Management of intraocular foreign bodies: A clinical flight plan

ArticleinCanadian Journal of Ophthalmology 48(1):8-12 · February 2013with43 Reads
Impact Factor: 1.33 · DOI: 10.1016/j.jcjo.2012.11.005 · Source: PubMed
Abstract

A systematic review of the literature on the diagnosis and management of traumatic intraocular foreign bodies (IOFBs) is presented together with a schematic "flight plan" to assist in clinical decision making when confronted with an IOFB. Several large retrospective series of IOFB have been published recently, with relevant observations regarding prognostic factors, endophthalmitis and retinal detachment incidence, timing of surgical intervention, and preventative measures. Eye trauma and IOFB, in particular, remain poorly suited to prospective study because of their variability. With few exceptions, retrospective observational series represent the strongest clinical evidence to guide our approach to IOFB. Synthesis of the available literature into a general guideline for management of IOFB would be helpful considering the typically hectic first few hours after such a patient presents to the ophthalmologist.

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Available from: Harry W Flynn, Nov 17, 2014
REVIEW ARTICLE
Management of intraocular foreign bodies: a clinical
flight plan
D. Wilkin Parke III, MD, Harry W. Flynn Jr., MD, Yale L. Fisher, MD
ABSTRACT
RE
´
SUME
´
A systematic review of the literature on the diagnosis and management of traumatic intraocular foreign bodies (IOFBs) is presented
together with a schematic ‘‘flight plan’’ to assist in clinical decision making when confronted with an IOFB. Several large retrospective
series of IOFB have been published recently, with relevant observations regarding prognostic factors, endophthalmitis and retinal
detachment incidence, timing of surgical intervention, and preventative measures. Eye trauma and IOFB, in particular, remain poorly
suited to prospective study because of their variability. With few exceptions, retrospective observational series represent the
strongest clinical evidence to guide our approach to IOFB. Synthesis of the available literature into a general guideline for
management of IOFB would be helpful considering the typically hectic first few hours after such a patient presents to the
ophthalmologist.
Revue syste
´
matique de la litte
´
rature sur le diagnostic et la gestion des corps e
´
trangers intraoculaires post-traumatiques (CE
´
IT),
accompagne
´
e d’un ) plan de vol * sche
´
matique pour faciliter la de
´
cision clinique face aux CE
´
IT. Plusieurs grandes se
´
ries
re
´
trospectives de CE
´
IT ont fait re
´
cemment l’objet de publications comprenant des observations pertinentes sur les facteurs de
pronostic, l’incidence de l’endophtalmie et du de
´
collement de la re
´
tine, le moment de l’intervention chirurgicale et les mesures de
pre
´
vention. Les traumatismes oculaires, et notamment les CE
´
IT, se pr
ˆ
etent encore mal
a d’e
´
ventuelles e
´
tudes
a cause de leur
variabilite
´
. Sauf pour tr
es peu d’exceptions, les se
´
ries d’observations re
´
trospectives pre
´
sentent les plus fortes donne
´
es cliniques
pour guider notre approche des CE
´
IT. La synth
ese de la litte
´
rature disponible dans le cadre d’une ligne directrice ge
´
ne
´
rale pour la
gestion des CE
´
IT aiderait
a conside
´
rer les quelques premi
eres heures tre
´
pidantes apr
es la pre
´
sentation d’un patient chez
l’ophtalmologiste.
Traumatic intraocular foreign bodies (IOFBs) are a
particularly significant and distinct subset of open globe
injuries, because of the elevated risk for endophthalmitis
and toxicity to the IOFB material, as well as the
considerations specific to its surgical removal. Because
the diagnosis of traumatic IOFB encompasses any foreign
material from the environment that is found within the
walls of the eye as a consequence of an open globe injury,
presentation varies widely. The IOFB may be unaccom-
panied by any significant intraocular damage outside of its
entry-site laceration in the eye wall, or may be associated
with massive internal damage in any or all compartments
of the eye. IOFBs have been previously classified accord-
ing to their location (anterior segment, posterior seg-
ment), material characteristics (metallic, magnetic, wood),
size, mechanism of injury, setting (work related, battle-
field), and duration (acute, long-standing). IOFBs are a
component characteristic of the open globe classification-
described by the Ocular Trauma Clasification Group.
1
Open globe injuries were subdivided into penetrating
injuries with an entrance wound or perforating injuries
with an entrance and exit wound, lacerations and blunt
ruptures, and as being either with or without a retained
IOFB. Entry site was categorized by the wound’s most
posterior extent as zone 1 for cornea, zone 2 for sclera up
to 5mm posterior to the corneoscleral limbus, and zone
3 for sclera more than 5mm poste rior to the limbus.
IOFBs can be acute or chronic, obvious or very subtle,
and appea r anywhere from relatively innocuous to devas-
tating on initial examination. They are almost always
accompanied by alarm on the part of the patient, the
physician, or both, and can be situations of high stress and
emotion. The components of this ‘‘flight plan’’ for the
diagnosis and management of IOFBs have been culled
from the existing literature (as per online MEDLINE
PubMed search for keywords including ‘‘intraocular
foreign body,’’ ‘‘ruptured globe,’ ‘‘eye trauma,’’ ‘‘open
globe,’’ ‘‘penetrating eye injury,’’ and ‘‘traumatic
endophthalmitis,’’ as well as various combinations), as
well as the more than 70 years of combined experience of
2 of this article’s authors (H.W.F. and Y.L.F.). The flight
plan should be us ed as a clinical guide to be updated and
improved as new evidence and experience comes to light.
Figs. 1–3, Table 1.
I
NCIDENCE AND
R
ISK
F
ACTORS
IOFBs have been reported in 10% to 41% of open
globe injuries.
2–6
In open globe injuries with traumatic
From the Department of Ophthalmology, Bascom Palmer Eye Institute,
University of Miami, Miller School of Medicine, Miami, Fla.
Originally received Nov. 14, 2012. Accepted Nov. 23, 2012
Correspondence to Harry W. Flynn Jr., MD, Bascom Palmer Eye Institute,
900 NW 1 7th Street, Miami, FL 33136; hfl ynn@med.mia mi.edu
Can J Ophthalmol 2013;48:8–12
0008-4182/13/$-see front matter & 2013 Canadian Ophthalmological
Society. Published by Elsevier Inc. All rights reserv ed.
http://dx.doi.org/10.1016/j.jcjo.2012.11.005
8
CAN J OPHTHALMOL
VOL. 48, NO. 1, FEBRUARY 2013
Page 1
endophthalmitis on presentation, IOFB may be even
more common, for example, 53% in 1 series.
7
Mechanism
of injury is predictive of the presence of IOFBs. High-
velocity, relatively small particles are the most common
foreign bodies found in the eye. Hammering, grinding, or
shaving metal, machine yard work such as lawn mowing,
and explosives exposure are particularly high risk.
2,6,8,9
Other common causes of open globe injuries such as falls,
sports injuries, or blunt assault do not produce as
many IOFBs.
Patients with IOFBs are overwhelmingly ma le
(490%) and young. Mean age at presentation is 25 to
39 years.
6,1014
Most have good preinjury visual
acuity. Outside of the injury, few have other serious
preexistingcomorbidities or a history of prior ocular
disease or surgery. Battlefie ld eye injuries differ from
their civilian noncombat counterparts in having a
greater risk for IOFBs and possibly a lower risk for
traumatic endophthalmitis, the latter potentially
because of the frequency of very high velocity metal
IOFBs that may become ‘‘sterilized’’ by the explosion and
speed.
15
D
IAGNOSIS
Most IOFBs are associated with a reported history of
trauma to the eye. Patients in 1 series presented for
examination a mean of 3.5 days after injury, although the
range was several hours to 248 days.
9
Thus, in most cases,
identifying a history of recent eye or face trauma is easy.
The diagnos tic challenge here is in differentiating those
Fig. 1
Metallic intralenticular foreign body.
Fig. 2
Metallic intravitreal foreign body.
Fig. 3
Metallic foreign body (fragment of staple) in posterior
segment.
Table 1
IOFB Flight Plan
Recognize the IOFB:
Consistent recent or past injury
Unilateral uveitis, cataract, iris heterochromia, iris damage, vitreous opacity,
intraocular mass
Identify Other Trauma:
Vital signs
Life-threatening injuries
Skull/cerebral damage
Immediate Care:
Good ocular history and examination of both eyes
CT scan, ultrasound, plain film
NPO status
Informed consent
Systemic antibiotic
Tetanus booster
Eye shield
ERG if toxicity suspected
Surgical Intervention:
Primary goals: safe extraction, closure of entry site, prevention of
endophthalmitis
Lens removal when necessary with or without intraocular lens
Vitrectomy for posterior segment IOFB
External electromagnetic for free-floating small IOFB minus significant traction
Long term care:
Modulation of inflammation and observation for infection and sympathetic
ophthalmia
Secondary surgery when necessary for proliferative vitreoretinopathy and
retinal detachment
Amblyopia prevention (pediatric)
Management of intraocular foreign bodies—Parke et al.
CAN J OPHTHALMOL
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9
Page 2
patients who have IOFBs from those with open glo be
injuries or blunt eye trauma in the absence of IOFBs.
IOFBs are found in the anterior segment 21% to 38% of
the time.
3,9,10
Anterior chamber, iris surface, or intralen-
ticular IOF Bs are typically diagnosed on the basis of slit-
lamp examination alone. Gonioscopy is re quired for
complete visualization of the angle when an anterior
segment IOFB is suspected. Iris, sulcus, and peripheral
intralenticular IOFBs may have coincident iris defects, iris
sphincter tears, or sectoral or total cataract. Posterior
segment IOFBs are the majority of IOFBs. Most are
identified in the vitreous, but others may be preretinal,
subretinal, or suprachoroidal in location. Thirty-four to
56% of posterior segment IOFBs are accompanied by
vitreous hemorrhage and 12% to 73% by trau matic
cataract, which may prevent visualization of the IOFB.
3,9
Imaging modalities are critical in the diagnosis, con-
firmation, and localization of IOFBs. Computerized
tomography (CT) has become the predominant imaging
technique in the setting of ocular trauma. It was
performed in 43% to 100% of patients in published
IOFB series and is a standard component of open globe
injury protocols at many institutio ns.
3,9,1618
CT with 1-
mm sections (and no contrast) can detect up to 100% of
metallic IOFBs greater than 0.05 mm
3
, although sensi-
tivity may be lower for nonmetallic material. Helical CT
may be superior for smaller metal fragments.
16
Plain films
less common as CT machine access and cost improve
represent the primary imaging modality in no recent
series. Plain films can miss nonmetallic IOFBs up to 60%
of the time and are inferior to CT in localizing IOFBs.
19
Echography is used in up to 42% of IOFBs and up to
64% of anterior segment IOFBs.
9
Ultrasound is more
user dependent than CT but can be up to 98% sensitive
in detecting IOFBs in the appropriate clinical set-
ting.
9,14,20
It is superior to CT in detecting coexistent
intraocular pathology such as retinal detachment, chor-
oidal detachment, and vitreous hemorrhage, and may be
superior in identifying scleral entry wounds.
9,20
Anterior
segment optical coherence tomography has been used in
the identification of anterior segment IOFBs, particularly
along the internal surface of the cornea, the angle, and the
iris. Magnetic resonance imaging is not used for IOFBs
despite its sensitivity because of risk for metallic object
movement and damage to adjacent tissue.
21
A minority of patients with IOFB deny any history of
trauma or report remote trauma only upon questioning.
22
Patients have reported their only eye trauma as being as
remote as 15 years prior.
9
In these situations, exposure to
trauma is not obvious, and distinguishing IOFBs from
nontraumatic eye conditions is necessary. Even in IOFBs
with a history of recent trauma, an entry site into the
globe was observed in only 86% of eyes, and it is not
unusual for small eye-wall lacerations to self-seal, con-
cealing the evidence of open globe injury.
2,4,9
Chronic
exposure to IOFBs can produce low-grade inflammation,
iris transillumination defects or heterochromia, recurrent
hyphema or vitreous hemorrhage, intraocular mass lesion,
or progressive cataract. Unilaterality, the presence of other
periocular sequelae of trauma, young or male patients,
and a clinical picture inconsistent with other diagnoses
should raise suspicion for chronic IOFBs. Gonioscopy,
depressed periphera l retinal examination (only in the
absence of an open wound), diagnostic imaging in the
form of echography or CT, and occasionally electroreti-
nography may be useful in these cases.
M
ANAGEMENT
In the setting of IOFBs, coincident damage to perio-
cular and systemic structures caused by the trauma is
common. Orbital fractures have been reported in 8% to
35% of patients with IOFB, lid lacerations in 38%, and
intracranial hemorrhage or contusion has been reported as
well.
9,23
This high incidence of periocular trauma man-
dates a careful initial examination of the ocular adnexa, a
relevant neurologic history and examination for altered
mentation or focal neurologic deficits, and inspect ion for
an afferent papillary defect. Systemic trauma is also
frequent; open globe injuries and IOFBs are often
diagnosed in general emergency department or traumatic
critical care patients who may have life-threatening
injuries.
24
This is particularly true of combat trauma
from explosive devices. Patients who have a history of
assault, gunshot wound, explosive injury, or an inability
to communicate an effective history need a systemic
examination with vital signs and occasionally a general
emergency department referral to rule out other damage.
IOFBs generally need to be removed because of the risk
for endophthalmitis (3%–30% of IOFBs) and toxi-
city.
3,5,9,2528
Timing of removal is controversial. Traumatic
endophthalmitis generally has a poorer prognosis than
postsurgical endophthalmitis, most likely because of the
virulence of the associated organisms. Bacillus cereus is the
causative organism in 16% to 46% of traumatic
endophthalmitis cases and portends a particularly poor
visual outcome.
5,27,2931
Staphylococcusispresentin23%
to47%ofeyes,fungusin10%,andupto18%are
polymicrobial.
26,3234
Previous articles have reported that
delay in IOFB removal increases the risk for endophthalmi-
tis.
27,35
A recent counter argument was provided by Colyer
and colleagues,
15
who described 79 combat-related IOFBs
that received prompt wound closure and systemic antibiotics
but delayed removal with no reported endophthalmitis. The
specificity of this evidence to combat injuries remains
unclear. Most series still report a practice of prompt IOFB
removal within 24 to 48 hours of presentation. Endophthal-
mitis, when present, is identified preoperatively in roughly
half of eyes and postoperatively in the other half.
36
Prophylactic antibiotics are widely given in various
forms with some evidence for an effect on endophthalmitis
Management of intraocular foreign bodies—Parke et al.
10
CAN J OPHTHALMOL
VOL. 48, NO. 1, FEBRUARY 2013
Page 3
rate. Systemic penicillin, cephalosporin, vancomycin, or
fluoroquinolone are commonly administered before or
during surgical IOFB removal. Fluoroquinolones have
been shown to have superior intraocular penetration after
systemic administration in intravenous or oral form.
37
Prophylactic intraocular vancomycin and ceftazidime are
used at the time of surgery in some centers with low
reported postoperative endophthalmitis rates.
38–40
Noninfectious toxicity is usually associated with metallic
IOFBs. Metal is reported in 60% to 88% of IOFBs, up to
90% of which may be magnetic.
8,9,11
Copper, iron, lead,
zinc, and nickel can all induce intraocular toxicity, with
copper and iron causing the most damage. Siderosis bulbi
secondary to iron creates iris heterochromia, cataract, retinal
pigment degeneration, and retinal vascular change. Subtle
siderosis may be best diagnosed on electroretinogram with a
decreased B wave. Chalcosis bulbi secondary to copper is
dependent on the copper ion concentration: if more than
85% of the IOFB, it can produce tremendous inflammation
with hypopyon, sterile endophthalmitis, and rapid progres-
sion to phthisis. Chronic mild chalcosis produces Kayser–
Fleisher rings, sunflower cataract, or refractile retinal and
anterior chamber crystals.
8,22
Other preoperat ive considerations include determina-
tion of last food intake (NPO status), previous anesthetic
reactions and systemic comorbidities for anesthesia plan-
ning, administration of tetanus booster and vaccine when
appropriate, and mechanically shielding the eye in the
setting of extensive intraocular and eye wall trauma.
Accurate patient and family counseling is frequently
difficult but critical preoperatively. Significant permanent
visual dysfunction and ocular morbidity is associated with
IOFBs. It is important to begin to prepare the patient for
the long and frequently uncertain postoperative course as
soon as possible. A significant number of these patients
are minors. Special considerations in the pediatric popu-
lation include appropriate parental consent, specialized
anesthesia, secondary examinations under anesthesia, and
amblyopia risk.
Primary surgical intervention should generally be
performed quickly. Closure of gaping entry sites is critical
to reduce the risk for endophthalmitis and limit extrusion
of intraocular contents. The presence of endophthalmitis
upon presentation likewise mandates immediate surgical
closure, culture, and antibiotic administration. As men-
tioned earlier, the necessity of removing the IOFB during
primary surgery remains controversial, but it should
probably be pursued if in the presence of a trained
surgeon and operative staff. Life-threatening injuries
always take precedence, and temporization with antibio-
tics and deferred IOFB removal is reasonable in critically
ill patients unable to undergo eye surgery.
Surgical prior ities include closure of the entry site,
removal of the intraocular foreign body, and prevention
or treatment of endophthalmitis. When necessary, recon-
struction of the anterior chamber and removal of
cataractous lens material may be performed. Intraocular
lens plac ement during primary surgery has been reported
with rapid visual recovery.
41
Vitrectomy is usually
required for posterior segment IOFB, although IOFB
on the peripheral retina may be removed by external
magnet with scleral cut down if minimal vitreous disrup-
tion is anticipated. This technique ma y be associated with
increased vitreous hemorrhage and proliferative vitreor-
etinopathy (PVR).
42
Retinal detachments are repaired at
time of vitrectomy. Prophylactic sclera buckling for
posterior segment IOFB has been advocated but has
limited data.
43
Postoperative events with the poorest prognostic asso-
ciation are endophthalmitis, retinal detachment, and
PVR. Retinal detachment after primary surgery occurred
in up to 79% of posterior segment IOFB eyes in older
studies and 11% to 23% in newer series.
3,9,12,14,44
Seventy percent of eyes with extensive retinal or choroidal
damage experienced development of PVR and secondary
detachment.
45,46
Vitreous hemorrhage and posterior
wound extent are also associated with a high risk for
PVR.
47
Close, long-term follow-up is required because
these and other postoperative complications can occur
months after the injury.
C
ONCLUSIONS
IOFBs, like all ocular trauma, are tremendously vari-
able in presentation and outcome. Detection of the IOFB
is typically simple but can occas ionally be difficult and
dependent on a high level of suspicion and a few sentinel
findings on examination. There is still significan t con-
troversy in the management of IOFBs, particularly the
timing and method of surgery, and the role of systemic
and intraocular antibiotic prophylaxis. A systematic,
thorough approach to these situations and attentiveness
to the evolving literature will serve clinicians well. Table 1
Disclosure: H.W.F. is aconsultant for Alcon, Allergan, Pfizer,
Santen, and Alimara. Otherwise the authors have no proprietary
or commercial interest in any materials discussed in this article.
Supported by: National Institute of Health Center Grant P30-
EY014801, an unrestricted grant to the University of Miami
from Research to Prevent Blindness, New York, New York.
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