|Year : 1998 | Volume
| Issue : 2 | Page : 91-92
Triple procedure in posterior segment intraocular foreign body
R Azad, YR Sharma, S Mitra, A Pai
Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi, India
Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Three patients with intraocular foreign bodies and traumatic cataracts underwent single stage pars plana lensectomy with anterior capsule preservation, vitrectomy, removal of the foreign body, and intraocular lens implantation. The preserved anterior capsule permitted support for the placement of an intraocular lens in the posterior chamber in the ciliary sulcus. The procedure enabled early visual rehabilitation. This procedure seems useful in the management of posterior segment intraocular foreign body associated with cataract.
Keywords: Intraocular foreign body, pars plana vitrectomy, intraocular lens, triple procedure
|How to cite this article:|
Azad R, Sharma Y R, Mitra S, Pai A. Triple procedure in posterior segment intraocular foreign body. Indian J Ophthalmol 1998;46:91-2
Seventy percent of intraocular foreign bodies (IOFB) lodge in the posterior segment. The presence of traumatic cataract in these cases complicates their management. Several authors have recently advocated single stage cataract extraction and posterior chamber intraocular lens (PC IOL) implantation with posterior segment procedures in patients with both cataract and vitreo-retinal disease. Most of these "combined" procedures have been performed in eyes with posterior segment diseases and cataracts that allow preservation of the posterior lens capsule. Alternatively, IOLs can be implanted in the anterior chamber as a second stage procedure following the successful posterior segment procedure. Slusher et al combined lensectomy and PC IOL implantation with vitrectomy and foreign body removal in two patients. Herein we report three cases of combined triple procedure which involved lensectomy sparing the anterior capsule of the lens, vitrectomy along with removal of the foreign body, and implantation of PC IOL.
| Materials and Methods|| |
Preoperative work up of all the patients studied included slitlamp examination, orbital x-ray, CT scan, standardised A and B-scan contact ultrasonography with axial length measurement (Ophthascan, Biophysic Medical), keratometry, and corneal endothelial specular microscopy (Alcon Procem 4). One-piece polymethylmethacrylate lens with 10° anterior angulated C loop haptics was used in all cases.
We performed a standard three-port vitrectomy with sclerotomies 4 mm from the limbus. Lensectomy using vitrectomy probe was performed while taking care to preserve the anterior capsule by maintaining high cutting rate and low suction. Anterior subcapsular epithelium was gently rubbed with the probe tip with zero suction in an attempt to strip the epithelial cells from the anterior capsule. Following vitrectomy and the foreign body removal using a diamond coated foreign body forceps, endolaser or cryopexy was used to create chorioretinal adhesion around any retinal breaks. The two sclerotomies were then temporarily closed with scleral plugs.
A 7 mm limbal incision was made and a PC IOL was placed in the ciliary sulcus on the preserved anterior capsule and the limbal incision was closed with interrupted 10-0 monofilament nylon sutures. Finally, the sclerotomies used for vitrectomy were closed with 6-0 vicryl sutures.
| Case Management|| |
The first case was 25-year-old man who presented with visual acuity of counting fingers with accurate light projection in his left eye. He had injured his left eye with a flying particle while doing some metal work. The linear defect in anterior capsule was 1.5 mm in length, 4mm lateral to the visual axis. CT scan and ultrasonic examination revealed vitreous haemorrhage along with 1.5 mm IOFB, 2 mm in front of the retina in the inferonasal quadrant between 6 and 6.30 o'clock. After lensectomy and vitrectomy, the IOFB was removed with the foreign body forceps and external retinal cryopexy was placed around the retinal defect at the impact site. A +19 D PC IOL was placed. The patient developed early anterior capsular opacity which was treated with YAG capsulotomy at 6 weeks. The patient's best correctable visual acuity in the involved eye was 6/9 following the capsulotomy procedure.
The second case was an 18-year-old boy who noted decreased visual acuity in his right eye while hammering a metal lathe. He presented to us after 10 days with visual acuity of 1 / 60 with accurate projection of rays in the involved eye. A self-sealing 2 mm horizontal lesion in the cornea just superonasal to the axis was noted. The patient had traumatic cataract with 2 mm oval horizontal defect in the anterior capsule, 3 mm nasal and 2 mm superior to the visual axis, along with vitreous haemorrhage and an IOFB of 1.5 mm size which was 2.9 mm in front of retinal superonasal to the disc. A +21 D PC IOL was placed after the successful lensectomy (sparing the anterior capsule), vitrectomy and removal of the IOFB. Early capsular opacification was treated with YAG capsulotomy after 6 weeks. The visual acuity improved to 6/9, and the patient continued to have the visual acuity of 6/9 till the last follow up which was 9 months after the YAG procedure.
The third case was a 21-year-old man, blacksmith by occupation, who presented with visual acuity of counting fingers at 1 foot with accurate light projection in the left eye. A self-sealed 1.5 mm linear wound at 10 o'clock position was noticed in the cornea along with traumatic cataract. Ultrasonography revealed vitreous haemorrhage and a 1.5 mm IOFB, 4 mm in front of the retina in the superonasal quadrant. In this patient again the combined triple procedure was performed. No post-operative capsular opacification was seen upto 3.5 months after surgery, and the patient's visual acuity was correctable to 6/6.
| Discussion|| |
The management of posterior segment IOFBs requires vitrectomy combined with removal of the foreign body either by intravitreal rare earth magnet or by intravitreal forceps., Removal of the vitreous prevents the formation of scaffold for growth of fibrovascular tissue.Lensectomy is often required in such cases since traumatic cataract is frequently a part of the typical clinical picture of such IOFBs, and simultaneous removal of the lens becomes necessary for adequate visualization of the IOFB.,
Since the lenticular foreign body exit wound through the posterior lens capsule is larger than the anterior capsular entrance wound, we made no efforts to preserve the posterior capsule. The penetrating sites in the anterior capsule did not enlarge during lensectomy and capsular polishing. This allowed anterior capsular support for a standard PC IOL. Preserving the anterior capsule minimises the corneal endothelial damage due to fluid turbulence and also prevents constriction of pupil from mechanical trauma during vitrectomy and removal of foreign body. But preservation of the anterior capsule can lead to the increased incidence of capsular opacification as evident in 2 of the total 3 cases. We noticed an average post-operative corneal endothelial cell loss of 8% which is less than the 14% loss in cataract surgery reported by Bourne et at.
Thus this combined triple procedure is safe in selected cases of IOFBs wherein the corneal laceration is small, self-sealing, out of the visual axis, and accompanied by a formed anterior chamber. This procedure can offer excellent visual results in certain selected cases of retained posterior segment IOFB. But since the chance of capsular opacification is very high when leaving anterior capsule totally, one can plan primary anterior capsulotomy with vitrectomy probe through pars plana after IOL insertion and closure of the limbal incision. This modification might also obviate the need for YAG laser capsulotomy postoperatively in these cases.
| References|| |
Cox MS, Schepens CL, Freeman HM. Retinal detachment due to ocular contusion. Arch Ophthalmol
Slusher MM, Sarin LK, Federman JL. Management of intraretinal foreign bodies. Ophthalmology
Kokame GT, Flynn AW, Blankenship GW. Posterior chamber intraocular lens implantation during diabetic pars plana vitrectomy. Ophthalmology
Koenig SB, Han DP, Miller WF, Abrams GW, Jaffe GJ, Burfon TC. Combined Phacoemulsification and pars plana vitrectomy. Arch Ophthalmol
Benson WE, Brown GC, Tasman W, Mcamara JA. Extracapsular cataract extraction, posterior chamber lens insertion and pars plana vitrectomy in one operation. Ophthalmology
Slusher MM, Craig M, Greven M, David YU. Posterior chamber intraocular lens implantation combined with lensectomy-vitrectonw and intraocular foreign body removal. Arch Ophthalmol
Hickingbotham D, Parel JM, Machemer R. Diamond coated all purpose foreign body forceps. Am J Ophthalmol
Slusher MM. Intraretinal foreign bodies: management and observation. Retina
Michels RG. Vitrectomy methods in penetrating ocular trauma. Ophthalmology
Bourne WM, Waller RR, Liesegang TJ, Brubaker RF. Corneal trauma in intracapsular and extracapsular cataract extraction with lens implantation. Arch Ophthalmol
Girard LJ, Travis A. Pars plana vitrectomy. Surv Ophthalmol