This document discusses intraocular foreign bodies (IOFBs) resulting from penetrating ocular trauma. It describes the classification of IOFBs as toxic (e.g. metallic) or inert (e.g. glass) and the various types of damage they can cause, including mechanical effects, introduction of infection, and reactions to the foreign material. Specific reactions to iron (siderosis) and copper (chalcosis) are also outlined. The locations where IOFBs can lodge in the eye are provided, as well as methods for localizing and managing retained IOFBs. Prompt removal of IOFBs is emphasized to prevent complications like endophthalmitis, secondary glaucoma, and sympathetic o

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