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Ophthalmic Pearls

T R AU M A

Identifying
Intraocular Foreign Bodies
by unni k. nair, md, anthony j. aldave, md, and emmett t. cunningham jr. md, phd, mph
edited by ingrid u. scott, md, mph, and sharon fekrat, md

O
cular trauma is a major cause 1
of blindness worldwide. In
the United States, it is esti-
mated that up to 2.4 million
ocular injuries occur each
year. Retained intraocular foreign bodies
(IOFBs) represent an important finding
following ocular trauma. The identifi-
cation of IOFBs can be quite challenging
clinically. Retained foreign bodies can
cause infection and inflammation in the
affected eye even years after the initial
insult. Several imaging modalities are
currently available to aid in screening
for the presence of retained IOFBs—
each with its own advantages and limi-
tations.

Cur r ent Imaging Modalities


Computed tomography (CT) is currently (1) Slit-lamp photomicrograph in a patient with a retained intraocular foreign
considered the “gold standard” for the body demonstrating characteristic fine pigment dusting of the anterior lens
detection, localization and characteriza- capsule. (See “Case Presentation,” next page for more about this image.)
tion of both metallic and nonmetallic
IOFBs. Traditionally, axial sections sep- but the sensitivity is user-dependent. near the anterior chamber.4
arated by 3 to 5 mm have been utilized In addition, it is important to note that Plain film x-rays alone may be used
as an initial screening study for IOFBs. a small amount of intraocular air can as a screening modality for IOFBs, but
Spiral CT is a newer advancement that occasionally be mistaken for an IOFB of all the imaging techniques, x-rays are
has helped overcome some of the limi- and that contact ultrasonography is most likely to yield an equivocal result.
tations of conventional CT, including contraindicated in globes suspected of Etherington and colleagues conducted
motion artifacts and long examination rupture. a retrospective review to characterize
times.1 But because studies comparing Ultrasound biomicroscopy (UBM) has the usefulness of both CT scanning and
the detection of steel IOFBs measuring been examined as an adjunct to CT scan- plain film x-rays as screening modalities
0.06 mm3 or larger have shown no dif- ning. Deramo and colleagues demon- for IOFBs. Their study revealed that if
ference in sensitivity between spiral and strated the usefulness of UBM in the an IOFB could be seen on a plain film
conventional scanning CT,2,3 either detection of suspected IOFB in nine eyes, x-ray, then 6-mm CT cuts would be suf-
imaging modality is probably adequate including two eyes in which CT scanning ficient to detect and localize the IOFB.
for detection of all but the smallest of failed to visualize wooden and metallic Conversely, when IOFBs were not able
IOFBs. foreign bodies. UBM was found to be to be seen on plain films, 3-mm CT cuts
Standard B-scan ultrasonography especially helpful in the management of were necessary to ensure accurate local-
can also be used to detect metallic IOFBs, small, nonmetallic IOFBs located in or ization.5

e y e n e t 31
Ophthalmic Pearls

Magnetic resonance imaging (MRI)


is contraindicated in the detection of Case Presentation
suspected metallic IOFBs because the

A
32-year-old man 2
associated electromagnetic field can
presented to his
cause foreign body migration, poten-
local ophthalmolo-
tially damaging intraocular tissues. An
gist complaining of acute
MRI is also more susceptible to motion
onset of redness, discom-
artifact than other imaging modalities.
fort and reduced visual
MRI may be considered when there is
acuity in his left eye.
a strong suspicion of a nonmetallic for-
Past ocular history was
eign body not seen with CT scanning or
remarkable for a corneal
B-scan ultrasonography.
metallic foreign body
that was removed from
Workup
his left eye three years
A complete history should be taken and
prior to presentation.
ocular examination performed on all
Past medical and surgi- (2) Conventional CT scan (axial cut) from below
patients suspected of having a retained
cal histories were unre- through the midportion of the globes demonstrating
IOFB. The history should include spe-
markable, and a review the presence of a focal density in the left eye, rep-
cific questions regarding occupation,
of systems was noncon- resenting a metallic intraocular foreign body.
prior eye trauma, the mechanism of the
tributory. The patient was
current injury and whether eye protec-
diagnosed with nongranulomatous anterior uveitis and treated with a
tion was worn at the time of the injury.
cycloplegic/mydriatic agent, topical prednisolone acetate 1 percent, and, subse-
Physical examination should look specif-
quently, a posterior sub-Tenon’s injection of 40 mg of triamcinolone acetonide.
ically for direct or indirect evidence of
After no improvement, the patient was then referred for further evaluation.
an open-globe injury, including vitreous
On presentation, BCVA was 20/20 in his right eye and 20/40 in his left, and
hemorrhage and/or streaming to a per-
IOP was 12 mmHg and 10 mmHg, respectively. There was no afferent pupillary
foration site. In long-standing IOFBs,
defect. Corneal sensation was normal, and symmetric and anterior segment exami-
a characteristic pigment dusting may
nation revealed bilateral well-healed corneal scars consistent with his history of
be present on the anterior lens capsule
prior corneal foreign body removal. The left eye had fine keratic precipitates on the
(Fig. 1). If a globe is still ruptured, sys-
inferior corneal endothelium, 2+ cells and trace flare in the anterior chamber and
temic antibiotics and tetanus prophy-
fine pigment dusting on the anterior lens capsule (Fig. 1). Posterior segment
laxis should be administered, and fur-
examination of the left eye revealed scattered cells in the anterior vitreous, mild
ther examination should be deferred
optic disc edema, patchy vascular sheathing and inferior vitreous opacities. Labo-
until surgical exploration can be con-
ratory testing revealed a normal chest x-ray, a negative RPR, a negative FTA-ABS,
ducted. When available, spiral CT scan-
a normal ESR, and normal serum ACE and lysozyme levels. Fluorescein angiogra-
ning utilizing 3-mm axial and coronal
phy showed late leakage from the optic nerve and confirmed the presence of
cuts through the orbit should be obtained
patchy vasculitis. B-scan ultrasonography showed no IOFB. Given the presence of
as a first-line study; conventional CT
characteristic pigment dusting on the anterior lens capsule, strong suspicion
scanning with 3-mm cuts is an accept-
remained for an IOFB. A CT scan of the orbits was obtained and revealed a metal-
able alternative. Plain film x-rays and
lic IOFB just behind the inferior iris in the left eye (Fig. 2). Pars plana vitrectomy
B-scan ultrasonography are convenient
was performed with removal of the IOFB. The ocular inflammation resolved rapidly.
to obtain and may be used as adjuncts
At follow-up examination five months after presentation, a posterior subcapsular
to CT scanning, but are generally less
cataract had developed but there were no signs of active inflammation.
sensitive and so “negative” results should
be interpreted with caution.
Dr. Nair is an ophthalmology resident at
1 Dass, A. B. et al. Ophthalmology 2001; California Pacific Medical Center in San Trauma at the Meeting
108(12):2326–2328. Francisco. Dr. Aldave is an associate profes- For more about IOFBs
2 Woodcock, M. G. L. et al. Ophthalmology sor of ophthalmology at the University of attend Instruction
2006;113(12):2262–2269. California, Los Angeles, where he is director Course 484, “Intra-
3 Chacko, J. G. et al. Ophthalmology 1997; of the cornea service. Dr. Cunningham is ocular Foreign Body
104(2):319–323. director of the uveitis service at California Injuries: An Update”
4 Deramo, V. A. et al. Trans Am Ophthalmol Pacific Medical Center and an adjunct clin- on Monday, Nov. 12, from 4:30 to
Soc 1998;96:355–365; discussion 365–367. ical professor of ophthalmology at Stanford. 5:30 p.m. $25 in advance of the
5 Etherington, R. J. and M. D. Hourihan. He thanks the San Francisco Retinal Foun- meeting until Oct. 17, $35 on site.
Clin Radiol 1989;40(6):610–614. dation and the Pacific Vision Foundation.

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