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CASE REPORT
Year : 1991  |  Volume : 39  |  Issue : 3  |  Page : 138-139

Case report : Intraocular foreign body in the angle masquerading as uveitis


O.E.U. Institute of Ophthalmology, Kasturba Medical College Hospital, Manipal-576119, Karnataka, India

Correspondence Address:
M G Kamath
O.E.U. Institute of Ophthalmology, Kasturba Medical College Hospital, Manipal-576119, Karnataka
India
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Source of Support: None, Conflict of Interest: None


PMID: 1841892

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  Abstract 

A case of occult intraocular foreign body presenting with iritis is discussed, illustrating the management.


How to cite this article:
Kamath M G, Nayak I V, Satish K R. Case report : Intraocular foreign body in the angle masquerading as uveitis. Indian J Ophthalmol 1991;39:138-9

How to cite this URL:
Kamath M G, Nayak I V, Satish K R. Case report : Intraocular foreign body in the angle masquerading as uveitis. Indian J Ophthalmol [serial online] 1991 [cited 2020 Jan 26];39:138-9. Available from: http://www.ijo.in/text.asp?1991/39/3/138/24448


  Introduction Top


Patients commonly present to the ophthalmologist with a history of a foreign body hitting the eye. Welders, metal workers, stone cutters and mechanics constitute the high risk group. Usually they present with an embedded intracorneal foreign body, or rarely with intraocular penetration. Superficial foreign bodies may easily be removed in the outpatient clinic and the patient sent home with antibiotic and cycloplegic drops. It is however mandatory to rule out an in­traocular foreign body by careful examination in all cases. Penetrating corneal wounds, subconjunctival haemorrhages, conjunctival chemosis, iris tears, iritis, lens opacities are all important signs of an occult intraocular foreign body. Anteroposterior and lateral X-ray views are also essential in the work up.


  Case report Top


RS, a 40 year old mechanic presented with a history of a small particle hitting the eye while fitting a metal piston, followed 2 hours later by pain, redness and watering. On Examination there was localized conjunctival congestion at the 7 O'clock limbus, associated with a superficial corneal foreign body 1 mm away from the limbus. There was also a partial thickness corneal laceration close to the foreign body 3 mm away from the limbus. The pupillary reactions were normal and the lens was clear. Visual acuity OS (uncorrected) was 6/9, pinhole 6/6; OD 6/6 (Snellen). The right eye was normal. The corneal foreign body was successfully removed under topical anaesthesia. Gentamicin eye drops hourly, and homatropine eye drops twice daily were prescribed. Orbital X-rays (both posterio-anterior and lateral) did not reveal any evidence of a radio-opaque foreign body. At follow-up four days later, the left eye showed a small nonstaining corneal stromal opacity at the site of the previous foreign body. There was marked ciliary congestion. Aqueous flare, cells in the anterior chamber and a focal anterior subcapsular cataract ( 2 mm in diameter) at the 3 O'clock meridian ([Figure - 1] preoperative view). Visual acuity was nor com­promised. Indirect ophthalmoscopy did not reveal any abnormality and the intraocular pressure was normal. Only with gonioscope could a foreign body (covered with exudate) be detected at the 5 O'clock meridian in the angle ([Figure - 2] Gonioscopy view with foreign body). Repeat X-ray of the left orbit failed to show any evidence of a radio-opaque foreign body. The patient was admitted, and received Gentamicin and Dexamethasone (0.1%) eye drops 6 hourly, pilocar­pine 2% eye drops 8 hourly, along with 10 mg prednisolone tablets 6 hourly while preparations for surgery were made.

Under local (retrobulbar) anaesthesia a circumferential scleral incision, 2 mm behind the limbus, 3 mm in length was made over the foreign body. The anterior chamber was entered with a keratome, and attempts at removal with a hand magnet failed. The wound was slightly enlarged, and the foreign body could be visualised. A curved suture tying forceps was then used to pick up the intraocular foreign body from the angle under direct visual control. ([Figure - 3] Photograph of the foreign body). The incision was closed using three interrupted 9-0 nylon sutures. Postoperatively he received steroid and antibiotic drops 6 hourly and homatropine drops twice daily. After 3 days the systemic steroids were tapered. On discharge, there were no signs of inflammation, and vision was identical to that found on admission. The postoperative appearance of the angle shows a small synechiae in the area previously occupied by the foreign body with the pupil well centred and the intraocular pressure normal. ([Figure - 4] Gonioscopy view postoperative with peripheral anterior synechiae). ([Figure - 5] Postoperative view - diffuse illumination).


  Discussion Top


Persistent iritis is the most common complication of occult anterior segment intraocular foreign bodies [1]. Most metallic, glass, or stone particles become lodged in the inferior angle if they do not possess enough momentum to penetrate the lens. Roentogenography often fails to shows non-opaque splinters and even small metallic (opaque) particles [2]. We did not use a bone free dental film though this technique may help demonstrate radio-opaque particles too small to be seen on conventional films [3]sub [4]sub .Inferior bullous keratopathy may help localizing a foreign body in the anterior chamber angle due to endothelial decom­pensation [5]. Visualization of the iridocorneal angle was emphasized as an essential part of the evaluation by the first report of G. M. Bruce (1933) [6]. Management requires preoperative miosis to open the angle max­imally, and to prevent lens damage during surgery. A trans-scleral approach is reported as being more successful and attended by fewer complications than a transcorneal approach [2]. Foreign body removal may be done from under a limbus based scleral flap or through a vertical sclerolimbal incision. The prognosis is very favourable if the intraocular foreign body is removed promptly and if no lens injury or infection has occurred.

In conclusion, removal of a corneal foreign body from an eye does not guarantee the absence of an occult intraocular foreign body; hence any corneal laceration following injury should signify an intraocular foreign body unless proved otherwise, by adequate evaluation.

 
  References Top

1.
Percival SPB : A decade of intraocular foreign bodies. Br. J. Ophthalmol. 56 : 454. 1972.  Back to cited text no. 1
    
2.
Thorpe HE : Foreign bodies in the anterior chamber angle and their management with the aid of gonioscopy. Am. J. Ophthalmol. 61 1339-1343. 1966.  Back to cited text no. 2
    
3.
Hartmann E, Gilles E : Roentogenographic diagnosis in ophthalmology; Philadelphia. J.B. Lippincott, 1959, 128-165.  Back to cited text no. 3
    
4.
Duke Elder S : System of Ophthalmology, Mechanical injuries: St Louis, C.V. Mosby 1972, Vol. XIV Part 1, 565-616.  Back to cited text no. 4
    
5.
Liabson PR : Inferior bullous keratopathy and unsuspected anterior chamber foreign bodies. Arch. Ophthalmol 74 : 191-197, 1965.  Back to cited text no. 5
    
6.
Bruce GM : Visualization of foreign bodies in the iridocorneal angle. Arch. Ophthalmol. 10 : 615, 1933.  Back to cited text no. 6
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]



 

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