You are in: eMedicine Specialties >
Ophthalmology > VITREOUS
Foreign Body, Intraocular
Article Last Updated: Aug 3, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Ferenc Kuhn, MD, PhD, Associate Professor of Clinical Ophthalmology, University of Alabama at Birmingham; Consulting Staff, American Society of Ocular Trauma, Helen Keller Foundation for Research and Education
Coauthor(s):
David T Wong, MD, FRCS(C), Associate Professor of Ophthalmology, Director of Fellowship Programs, Department of Ophthalmology, St Michael's Hospital, Faculty of Medicine, University of Toronto, Canada;
Louis Giavedoni, MD, FRCSE, Co-Chief, Assistant Professor, Department of Ophthalmology, St Michael's Hospital, University of Toronto, Canada
Editors: Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center; Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles; Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
intraocular foreign body, IOFB, intraocular foreign bodies, IOFBs, endophthalmitis, ocular trauma, eye injury
Background
Intraocular foreign bodies (IOFBs) are rather variable in presentation, outcome, and prognosis. With increased awareness and advanced surgical techniques, the outcome and the prognosis for these potentially devastating injuries have substantially improved. The most important limiting factor today is the damage occurring at the time of the initial injury.
Pathophysiology
The final resting place of and damage caused by an IOFB depend on several factors, including the size, the shape, and the momentum of the object at the time of impact, as well as the site of ocular penetration.
In addition to the initial damage caused at the time of impact, the risk of endophthalmitis and subsequent scarring play an important role in the planning of the surgical intervention.
Frequency
United States
According to the United States Eye Injury Registry (USEIR), the frequency in the United States is 16%. The most common cause is hammering; the incidence over time shows a decrease at the workplace and an increase in the home.
International
The frequency greatly varies (up to 41%) worldwide, depending upon the population surveyed.
Mortality/Morbidity
Most IOFBs cause internal damage, and most will come to rest in the posterior segment. Commonly injured structures include the cornea, the lens, and the retina.
Sex
According to the USEIR, 93% of patients with IOFBs are male.
Age
According to the USEIR, the average patient is aged 31 years.
History
A few direct questions should be sufficient for the ophthalmologist to suspect the presence of an IOFB in eyes with an open globe injury. In case of doubt, it is advisable to error on the side of an IOFB presence. The most common cause for litigation against the ophthalmologist in a trauma case is a missed IOFB. It is important to remember that the patient may be unaware of any object entering (even striking) the eye, and the vision may be unaffected initially.
Physical
A complete examination of both eyes is necessary, including the visual acuity.
- A corneal entry wound and a hole in the iris provide trajectory information.
- The slit lamp is extremely useful in detailing all anterior segment pathologies.
- The indirect ophthalmoscope through a dilated pupil may allow direct visualization of the IOFB, which gives the most useful information for the surgeon.
- Gonioscopy and scleral depression are not recommended unless the entry wound has been surgically closed.
Causes
Hammering and using power tools are the most important causes. Protective eyewear, if appropriate (3 mm of polycarbonate), prevents virtually all injuries.
Sudden Visual Loss
Lab Studies
- Culture an IOFB or a sample of vitreous if an infection is suspected. Remember that a positive result does not mean that an infection is occurring and that a negative result does not preclude the possibility of endophthalmitis.
Imaging Studies
- CT scans are the test of choice for IOFB localization. A consultation with the CT technician is helpful in selecting the optimal section so as to reduce the risk of a false-negative result. Helical CT scans have a very high identification rate.
- Plain x-ray is useful if a metallic IOFB is present and a CT scan is unavailable.
- MRI generally is not recommended for metallic IOFBs.
- Ultrasound is a useful tool in localizing IOFBs, and its careful use is possible even if the globe is still open; alternatively, intraoperative use after wound closure can be attempted. The ultrasound biomicroscope may help with IOFBs in the anterior segment.
Other Tests
- Electroretinography is useful if a chronic IOFB is found and siderosis threatens or is present.
Medical Care
Systemic and topical antibiotic therapy may be started prior to the surgical intervention. Topical corticosteroids are also important to minimize the inflammation. A tetanus booster may also be appropriate.
Surgical Care
The timing of intervention is primarily determined by whether the risk of endophthalmitis is high. If the risk is high, immediate (emergency) surgery is indicated; in most other cases, the surgeon has the option of deferring intervention for a few days to reduce the risk of intraoperative hemorrhage. If endophthalmitis occurs, it is present at the time of patient presentation in over 90% of the cases.
- IOFBs in the anterior chamber are typically removed through a paracentesis (not through the original wound) performed at 90-180° from where the IOFB is located. Viscoelastics should be used to reduce the risk of iatrogenic damage to the corneal endothelium and the lens.
- An intralenticular IOFB does not necessarily cause cataract. Unless there is a risk of siderosis or the loss to follow-up is high, the IOFB and the lens may be left in situ. Otherwise, usually, the IOFB is extracted first, the lens is extracted second, and an intraocular lens (IOL) is implanted simultaneously.
- A posterior segment IOFB requires a vitrectomy, unless the tissue damage is minimal. The posterior hyaloid should always be removed, and any deep impact should be prophylactically treated. For the actual removal, the best tool to extract a ferrous IOFB is a strong intraocular magnet. For nonmagnetic IOFBs, a proper forceps or a lasso may be used. External electromagnets should not be used since they do not allow controlled extraction.
- Rarely, a scleral cut-down is used.
Activity
- No activity restriction is necessary once the wound heals and there is no need for positioning.
The goal of pharmacotherapy is to reduce morbidity and to prevent complications.
Drug Category: Antibiotics
For use in every case (systemic and topical); intravitreal usually only if infection is present or the case is high risk.
| Drug Name | Vancomycin (Vancocin, Vancoled, Lyphocin) |
|---|
| Description | DOC for gram-positive coverage. Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive, or have failed to respond to penicillins and cephalosporins, or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures. |
|---|
| Adult Dose | Topical: 50 mg/mL q1h
Intravitreal: 1 mg/0.1 cc
Periocular: 25 mg
1 g IV q12h |
|---|
| Pediatric Dose | Topical: Administer as in adults
Intravitreal: Administer as in adults
10 mg/kg/dose IV q6h |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | In systemic dosing erythema, histaminelike flushing and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced, when coadministered with nondepolarizing muscle relaxants |
|---|
| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
|---|
| Precautions | Corneal toxicity; in systemic administration, caution in renal failure and neutropenia; Red Man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given as 2-h administration or as PO or IP administration; Red Man syndrome is not an allergic reaction |
|---|
| Drug Name | Ceftazidime (Ceptaz, Fortaz, Tazicef, Tazidime) |
|---|
| Description | First-line choice for intravitreal gram-negative coverage. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. |
|---|
| Adult Dose | Topical: 50 mg/mL q1h
Intravitreal: 2.25 mg/mL
Periocular: 100 mg
1 g IV q12h |
|---|
| Pediatric Dose | Topical: Administer as in adults
Intravitreal: Administer as in adults
|
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | False-positive in glucose urine testing with copper reduction test (Benedict or Fehling solution); false-negative in ferricyanide test; positive Coombs test
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Adjust dose in renal impairment when administered systemically |
|---|
Drug Category: Antifungals
Their mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.
| Drug Name | Amphotericin B (Amphocin, Fungizone) |
|---|
| Description | Produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal cell membrane, causing intracellular components to leak with subsequent fungal cell death. |
|---|
| Adult Dose | Intravitreal injections: 5-10 mcg
Systemic: Best to consult internist/infectious disease specialist; test dose 1-5 mg IV over 30 min; if no chills/rigors, proceed to dosage of 0.25-1.5 mg/kg/d infused over 2-6 h; not to exceed 1.5 mg/kg/d |
|---|
| Pediatric Dose | Not established; consult infectious disease specialist |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Antineoplastic agents may enhance the potential of amphotericin B for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; the risk of renal toxicity is increased with cyclosporine |
|---|
| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
|---|
| Precautions | Monitor renal function, serum electrolytes such as magnesium and potassium, liver function, CBC, and hemoglobin concentrations; resume therapy at lowest level (eg, 0.25 mg/kg) when therapy is interrupted for more than 7 d; hypoxemia, acute dyspnea, and interstitial infiltrates may occur in neutropenic patients receiving leukocyte transfusions (separate time of amphotericin infusion from time of leukocyte transfusion) |
|---|
Further Inpatient Care
- Unless serious complications are present, the patient can be discharged shortly after surgery. Educate the patient about the potential of both early complications (eg, intraocular pressure elevation) and late complications (eg, scarring).
Further Outpatient Care
- Follow-up visits are necessary for up to 4 months to determine whether proliferative vitreoretinopathy has occurred. Rehabilitation service may be necessary if permanent visual impairment is present.
In/Out Patient Meds
- Topical antibiotics and corticosteroids in the early postoperative period are indicated.
Deterrence/Prevention
- Safety eyewear made of polycarbonate virtually eliminates the risk of IOFBs.
Complications
- Endophthalmitis, corneal scarring, elevated intraocular pressure, cataract, retinal detachment, and metallosis (eg, chalcosis, siderosis) are possible complications.
Prognosis
- The prognosis is generally relatively good. Over one half of eyes with IOFB injury regain/retain reading vision.
Patient Education
- Eye protection when partaking in risky activities (eg, hammering, mowing the lawn) is strongly recommended.
Medical/Legal Pitfalls
- Not finding an IOFB preoperatively or intraoperatively.
| Media file 1:
Metal intraocular foreign body located in the left temporal pars plana region seen on axial CT scan. |
 |  View Full Size Image | |
Media type: CT
|
| Media file 2:
Same metallic intraocular foreign body as in Image 1, as seen on coronal CT scan view. |
 | View Full Size Image | |
Media type: CT
|
- Azad RV, Kumar N, Sharma YR, et al. Role of prophylactic scleral buckling in the management of retained intraocular foreign bodies. Clin Experiment Ophthalmol. Feb 2004;32(1):58-61. [Medline].
- Barry DR. Effects of retained intraocular foreign bodies. Int Ophthalmol Clin. Spring 1968;8(1):153-70. [Medline].
- Behrens-Braumann W, Praetorius G. Intraocular foreign bodies: 297 consecutive cases. Ophthalmologica. 1989;198(2):84-8.
- Boldt HC, Pulido JS, Blodi CF, et al. Rural endophthalmitis. Ophthalmology. Dec 1989;96(12):1722-6. [Medline].
- Brown IA. Intraocular foreign bodies. Nature of injury. Int Ophthalmol Clin. Spring 1968;8(1):147-52. [Medline].
- Coleman DJ, Jack RL, Franzen LA. Ultrasonography in ocular trauma. Am J Ophthalmol. Feb 1973;75(2):279-88. [Medline].
- Coleman DJ, Lucas BC, Rondeau MJ, Chang S. Management of intraocular foreign bodies. Ophthalmology. Dec 1987;94(12):1647-53. [Medline].
- Cooke CA, Mulholland DA. A closer look at anterior segment intraocular foreign bodies. Eye. Apr 2005;19(4):476-8. [Medline].
- Cridland N. Magnetic extraction. Int Ophthalmol Clin. 1986;8(1):213-29.
- Demircan N, Soylu M, Yagmur M, et al. Pars plana vitrectomy in ocular injury with intraocular foreign body. J Trauma. Nov 2005;59(5):1216-8. [Medline].
- Duker JS, Fischer DH. Occult plastic intraocular foreign body. Ophthalmic Surg. Mar 1989;20(3):169-70. [Medline].
- Erakgun T, Akkin C, Mentes J. Management of the posterior segment foreign bodies with a simple snare. Retina. Dec 2003;23(6):858-60. [Medline].
- Johnston S. Perforating eye injuries: a five year survey. Trans Ophthalmol Soc U K. 1971;91:895-921. [Medline].
- Knox FA, Best RM, Kinsella F, et al. Management of endophthalmitis with retained intraocular foreign body. Eye. Feb 2004;18(2):179-82. [Medline].
- Kuhn F, Heimann K. A new permanent magnet for removal of intra-ocular ferromagnetic foreign bodies. Klin Monatsbl Augenheilkd. Apr 1991;198(4):301-3. [Medline].
- Kuhn F, Morris R, Witherspoon CD. Intraocular foreign body (posterior segment). In: Masters Techniques in Ophthalmic Surgery. Baltimore: Williams and Wilkins;. 1995:1201-1212.
- Kuhn F, Mester V, Morris R. Intraocular foreign bodies. In: Ocular Trauma: Principles and Practice. New York: Thieme;. 2002:235-263.
- Kumar A, Kumar V, Dapling RB. Traumatic cataract and intralenticular foreign body. Clin Experiment Ophthalmol. Dec 2005;33(6):660-1. [Medline].
- Lo Bue TD, Deutsch TA, Lobick J. Detection and localization of nonmetallic intraocular foreign bodies by magnetic resonance imaging. Arch Ophthalmol. 1988;106(2):260-1.
- Lubniewski A, Olk RJ, Grand MG. Ocular dangers in the garden. A new menace--nylon line lawn trimmers. Ophthalmology. Jul 1988;95(7):906-10. [Medline].
- Mader TH, Carroll RD, Slade CS, et al. Ocular war injuries of the Iraqi Insurgency, January-September 2004. Ophthalmology. Jan 2006;113(1):97-104. [Medline].
- Michels RG, Rice TA. Bimanual bipolar diathermy for treatment of bleeding from the anterior chamber angle. Am J Ophthalmol. Dec 1977;84(6):873-4. [Medline].
- Mieler WF, Ellis MK, Williams DF, Han DP. Retained intraocular foreign bodies and endophthalmitis. Ophthalmology. Nov 1990;97(11):1532-8. [Medline].
- Penner R, Passmore JW. Magnetic vs nonmagnetic intraocular foreign bodies. An ultrasonic determination. Arch Ophthalmol. Nov 1966;76(5):676-7. [Medline].
- Percival SP. A decade of intraocular foreign bodies. Br J Ophthalmol. Jun 1972;56(6):454-61. [Medline].
- Potts AM, Distler JA. Shape factor in the penetration of intraocular foreign bodies. Am J Ophthalmol. 1986;100:183-187.
- Roper-Hall MJ. Review of 555 cases of intraocular foreign body with special references to prognosis. Br J Ophthalmol. 1954;38:65-99.
- Smiddy WE, Hamburg TR, Kracher GP, et al. Contact lenses for visual rehabilitation after corneal laceration repair. Ophthalmology. Mar 1989;96(3):293-8. [Medline].
- Soheilian M, Abolhasani A, Ahmadieh H, et al. Management of magnetic intravitreal foreign bodies in 71 eyes. Ophthalmic Surg Lasers Imaging. Sep-Oct 2004;35(5):372-8. [Medline].
- Sternberg P Jr, de Juan E Jr, Michels RG, Auer C. Multivariate analysis of prognostic factors in penetrating ocular injuries. Am J Ophthalmol. Oct 15 1984;98(4):467-72. [Medline].
- Thach AB, Ward TP, Dick JS, et al. Intraocular foreign body injuries during Operation Iraqi Freedom. Ophthalmology. Oct 2005;112(10):1829-33. [Medline].
- Thompson JT, Parver LM, Enger CL, et al. Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System. Ophthalmology. Oct 1993;100(10):1468-74. [Medline].
- Weissgold DJ, Kaushal P. Late onset of rhegmatogenous retinal detachments after successful posterior segment intraocular foreign body removal. Br J Ophthalmol. Mar 2005;89(3):327-31. [Medline].
- Williams DF, Mieler WF, Abrams GW, Lewis H. Results and prognostic factors in penetrating ocular injuries with retained intraocular foreign bodies. Ophthalmology. Jul 1988;95(7):911-6. [Medline].
- Williams S, Char DH, Dillon WP, et al. Ferrous intraocular foreign bodies and magnetic resonance imaging. Am J Ophthalmol. Apr 15 1988;105(4):398-401. [Medline].
- Wong TY, Tielsch JM. A population-based study on the incidence of severe ocular trauma in Singapore. Am J Ophthalmol. Sep 1999;128(3):345-51. [Medline].
- Zinreich SJ, Miller NR, Aguayo JB, et al. Computed tomographic three-dimensional localization and compositional evaluation of intraocular and orbital foreign bodies. Arch Ophthalmol. Oct 1986;104(10):1477-82. [Medline].
Foreign Body, Intraocular excerpt Article Last Updated: Aug 3, 2006
|
