|Year : 2021 | Volume
| Issue : 3 | Page : 492-494
Intra-lenticular metallic foreign bodies – A series of three cases
Richa Gupta, Abhishek Varshney
Departments of Glaucoma and Vitreoretina, CL Gupta Eye Institute, Moradabad, Uttar Pradesh, India
|Date of Submission||19-Oct-2020|
|Date of Acceptance||21-Feb-2021|
|Date of Web Publication||02-Jul-2021|
Dr. Richa Gupta
MS Ophthalmology, FICO (UK), Department of Glaucoma, CL Gupta Eye Institute, Ram Ganga Vihar, Phase 2(Ext) Moradabad - 244 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Three consecutive cases presenting with intra-lenticular foreign bodies (ILFBs) were included in this series. ILFB retrieval with Kelman–McPherson forceps, along with cataract extraction and intraocular lens implantation in the bag was performed as a single-staged procedure for all under peri-operative systemic and topical steroids. Their visual recovery was excellent at 4 months with best-corrected visual acuity of 20/20, N6. Careful clinical and relevant radiological evaluation is paramount following penetrating ocular injury to rule out intraocular foreign body, especially ferrous, to avert the most visually debilitating sequelae of ocular siderosis. This series highlights a favourable outcome of ILFB removal with concurrent management of cataract.
Ferrous intraocular foreign body, intra-lenticular foreign body, penetrating injury, traumatic cataract
|How to cite this article:|
Gupta R, Varshney A. Intra-lenticular metallic foreign bodies – A series of three cases. Indian J Ophthalmol Case Rep 2021;1:492-4
Up to 40% of penetrating ocular injuries are associated with retained intraocular foreign body (IOFB), out of which, intra-lenticular foreign bodies (ILFBs) constitute of roughly 5%. They can be categorized as metallic, iron being most common, and non-metallic types (glass, wood) and may result in consequential cataract, though asymptomatic cases have also been reported. Usually, ILFBs can either be detected by direct visualization on slit-lamp or can be confirmed with B-scan ultrasonography or computed tomography (CT)., Here, we report three cases who underwent successful cataract extractions with ILFB removal.
| Case Series|| |
All patients underwent a detailed history taking and clinical evaluation including dilatation with tropicamide 1% eye drop, details of which have been presented in [Table 1]. The corneal entry wound was self-sealed/healed in all cases. Immersion ocular echography (B scan) of the affected eye exhibited an intra-lenticular, highly echogenic foreign body with back shadowing and high spike on A scan in low gain. Examination of contralateral eye was unremarkable for all. Clinical characteristics of all cases are presented in [Figure 1], [Figure 2], [Figure 3].
|Figure 1: (a) Slit-lamp examination showing a cataractous lens, with a defect in anterior lens capsule (Panel a, dashed border) and an intra-lenticular foreign body (Panel a, arrow). (b) Intra-lenticular highly echoic foreign body on immersion ocular echography in low gain. (c) FB retrieved (1.25 × 1 × 0.5 mm). (d) Post-operative picture with corneal scar (Panel d, arrowhead)|
Click here to view
|Figure 2: (a) Retrieved ILFB during cataract extraction (3.5 × 3 × 0.5 mm). (b) Hyper-echoic intra-lenticular foreign body on B scan|
Click here to view
|Figure 3: (a) Full-thickness iris hole with traumatic cataract. (b) Posterior iris pigments incarcerated in anterior lens cortex visible after dilatation|
Click here to view
For all three patients, informed written consent was taken and primary lens extraction with IOFB removal with intraocular lens (IOL) implantation was planned under perioperative steroid cover, under guarded visual prognosis. Intra-operatively, anterior capsule was stained with 0.1 ml of 0.1% trypan blue dye, and the pre-existent capsular tag was fashioned into continuous curvilinear capsulorhexis with capsulorhexis forceps (Indo-German Surgical Corp, India). Kelman–McPherson forceps (Appasamy Associates, India) were used to carefully manipulate and deliver the ILFBs. For case 3, lens debulking was performed first to immobilize the deeply embedded FB. With integrity of posterior capsule in question, hydro-dissection was avoided and low bottle height and gentle techniques were employed. In all patients, lens was removed using irrigation/aspiration (I/A) tip. Careful scrutiny revealed an intact posterior lens capsule, and hence, foldable acrylic hydrophilic IOL was implanted in the bag and its stability ensured. The corneal wound integrity was maintained and did not warrant any intervention.
Patients received topical cycloplegics, antibiotics and intensive oral and topical steroids, tapered over next 8 weeks. Patients recovered well with an uneventful post-operative period. A careful examination was performed and confirmed no residual IOFB or signs of siderosis bulbi. At 4 months, their best-corrected visual acuity was 20/20, N6 in operated eye.
| Discussion|| |
ILFBs, if occult, can be easily missed and can remain asymptomatic for years. Imaging studies can corroborate a high degree of suspicion and aid in their detection. Ultrasonography has been shown to be a very valuable tool, that is both sensitive and specific for IOFB localization., This compares with our series, where immersion ocular echography helped in ascertaining the intra-lenticular location of two ILFBs. Additional information like posterior lens capsule status and posterior segment inflammation can also be obtained simultaneously. The role of CT scan remains equivocal with some authors advocating its use, while others arguing that CT cuts may miss small IOFBs.
The most commonly reported indication for surgery is cataract formation, though its nature and extent remain highly variable. Small anterior lens capsule breaches tend to re-epithelize, restricting free influx of ions and fluid, thereby limiting cataract progression. In such scenario, conservative management with close follow-ups is a reasonable option. Capsular defects of >3 mm size often give rise to total cataracts.
Other indications entailing ILFB removal are anterior uveitis, glaucoma, lens subluxation and ocular siderosis, which remains the most devastating sequelae of retained ferrous IOFB., It is caused by dissociation and iron deposition in intraocular epithelial structures, leading to toxic effects on cellular enzymes, with resultant cell death. Pigmentary retinopathy has a profound effect on vision and electroretinogram amplitudes.
Surgical technique for removal of retained ILFB is dependent on its nature, lens status and extent of injury. In eyes with intact capsular bag, concurrent ILFB and cataract removal with IOL implantation as single-staged procedure is surgery of choice. Possibility of coexistent posterior capsular dehiscence warrants avoiding hydro-dissection and special caution in gently aspirating the hydrated cortical matter with an I/A tip, with low fluidics, minimizing anterior chamber turbulence.
All of our patients presented with diffuse, intumescent cataract and IOL implantation in the capsular bag was possible in all. None required scleral fixation of IOL. Retrieval of ILFBs was observed to be safe with Kelman–McPherson forceps. Nature of ILFBs in all three eyes was found to be metallic (ferrous). Though we did not encounter coexistent posterior capsular tear, it is worthwhile to plan and be prepared for vitrectomy. In our case series, the patients were relatively young men of productive age group and means of injury were metal-on-metal tool-related occupational activities. This has been paralleled in previously published data on patient profile in retained IOFBs.,
In their univariate analysis of 96 eyes, Ehlers et al. found that IOFB in anterior segment and with smaller entry wound length was statistically significant for good visual outcome (≥20/50). In our series, corneal entry wound size ranged from 1.25 to 2.2 mm. This, in addition to minimal or no globe disruption, may explain the excellent final visual outcome (20/20) in all our three cases.
Moderate-to-severe post-operative inflammation needs to be anticipated and dealt with peri-operative systemic and topical steroids. Foreseeing exuberant inflammation in the post-operative period, 60 mg of oral steroids was started 3 days before surgery and was continued post-operatively in weekly tapering dose.
| Conclusion|| |
In conclusion, retained ILFB can manifest after several years and should be considered, unless ruled out, in all patients with history of penetrating injury with or without iris hole or cataract. Ocular echography is an indispensable tool for its localization. A good visual prognosis, before ocular siderosis ensues, is more than likely with ILFB retrieval, cataract extraction and IOL implantation and does not demand any special instrument or expertise other than a routine anterior segment surgery.
Authors would like to thank Mr. Lokesh Chauhan for his technical support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Loporchio D, Mukkamala L, Gorukanti K, Zarbin M, Langer P, Bhagat N. Intraocular foreign bodies: A review. Surv Ophthalmol 2016;61:582-96.
Arora R, Sanga L, Kumar M, Taneja M. Intralenticular foreign bodies: Report of eight cases and review of management. Indian J Ophthalmol 2000;48:119-22.
] [Full text]
Lee W, Park SY, Park TK, Kim HK, Ohn YH. Mature cataract and lens induced glaucoma associated with an asymptomatic intralenticular foreign body. J Catract Refract Surg 2007;33:550-2.
O'Duffy D, Salmon JF. Siderosis bulbi resulting from an intralenticular foreign body. Am J Ophthalmol 1999;127:218-9.
Farvardin M, Mehryar M, Karanjam MA, Ashraf H, Mahdizadeh M, Rahimi M, et al
. The accuracy of ocular sonography in detection and measurement of intraocular foreign bodies. Iranian J Ophthalmol 2008;20:20-3.
Pokhraj PS, Jigar JP, Mehta C, Narottam AP. Intraocular metallic foreign body: Role of computed tomography. J Clin Diagn Res 2014;8:RD01-3.
Fagerholm PP, Philipson BT. Human traumatic cataract: A quantitative microradiographic and electron microscopic study. Acta Ophthalmol (Copenh) 1979;57:20-32.
Medina FM, Pierre Filho Pde T, Lupinacci AP, Costa DC, Torigoe AM. Intralenticular metal foreign body: Case report. Arq Bras Oftalmol 2006;69:749-51.
Asencio-Duran M, Vázquez-Colomo P-C, Armadá-Maresca F, Fonseca-Sandomingo A. Siderosis bulbi. Clinical presentation of a case of three years from onset. Arch Soc Esp Oftalmol 2012;87:182-6.
Ehlers JP, Kunimoto DY, Ittoop S, Maguire JI, Ho AC, Regillo CD. Metallic intraocular foreign bodies: Characteristics, interventions, and prognostic factors for visual outcome and globe survival. Am J Ophthalmol 2008;146:427-33.
[Figure 1], [Figure 2], [Figure 3]