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
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
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
17.
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 .
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
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