Year : 2000 | Volume
: 48 | Issue : 2 | Page : 119--22
Intralenticular foreign bodies: Report of eight cases and review of management
R Arora, L Sanga, M Kumar, M Taneja
Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi
Purpose: The management of intralenticular foreign bodies (ILFBs) with or without cataract has varied from time to time in the last century. We evaluated the surgical removal of the ILFBs with cataract extraction as a single-stage procedure.
Methods: Eight consecutive cases with intralenticular foreign bodies presenting to the trauma centre at our institute, were included in the study. Planned ILFB removal with cataract extraction and IOL implantation as a single-stage procedure was done in all the patients. They were followed up from 2 months to 2 years after the surgery.
Results: ILFBs were removed with Kelman-Mcpherson forceps in seven cases and in one it was expressed with the nucleus during extra capsular cataract extraction. Co-existent posterior capsular tears were seen in two eyes, of which only one needed a localized vitrectomy. Posterior chamber intraocular lens implantation was possible without any complication in all the cases. Postoperative uveitis seen in three cases was easily controlled with periocular steroids. Best corrected visual acuity at last examination was 6/9 or better in 7 cases and 6/12 in one case with posterior capsular opacification.
Conclusions: Timing and necessity of ILFB removal may be adjusted according to the foreign body characteristics and associated ocular trauma, choosing, as far as possible, the least traumatic procedure. Use of forceps rather than magnets is safer for the removal of the ILFB. Co-existent posterior capsular tears need to be anticipated and dealt with when encountered.
|How to cite this article:|
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
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Arora R, Sanga L, Kumar M, Taneja M. Intralenticular foreign bodies: Report of eight cases and review of management. Indian J Ophthalmol [serial online] 2000 [cited 2022 Sep 25 ];48:119-22
Available from: https://www.ijo.in/text.asp?2000/48/2/119/14892
Intralenticular foreign bodies (ILFBs) are not commonly encountered. They constitute 7-10% of all intraocular foreign bodies.[1, 2] The recommended management of ILFBs has changed over the last century. Most authors suggest an evaluation of the circumstances of trauma, foreign body characteristics (size, chemical composition and infectivity), lens status (clear or cataractous) and time of presentation before surgical intervention.[3-6] If surgery, that is ILFB removal with or without cataract surgery, is considered necessary, a technique most appropriate and least traumatic to the already injured eye, must be performed.
A series of eight eyes with retained ILFB and cataract is presented. The nature of injury, foreign body, associated ocular trauma and detailed surgical procedures for the successful removal of ILFB and cataracts are reported.
Materials and Methods
We reviewed the charts of eight consecutive cases of ILFB who presented to our trauma service between December 1994 and October 1996. The patients ranged in age from 12 to 35 years. The aetiology of trauma in six cases was occupational. The time interval between the injury and presentation ranged from the day of injury to 2 years. Seven patients had small corneal opacities signifying the wound of entry and one patient needed suturing of the perforation. The best corrected visual acuity (BCVA) of the patients ranged from accurate projection of rays to 6/9 (Table).
Five patients had total cataract, while three had localized lenticular opacities. The ILFB was seen to be impacted in the lens in six cases, while the remaining two were diagnosed preoperatively on radiologic/sonographic examination. The patients with total cataract and impacted ILFB underwent early ECCE with PCIOL implantation; the ILFB was removed with Kelman-Mcpherson forceps. The foreign body, whenever it was seen on the anterior capsule, was dislodged into the anterior chamber with irrigation and removed under direct visualization. The salient features of the surgery were gentle expression of the nucleus in patients above 25 years and simple aspiration of the soft cataractous lens in patients below 25 years. Two patients with localized lenticular opacity at initial presentation developed total swelling of the lens at one month follow up and thereafter underwent cataract extraction and IOL implantation with the removal of ILFB. Postoperative medication comprised of use of 0.1 % dexamethasone phosphate four times daily in patients with mild to moderate anterior chamber reaction. Three patients with severe inflammation needed multiple periocular dexamethasone phosphate injections in. addition to topical 2-hourly 0.1% dexamethasone phosphate regimen. All the patients received topical antibiotics for the first 2 weeks.
All the patients in our series were males, 12 - 35 years old. ILFB removal and simultaneous cataract extraction with posterior chamber sulcus fixated IOL implantation as a single-stage procedure was performed in all the eyes. The follow up ranged from 8 weeks to 2 years. The BCVA at the last follow up ranged from 6/6 to 6/ 12. The nature of the removed ILFBs was found to be metallic in five eyes, wooden in two and glass in one eye (Table). All the metallic foreign bodies were ferrous in nature.
The type and circumstances of the injury related to the nature of patient's work except in the 12-year-old boy (patient # 2) who was only an observer and the 16-year-old boy (patient # 5), a student, who was injured when blowing a capillary tube over a flame.
Except for one patient, who presented on the same day following trauma, all the others had a delayed presentation ranging from 1 month to 2 years by which time the intraocular inflammation had subsided. Globe disruption was minimal in all the cases. The corneal wounds were small and self-sealed except one eye which needed corneal suturing. The only evidence of corneal perforation in all, apart from the one which required corneal repair, was a minute corneal opacity/scar.
Orbital X-rays of five patients with metallic foreign body (FB) revealed small radio-opaque opacity in three eyes and none in two eyes. No radio-opaque objects were visualized in eyes with wooden or glass FB. In patient # 4, though no radio-opaque FB was visible, ultrasound with 15 MHz probe detected the FB in the Lens.
Coexistent localized posterior capsular tears were evident after lens aspiration in two eyes (Table). They were small, with vitreous disturbance in only one case which needed a localized anterior vitrectomy. PCIOL implantation in the ciliary sulcus was done without any complication in all the eyes. None of the cases required scleral fixation of the IOL.
Postoperative inflammation was excessive in three patients. Two of these had presented early following the trauma and another had uncontrolled intraocular pressure (IOP) due to swollen lens prior to surgical intervention. The inflammation was mild to moderate in the remaining five patients with delayed presentation following the trauma. No posterior segment abnormality was detected postoperatively on indirect ophthalmoscopy. Also, no additional foreign body was detected.
Intralenticular foreign bodies account for approximately 7-10% of all the IOFBs.[1, 2] They may be metallic or nonmetalic in nature. Nonmetalic ILFBs as cilia,[7, 8] glass, stone, vegetable matter[5, 10] and coal have been reported. When injured in this manner lens has altered capsular integrity which results in the formation of visually significant cataract. There is usually a minimal accompanying globe disruption but complications like uveitis, glaucoma, abscess formation, endophthalmitis and intralenticular metallosis have been occasionally reported.
The recommended management of ILFBs has changed often during the last century. Initially intracapsular cataract extractions (ICCE) were advocated[12, 13] but after the 1930s the popular procedures involved removal of IFLBs by manipulating them into the anterior chamber either manually or with assistance of a magnet and then removing them through the original corneal entry site or via a separate surgical incision. These two steps were performed either as a single-staged procedure or as two separate surgeries.
Since 1985, there have been reports of ILFBs expressed with the lenticular nucleus. ECCE with PCIOL combined with extraction of lenticular magnetic foreign body has been reported to be successful.[5, 6] Wang found the combined procedure to give good results in 14 eyes, three of which had suture-fixated IOL because of posterior capsular tear.
The decision to remove ILFBs must depend on foreign body characteristics including size, chemical composition and the possibility of infection. Since ILFBs tend to be small, the ruptures in the anterior capsule may seal spontaneously associated with only focal cataractous changes. If this is outside visual axis, it may not require intervention. Spontaneous reopening of the sealed rupture may occur occasionally with subsequent leakage of the lens matter which may cause severe inflammation and secondary glaucoma. Controlling raised IOP is then extremely difficult as was seen in our patient # 3.
Metallic FBs may give rise to intraocular metallosis and inflammation; ferrous containing ILFBs causing siderosis bulbi and copper containing FBs a chalcosis Organic matter is highly likely to introduce either bacterial or fungal infection. None of these reported ocular effects of ILFBs were seen in the present series.
With regard to the surgical procedure in the present series of ILFBs, a manually controlled removal of the foreign body under visualization was preferred. After conventional 'can opener'/linear capsulotomy and gentle aspiration of the cataractous lens matter, the foreign bodies were removed with Kelman-Mcpherson forceps in six cases, and in one case the foreign body was expressed with the nucleus, embedded on its posterior surface. In one case, the foreign body was removed before lens aspiration. The capsulotomy pattern varied with the status of the anterior capsular tear. A severe anterior segment inflammation was seen in three patients in whom surgery was performed soon after the injury including the case with free floating lens matter in the anterior chamber with secondary glaucoma. The inflammation could be controlled easily with periocular steroids.
From our series of patients with ILFB we emphasize that the decision to remove ILFB with cataract should be based on the degree of cataract, any complication, specially uveitis or glaucoma and patient's visual needs. A small ILFB with capsular tear and a localized lenticular opacity may be left undisturbed and closely followed for the development of any complication. In the event of the development of problems of free floating lens matter in the anterior chamber, uveitis or raised intraocular pressure, surgical intervention should be undertaken. Use of forceps for ILFB removal was found to be safer than the conventionally used magnets. Aspiration or expression of cataract with IOL implantation during the same procedure as ILFB removal worked well in our series. As a pre-existing traumatic posterior capsular rupture is possible, a minimal and gentle aspiration or nuclear expression is recommended. Thus one should be prepared for posterior capsular tears and vitrectomy. A moderate to severe postoperative inflammation encountered can be easily managed with periocular steroids. All these factors influence the decision to operate, and the nature of surgical intervention. In addition, the use of periocular steroids are important in the effective management of patients with intralenticular foreign bodies.
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