments totaling more than $3,586,000 were made in 32 (30%) of the claims (median payment, $90,000). The difference between the preoperative visual acuity and the final visual acuity was predictive of an indemnity payment (odds ratio [OR], 2.28; P=.001) and going to a trial (OR, 2.93; P=.000). Development of corneal edema was associated with an indemnity payment (OR, 3.50; P=.037). Timing of referral and elevated intraocular pressure (IOP) were statistically significant in univariate analyses but not in multivariate analyses for a trial.

CONCLUSIONS

Whereas the majority of claims were dismissed, claims associated with greater visual acuity decline, corneal edema, or elevated IOP were more likely to result in a trial or payment. Ways to reduce significant vision loss, including improved management of corneal edema and IOP, and timely referral to a subspecialist should be considered.

[Corneal foreign bodies in children]

The purpose of the study was to answered three questions. Which part of all patients with diagnosis of corneal foreign body (CFB) diagnosed in period from 2006 to 2010 were children? Is there any dependence on sex like in adults? Is there any typical mechanism of injury in children?

METHODS

Retrospective study analyzed data of 2381 patients with diagnosis of CFB, 2225 men and 156 women. There were in the group 0-17 years 154 patients, 82 boys and 72 girls, in group 18-64 years 2103 men and 80 women and in group patients older than the age of 65 years 40 men and 4 women. Mechanism of injury was analyzed in the group of children.

RESULTS

CFB is a common condition in working-age adult men due to occupational exposure, eg grinding, drilling or cutting. CFB is very rare in adult women. Similar dominance of men was in the group of patients older then the age of 65 years. The results demonstrate, that both sex in group of children occurred equally. The majority of the mechanism of injury in children wasnt recognized (115 children). The biggest recognised group was use of swing in case-history of 17 children with corneal metallic foreign body, 15 of them were children younger than the age of 7 years. Seven children suffered injury by part of plants such as thorns or bark from branch of tree. Three boys had in case-history common mechanism of grinding. Remaining mechanisms of injury were less frequent.

CONCLUSION

From 2006 to 2010, 154 (6.5 %) pediatric eye injuries of CFB were treated in Department of Ophthalmology for Children and Adults. Both sex in group of children occurred equally. Although majority of mechanism of injury remained unrecognised, use of swing is among children younger then the age of 7 years important unknown mechanism of injury. Is possible to prevent it, eg rust prevention of metallic suspensions of swing, protective eyeweare, cap.

Visual outcome and prognostic factors in posterior segment intraocular foreign bodies

OBJECTIVE

To identify the prognostic factors that predict visual outcome in eyes with penetrating ocular injuries with retained intraocular foreign bodies (IOFBs).

DESIGN

Retrospective cases series

MATERIAL AND METHOD

The authors reviewed the records of 228 patients who had penetrating eye injuries with retained posterior segment IOFBs managed at Siriraj Hospital between June 1995 and February 2008. One hundred and forty-one patients (61.8%) were included in the present study. Associations between final visual outcome and various pre-operative and post operative variables were statistically analyzed.

RESULTS

After a mean follow-up of 10.4 +/- 7.7 months, 68 eyes (48.2%) achieved visual acuity of 6/18 or better The final visual acuity ranged between 6/24 and 6/60 in 22 eyes (15.6%) and 51 eyes (36.2%) had visual acuity less than 6/60. Final visual acuity significantly depended on initial visual acuity (p = 0.002), size of entry wound (p = 0.020), size of foreign body (p = 0.018), presence of vitreous hemorrhage (p = 0.014), retinal detachment (p = 0.026) and endophthalmitis (p < 0.0001).

CONCLUSION

Visual outcome in penetrating ocular injuries with retained IOFBs was affected by initial visual acuity, size of entry wound, size of foreign body, vitreous hemorrhage, retinal detachment and endophthalmitis. These factors may be helpful for pre-operative counseling and predicting the final visual outcome.

Vitreoretinal surgery in the management of war-related open-globe injuries

BACKGROUND

Ranking among the most severe combat damages, war-related open-globe injuries (WROGIs) are not uniform, so the treatment approaches are sometimes unclear. The essential issue is to define exact indications for time- and resource-intensive vitreoretinal surgery (VRS), known to be an effective procedure for severe posterior segment injuries. We studied WROGI structure, and summarized the experience of specialized ophthalmologic care (SOC) management during local armed conflicts (LACs).

METHODS

This was a retrospective multicenter study that included case series of 203 wounded subjects (314 eyes) with WROGIs sustained during LACs treated in the hospitals of first, second and third echelons of SOC. Ocular trauma was classified according to the International Society of Ocular Trauma (ISOT) classification, and only open-globe injuries (OGI) made up two groups of study: injured eyes that underwent VRS, n = 135, and those eyes on which VRS was not performed, n = 119. Two subgroups according to stages of VRS were also included. We reviewed the demographic characteristics, the time between injury and surgery, the number of stages in which surgery was performed, and initial visual acuity (IVA) at arrival and final visual acuity (FVA), 12 months after surgery.

RESULTS

WROGI constituted 65.1 % of all eyes injured. The visual outcomes after VRS were favorable in ruptures of the eye, penetrating WROGIs, intraocular foreign body (IOFB) WROGIs, perforating WROGIs (types A, B, C, D) of grades 1-4. Those WROGIs of grade 5 had poor visual outcomes irrespective of the surgeries. In 19.1% of all cases wherein either the eye wall or eye content were extensively damaged (included types A, C, D, E of grade 5), all attempts to save the eye through reconstructive surgery were unsuccessful and led to enucleation (evisceration).

CONCLUSIONS

Medical service management in LACs demands to define groups of priority for VRS between the wounded with WROGI during triage at the first echelon of SOC. Multistage VRS determines unfavorable outcomes of the WROGI. Treatment should be determined by diagnosis, and there is a need to introduce a new category into the OGI classification--eye destruction, because only this damage determines the choice of enucleation/evisceration of the eye.

Corneal metallic foreign body injuries due to suboptimal ocular protection

Retrospective review of 100 consecutive presentations of metallic corneal foreign body to the Royal Victorian Eye and Ear Hospital emergency department was undertaken between November and December 2009. The majority of the patients (97%) were male with a mean age of 42 ± 13 years (range 19-73 years). The most common mode of injury was grinding (88%). Nearly half (45%) of patients were wearing "safety eye wear" at the time of injury. Combination of 25-gauge needle and burr was the commonest method employed for removal of foreign body. Overall, 88% (n = 88) cases healed with corneal scar at the site of corneal foreign body and 1 case developed bacterial keratitis. Metallic corneal foreign bodies are common presentations to the emergency department and may be related to inadequate implementation of occupational safety measures.

[Potential of ultrasound biomicroscopy in diagnosis of ocular trauma with intraocular metallic foreign bodies]

A detailed analysis of ultrasound biomicroscopy (UBM) scanogramms of 4 patients with a history of trauma and signs of metallosis is performed. In all cases foreign body was found and its precise localization in relation to anterior segment structures was identified. The following changes were revealed and described: pathological changes of cornea, lens and its fibers, uveal tract in silent zone, zone of retinal periphery and secondary vitreous changes due to trauma itself and chemically active foreign body invasion and long persistence. UBM is recommended to be the part of examination algorithm in patients with penetrating ocular trauma and screening of latent metallosis.