INTRAOCULAR FOREIGN BODY

1. INTRAOCULAR FOREIGN BODY
PRESENTER DR SANIL SAWANT
MODERATOR DR DEVENDRA VENKATRAMANI

2. Ocular trauma constitutes one of the important cause of
visual loss and subsequent disability.
Penetrating injuries are divided into various subcategories
based on specific types of injuries .
Intraocular foreign bodies may complicate penetrating injury

3. BETTS CLASSIFICATION OF OCCULAR TRAUMA

4. FOREIGN BODY CLASSIFICATION
1) TOXIC
Metallic
 Magnetic – iron, steel, nickel
 Non magnetic – copper, aluminium, mercury, zinc
Non-metallic – vegetative matter
2) INERT
Metallic – Gold, silver, platinum
Non-metallic – Glass, carbon, stone, porcelain, plaster, rubber

5. MODES OF DAMAGE
Mechanical effects
Introduction of infection
Reaction of foreign body
Post-traumatic iridocyclitis
Sympathetic ophthalmitis

6. MECHANICAL EFFECTS
Depends on the size, velocity and type of foreign body
Foreign bodies greater than 2 mm cause extensive damage
Lesions depends upon the route of entry and the site up to
which foreign body has travelled

7. LOCATIONS OF IOFB
1)Anterior chamber –
Usually sinks in the bottom
Tiny foreign body can be visualised only on gonioscopy
2) Iris –
In the stroma
3) Posterior chamber –
Behind the iris after entering through pupil or making a hole in
the iris

8. Lens –
On anterior surface or inside the lens (either an opaque tract
may be seen in lens or may become cataractous)
Vitreous cavity
Retina , choroid and sclera
Orbital cavity

9. INTRODUCTION OF INFECTION
Metallic foreign are usually sterile due to heat generated
by them
Wood and stones carry a great chance of infection
Usually ends in endophthalmitis and panophthalmitis

10. REACTION OF FOREIGN BODY
Inorganic foreign body
No reaction by inert substances which includes glass,
porcelain, gold, silver and platinum
Local irritative reaction leading to encapsulation of
foreign body occurs with lead and aluminium particles .
Suppurative reaction excited by pure copper, zinc, nickel
and mercury particles .
Specific reactions by iron (siderosis) and copper alloys
(chalcosis)

11. SIDEROSIS BULBI
Degenerative changes produced by an iron foreign body
Usually occurs 2 months to 2 years of the injury
MECHANISM –
The iron particle undergo electrolytic dissociation by the
current of rest and its ions are disseminated throughout
the eye.
These ions combine with intracellular protein and produce
degenerative changes
 Epithelial structures of the eye are most affected

12. CLINICAL MANIFESTATIONS
Anterior epithelium and capsule of lens are involved first.
Rusty deposits are arranged radially in a ring; later cataract
develops
Iris first stained greenish and latter on reddish brown
Retinal pigmentary changes can resemble retinitis pigmentosa
ERG shows progressive attenuation of b wave over time
Secondary open angle type of glaucoma due to degenerative
changes in trabecular meshwork

13. (reference –webeye.ophth.uiowa.edu )

15. CHALCOSIS
Specific changes produced by alloys of copper in the eye
IOFB with high copper content involves violent
endophthalmitis often with progression to phthisis bulbi
Alloys with low copper content like brass and bronze results in
chalcosis

16. CLINICAL MANIFESTATIONS
Kayser-Fleischer ring is golden brown ring which occurs
due to deposition of copper under peripheral part of
Descemet’s membrane of the cornea
Sunflower cataract produced by deposition of the
capsule under posterior capsule of the lens
Brilliant golden green in colour
Retina – deposition of golden plaques at the posterior
pole which reflects light with a metallic sheen
Degenerative retinopathy does not develop as it is
less retinotoxic compared to iron

18. REACTION OF ORGANIC FOREIGN BODY
E.g. wood and other vegetative material produce proliferative
reaction characterised by formation of giant cells
Caterpillar hair produces ophthalmia nodosum ,which is
characterised by severe granulomatous iridocyclitis with
nodule formation .

19. SYMPATHETIC OPHTHALMITIS
Serious bilateral granulomatous panuveitis which follows
penetrating ocular trauma
Injured eye is exciting eye and fellow eye is sympathizing
eye .
A)Predisposing factor
Follows penetrating wound
Wounds in the ciliary region (dangerous zone ) are more
prone to it
more common in children than adults

20. Dalen-Fuchs nodules formed due to proliferation of pigment
epithelium (of iris, ciliary body and choroid ) associated with
invasion of lymphocytes and epithelioid cells
eyecalcs.com

21. CLINICAL PICTURE
1)Exciting ( injured eye ) –
Shows clinical feature of persistent low grade plastic uveitis
Ciliary congestion , lacrimation and tenderness
Keratic precipitates may be present at the back of the cornea
2) Sympathizing ( sound eye ) –
Usually involves 4 -8 weeks of injury in the other eye
Manifest as acute iridocyclitis

22. TREATMENT
Prophylaxis
meticulous repair of the wound using microsurgical technique
taking great care that uveal tissue is not incarcerated in the
wound .
Corticosteroids (topical + sytemic), immunosuppressants

23. COMPLICATIONS – In Summary
Rust ring on cornea at entry point
Persistent inflammation
Corneal defects
Infection – endophthalmitis
Secondary glaucoma
Lens damage –traumatic cataracts
Retinal/vitreous damage
Sympathetic ophthalmia

24. MANAGEMENT OF RETAINED IOFB
DIAGNOSIS –
History – a careful history about the mode of injury may
give clue about the type of IOFB
Time elapsed since injury
Ocular examination –A thorough ocular examination
including slit lamp examination. Gonioscopy in select
cases

25. SLIT LAMP PHOTOGRAPHY
Pathway of IOFB showing iris
hole
Coaxial full-thickness corneal
scar, iris hole, and/or
lenticular opacity are highly
suspicious of penetrating
trauma and possible IOFB

26. LOCALISATION OF IOFB
X-Ray
Plain X rays orbit Anterio-posterior and lateral views
as most foreign bodies are opaque .
Limbal Ring Method–
Obsolete
Metallic ring of corneal diameter stiched at limbus and x
ray taken in three exposures one while patient looking
straight , upwards and downwards .

27. LIMBAL RING

28. USG
Features of IOFB on A scan
Steeply rising wide echo spike seen
The reflectivity of the spike is extremely high (100% ) which
persists on low gain
Sound attenuation is very strong

29. Features of B scan
Appears hyperechoic in contrast to clear vitreous
Sound attenuation is very strong . IOFB causes shadowing
of ocular and orbital structure behind it .
Associated ocular damage like vitreous haemorrhage,
retinal detachment can be assessed
USG localisation can tell position of even radiolucent
foreign body

30. B SCAN

31. CT SCAN-
Best method of localising IOFB
Axial and coronal cut of < 1.5 mm are advised
MRI
Contraindicated in case of metallic foreign body

32. MANAGEMENT
Requires immediate closure of wound and removal of
IOFB .
Delay> 24 hrs produces four fold increase risk of
endophthalmitis and vision loss
Prompt removal before encapsulation facilitates removal and
prevents IOFB toxicity
Eyes should be protected with eye shield
IV broad spectrum antibiotic
Tetanus prophylaxis
 ( Thomson JT et al . Infectious endophthalmitis after retained IOFB .
 Principles and practice of vitreo retinal surgery . 1993 , 1468-1474 . )


33. TREATMENT
IOFB should always be removed unless inert, sterile
Foreign body in anterior chamber removed through
corresponding corneal incision directed straight towards the
foreign body
3 mm incision internal to limbus is taken
Magnetic foreign removed with hand held magnet and
nonmagnetic foreign body picked with toothless forceps .
Viscoelastic protects delicate structures

34. Foreign body entangled in iris tissue –
Sector iridectomy of part containing magnetic and non
magnetic foreign body .
Foreign body in lens
Lens extraction with IOL implant
Forceps removal with a pars plana vitrectomy –
Use of intraocular magnet or forceps, via sclerotomy or
limbal route in aphakes

35. PROGNOSIS
Depends on
Initial BCVA
Time of surgery
Initially attached retina
Scleral entry site
Presence of afferent pupillary defect
Mechanism of injury
Vitreous hemorrhage
(Akesbi J et al . IOFB of posterior segment : retrospective analysis and management of
57 cases . J Fr Ophtalmol 2011 Nov ;34 (9) 634- 640 .

36. CASE
42 /M came with c/o DOV , pain ,redness in LE since one
day
H /O foreign body (steel) particle entry in LE one day
back
BCVA RE: 6/9, LE: HM

40. THANK YOU