Year : 2000 | Volume
: 48 | Issue : 1 | Page : 33--6
Intraocular cilia associated with perforating injury
L Gopal, AS Banker, T Sharma, S Parikh, PS Bhende, S Chopra
Medical and Vision Research Foundation, 18 College Road, Chennai-600 006, India
Medical and Vision Research Foundation, 18 College Road, Chennai-600 006
Purpose: To report a case series of penetrating injury complicated by occurrence of intraocular cilia.
Methods: Retrospective analysis of charts of 11 eyes of 11 patients with penetrating injury and intraocular cilia, presenting between September 1978 and November 1998. Ten eyes underwent surgery for trauma-related problems such as cataract, vitritis, retinal detachment etc., at which time intraocular cilia were removed. One eye did not have surgery and continues to harbour cilia at the posterior perforation site.
Results: Metallic wire was responsible for injury in 6 of 11 eyes with intraocular cilia. Five eyes had significant intraocular inflammation. The cilia were located in the anterior segment in 4 eyes; in the posterior segment in 6 eyes and in both in one eye. At the last follow up, 72.7% had 6/18 or better vision. Poor vision in the rest was due to recurrent retinal detachment (2 eyes) and macular scarring (1 eye).
Conclusion: Intraocular cilia are more commonly associated with injury by a metallic wire. The presentation and management of an injured eye does not seem to be influenced by the presence of cilia in the eye.
|How to cite this article:|
Gopal L, Banker A S, Sharma T, Parikh S, Bhende P S, Chopra S. Intraocular cilia associated with perforating injury.Indian J Ophthalmol 2000;48:33-6
|How to cite this URL:|
Gopal L, Banker A S, Sharma T, Parikh S, Bhende P S, Chopra S. Intraocular cilia associated with perforating injury. Indian J Ophthalmol [serial online] 2000 [cited 2022 May 16 ];48:33-6
Available from: https://www.ijo.in/text.asp?2000/48/1/33/14857
The presence of intraocular cilia (eyelashes) following penetrating injury or surgical intervention is rare. It was first reported by Lerche in 1835. Intraocular cilia have been found in the anterior[2,3] and posterior chambers, embedded in the iris, within the vitreous cavity and within the lens.[7,8] So far, there has been only one case report of the cilia embedded in the retina. The fate of the eyelash and the reaction of the eye to the same vary. The cilium may remain in the eye for a long period without eliciting any response. On the other hand, acute inflammatory reaction and even sympathetic ophthalmia have been attributed to intraocular cilia. Recently, Propionibactcrium acnes lens abscess has been reported after traumatic implantation of cilia in the lens. Oh et al reported a case of intraocular cilia in the vitreous cavity in a 49-year-old female with no history of trauma. The path of entry of the eyelash remained unexplained and the eye suffered from Staphylococcus aureus endophthalmitis and rhegmatogenous retinal detachment. We report herein 11 cases of intraocular cilia following accidental trauma and discuss the problems related to this unusual intraocular foreign body.
Materials and Methods
Of 2718 consecutive cases of intraocular foreign bodies seen between September 1978 and November 1998 at this institution, only 11 involved cases of intraocular cilia (0.4%). The clinical details are provided in the Table. There were 8 males and 3 females ranging in age from 7 to 41 years (average 25.2 ± 15.2 yrs). A metallic wire was responsible for the injury in 6 out of the 11 eyes. The wound of entry was corneal in 9 eyes and scleral in 2 eyes. At presentation, 5 eyes had significant intraocular inflammation: exudative membrane in pupillary area (2 eyes), vitritis (2 eyes) or both (1 eye). One eye presented with a 4-year-old injury and had a well tolerated intraocular cilia at the perforation site. The cilia were located in the vitreous cavity in 3 eyes; at the site of posterior perforation in 3 eyes (Figure); at the entrance wound in one eye; in the pupillary area in two eyes; and adherent to the iris/ciliary body in one eye. In one eye, the cilia were located in three locations - the ciliary body area, vitreous cavity and at the posterior perforation site. Two eyes had traumatic retinal detachment with proliferative vitreoretinopathy (PVR). Case 9 had retina incarcerated in the wound with intraocular fibrosis from that area, while case 10 had PVR grade 2. All but one eye had surgical intervention for trauma-related problems such as cataract, vitritis, vitreous incarceration in entrance and exit site, retinal detachment, etc. In cases 5 and 8 the cilia were located in the exudates across the pupillary area and were removed along with the removal of the lens. In the rest, the cilia were removed along with vitreoretinal surgical techniques as required. The cilia were removed with intraocular forceps and as such is a relatively simple procedure. In the two cases with retinal detachment, extensive membrane peeling and silicone oil tamponade was used while in the rest vitrectomy to clear the media and endolaser to surround any posterior retinal perforation was performed. In many cases the presence of cilia was identified only during surgery while clearing the vitreous cavity. Cultures of the vitreous or pupillary membranes in the 5 eyes with inflammation were negative for growth of bacteria or fungi. The cilia themselves were not cultured. Light microscopy of the cilia did not show any abnormalities. Electron microscopic studies could not be performed.
The follow up ranged from 2-36 months (Mean 10.6 ± 13.73 months). As indicated, one eye did not undergo surgery. Of the remaining 10 eyes, surgery for retinal detachment related to trauma was done in 2 eyes using complex vitreo retinal techniques and silicone oil tamponade. Both these eyes had recurrent retinal detachment due to recurrent PVR. The remaining eyes had good anatomical outcome after one or more surgeries. A second surgery was needed for macular pucker (one eye), post vitrectomy retinal detachment (one eye) and cataract (one eye). The visual acuity at last follow up was better than 6/12 in 8 eyes (Table). Two eyes with recurrent retinal detachment had only hand movement vision while one eye with macular scar had 2/36 vision.
Intraocular cilia following penetrating injury are extremely rare. In one series the incidence was quoted as 2 out of 374, 721 patients. Our series confirmed the rarity of the situation (11 out of 383, 733 patients ). These formed 0.4% of all intraocular foreign bodies seen by us. An explanation has been offered by Duke Elder1 for this low incidence. In case of penetrating injury, the lids are expected to close reflexly only after the foreign body contacts the conjunctiva or cornea, by which time it has cleared the lid margin. Hence the eyelashes do not come in the path of the foreign body. We found that 6 out of our 11 cases had injury with a metallic wire. In the rest, the injury occurred with wooden piece (one eye), glass piece (one eye), needle (one eye), rifle bayonet (one eye), and fire-cracker (one eye).
Barring the case with fire-cracker injury, in the rest, a relatively slow moving object struck the eye (in comparison to a fast metal chip). This may enable the eyelashes to come in the path of the object due to reflex eye closure. The eyelashes are also more likely to get epilated when a relatively blunt-tipped object strikes the eye compared to a sharp metal chip. Metrikin et al also described higher incidence of metal wire injury among the cases of intraocular cilia.
The reaction of the eye to the cilia has been reported to be variable and unpredictable. This varied from absolute lack of reaction for as long as 32 years, to severe intraocular inflammation. Various reports have cited plastic iridocyclitis, granulomatous inflammation, cyst formation and even sympathetic ophthalmia as occurring in eyes with intraocular cilia associated with perforation injury. However, the causal relationship between the two has never been established. Most of these complications could have occurred following the injury even without the cilia. Fish et al described an intra-lenticular abscess caused by Propionibacterium acne due to lens damage associated with cilium. It was presumed that the organism was carried with the cilium into the lens. The cilium in this case acted as any other contaminated foreign body.
Of the 11 cases in this series, one (case 6) did not have removal of cilia. This eye did not show any specific reaction, despite the presence of intraocular cilia for 4 years, barring the scarring associated with the posterior perforation. Among the remaining 10 cases, 5 presented with variable degree of inflammation. There is nothing to suggest that this is specifically related to the presence of intraocular cilia. This could be an inflammation/ infection caused by the injury itself. Case 2 had recurrent vitritis following initial conservative treatment with intravitreal injection of antibiotic and steroid combination. Following vitrectomy with removal of the cilia, the infection cleared, although the patient needed further surgery for retinal detachment that occurred subsequently. Although it is tempting to attribute the recurrent vitritis to the persistent presence of cilia in the eye, the causal relationship still remains speculative. In the remaining cases, the vitrectomy was indicated for the complication of perforating injury and not necessarily for the removal of the intraocular cilia.
Humayun et al, through studies of cilia removed from within the eye, have shown structural changes on scanning electron microscopy. These changes involved loss of lamellar structure and presence of electron-dense protein-like material on the cilia. It was also suggested that epithelial cysts that occurred following injury along with intraocular cilia could have originated from the epithelium of the root of the hair follicle. However, Bonnet, Paufique and Bussy (cited by Duke Elder) have suggested that the cyst formation is secondary to the surface epithelium being carried into the eye at the time of injury and not from the cilia. Hence one may not be wrong in surmising that the cilia that are carried into the eye may act as a contaminated foreign body. In the absence of intraocular infection, the cilia may remain in the eye for several years without causing any specific problem.
Another important feature which makes intraocular cilium an unique type of an intraocular foreign body, is the relative difficulty in detecting it ultrasonographically Being a very minute object (<0.5mm in diameter) it cannot be detected by ultrasonography unless it is surrounded by a fibrous capsule, in which case it can give rise to echoes of high reflectivity with or without orbital shadowing. Of the 9 cases in our series in which ultrasonography was performed, characteristic high reflective echoes were seen in two.
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