|Year : 2015 | Volume
| Issue : 2 | Page : 35-40
Clinical presentations and outcomes following ocular injury with intraocular foreign bodies
Mansukhani Sasha Anil, Nicholson Anjali Daraius, Murade Sujit Mardansingh, Hussain Faraaz Syed
Department of Ophthalmology, Topiwala National Medical College and B. Y. L. Nair Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||12-Nov-2015|
Mansukhani Sasha Anil
Akshi Eye Center, 169 A, Mayur Niwas, 2nd Floor, Dr. Ambedkar Road, Dadar T. T. Circle, Dadar East, Mumbai - 400 014, Maharashtra
Context: Globally, of 55 million ocular trauma cases occurring per year, 1.6 million are rendered blind. Intraocular foreign bodies (IOFBs) form a major subset (40%) of the penetrating eye injuries. Aims: To study the clinical presentations, visual outcomes, and the prognostic factors in penetrating eye injuries with IOFB. Settings and Design: This is a prospective cohort study conducted at a tertiary care center. Thirty-three eyes of 33 consecutive patients presenting to our center between March and December 2012 with IOFB injury were included in the study. Materials and Methods: After obtaining informed consent, detailed history and examination findings were noted at presentation. Computed tomography scanning was done in all patients. The details of the IOFB extraction procedure were noted and the patients were followed up for 3 months following the surgery. Statistical Analysis Used: All statistical calculations were performed in Stata (12.1) using the t-test. Results: Fifty-three percent were males between 15 and 30 years of age. Seventy-three percent had foreign body located in the posterior segment, whereas 27% were located in the anterior segment. The incidence of endophthalmitis was 16.67%. The final best corrected visual acuity appeared to be worse with poorer vision at presentation, larger foreign body size, scleral entry wound, and foreign body removal during a secondary surgery. Conclusions: Penetrating eye injuries with IOFB usually occurred in young males at work places. Factors leading to poor visual outcome were poor vision at presentation and larger foreign body size.
Keywords: Intraocular foreign body, ocular trauma, penetrating eye injury
|How to cite this article:|
Anil MS, Daraius NA, Mardansingh MS, Syed HF. Clinical presentations and outcomes following ocular injury with intraocular foreign bodies. Sudanese J Ophthalmol 2015;7:35-40
|How to cite this URL:|
Anil MS, Daraius NA, Mardansingh MS, Syed HF. Clinical presentations and outcomes following ocular injury with intraocular foreign bodies. Sudanese J Ophthalmol [serial online] 2015 [cited 2019 Sep 20];7:35-40. Available from: http://www.sjopthal.net/text.asp?2015/7/2/35/169384
| Introduction|| |
Ocular trauma is one of the major causes of blindness in the economically productive age group. Every year there are around 55 million cases of ocular trauma globally, of which 1.6 million are rendered blind.  Intraocular foreign bodies (IOFBs) form a major subset of the penetrating eye injuries (40%).  Despite advances in surgical treatment, management of IOFBs continues to be challenging. IOFBs frequently cause severe visual loss, 22-43% resulting in final vision worse than 6/60 in the injured eye. ,
This study was undertaken to determine the clinical presentation, visual outcomes, and prognostic factors in injuries with IOFB.
| Materials and methods|| |
This study is a prospective cohort study conducted at a tertiary care center from March to December 2012. Prior approval from the Institutional Ethics Committee was taken and informed consent was obtained from each subject. This study was conducted in accordance with the tenets of the Declaration of Helsinki. Thirty-three eyes of 33 consecutive patients presenting to our center with IOFB injury were recruited and were followed up for 3 months. Exclusion criteria included patients with a history suggestive of prior ocular trauma and patients with iatrogenic foreign bodies. Three patients were lost to follow-up (attrition rate 9%) and were not included in the analysis. Data of 30 patients were recorded prospectively and analyzed.
Careful detailed history, including mechanism of injury was noted. Vision was taken and anterior segment examination was done by slit lamp biomicroscopy.
Posterior segment examination was done by direct and indirect ophthalmoscopy. If the foreign body was visible, its size and location was noted. Radiological investigations included X-ray orbit in anteroposterior and lateral view. Computerized tomography scan (CT scan) was done to confirm the diagnosis, for the location and the material of the IOFB.
In selected patients in whom the foreign body was not well visualized on CT scan, a gentle B-Scan ultrasonography was done. Preoperative investigations including blood tests and electrocardiogram were done.
Initial management consisted of topical antibiotics for infection prophylaxis in the form of moxifloxacin 0.3% eye drops was given 1 hourly. Atropine eye drops was given in cases of uveitis for cycloplegia and pain relief. A protective eye shield was applied to prevent any further damage.
Systemic treatment consisted of administering an intramuscular tetanus toxoid vaccine 0.5 ml, if not taken in the last 5 years. Intravenous broad spectrum antibiotic prophylaxis in the form of injection cefotaxim twice a day was given with appropriate dose adjustments made in the pediatric population. Injection dexamethasone 8 mg was given intravenously twice a day except in patients in whom endophthalmitis was suspected clinically, in which case the steroid was withheld.
Patients were explained the nature of the injury and written informed consent was taken for globe exploration with tear suturing.
The IOFB was removed in one of two ways:
1. Primary extraction - It consisted of removal of the IOFB during the primary surgery along with globe exploration and entry wound suturing. In the cases of self-sealed wounds and good media clarity, primary extraction was preferred.
2. Secondary extraction - In these cases, the first surgery was done to close the entry wound, with or without cataract extraction. The IOFB was removed in the second procedure, taken up at a later stage when ocular conditions were more conducive to posterior segment surgery.
Anterior segment foreign bodies were removed after anterior chamber entry, with the help of viscoelastics and forceps. For posterior segment IOFBs, 20 gauge pars plana vitrectomy was done, and extraction was done with the help of forceps or an intraocular magnet for metallic IOFBs. IOFB <6 mm, were removed by enlarging the scleral port itself, while larger ones were extracted through a limbal wound after a lensectomy or cataract removal. Silicon oil and PFCL were used if necessary. Scleral buckling was done with the help of 42 number band and Watzke's sleeve.
Postoperative care included topical antibiotics, steroids, cycloplegic and lubricants, and continual of systemic antibiotics (5 day course). Oral steroids were given at 1 mg/kg with 5 day tapering unless contraindicated medically or in suspicion of infection.
Complete ophthalmological examination were performed on the first postoperative day and then at 7 days, 1 month, and 3 months after the surgery of extraction, with more frequent examination in patients with uveitis and infection. All patient information was entered into an Excel database. All statistical calculations were performed in Stata 12.1 (Statacorp, College Station, Texas) using the t-test.
| Results|| |
The mean age of presentation was 30.9 years; the youngest patient was 12 years and the oldest was 60 years. Sixteen out of 30 patients were in the 15-30 years age group (53%). Twenty-seven out of 30 patients were males (90%), whereas only 10% were females. The majority of the patients were construction workers; 12 out of 30 (40%), followed by mechanics (20%), and carpenters (13%). Twenty-six out of 30 patients were workers while four were bystanders. Most of the injuries; 28 out of 30 (93%), occurred in the work environment, and none of the 28 workers was wearing protective goggles. A minority of the injuries; 2 out of 30 (7%) occurred out of the workplace.
Thirteen out of 30 patients presented with vision finger counting close to face (FCCF) or less (43%). Patients presenting with vision 6/12 and better were 8 out of 30 (27%). Twelve patients presented between 1 and 2 days following injury (40%). Patients presenting more than 7 days after injury were 8 out of 30 patients (27%). Hammering was the most common mechanism of injury (63%), followed by drilling, and cutting metal.
The mean entry wound size was 3 mm, the largest and smallest wound being 10 and 0.5 mm, respectively. Nineteen out of 30 (63%) of the entry wounds were sized from 2 to 5 mm in length.
Nineteen out of 30 IOFBs entered through the cornea (63%), followed by sclera (27%), and then limbus (10%). Seventeen of the 30 patients required suturing of the entry wound while 13 out of 30 had self-sealing wounds. Twenty-two out of 30 patients (73%) had IOFBs located in the posterior segment while 8 (27%) were located in the anterior segment. [Figure 1] and [Figure 2] show anterior segment foreign bodies while [Figure 3] shows a posterior segment foreign body.
|Figure 1: Anterior chamber foreign body embedded in the iris with fibrous encapsulation|
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|Figure 3: Posterior segment foreign found on the retina. Choroidal coloboma also incidentally noted|
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[Figure 4] is a CT scan sagittal view showing the foreign body in the posterior segment.
Fourteen IOFBs were located in the vitreous (47%), followed by five in the anterior chamber (17%), and five which were intraretinal (17%). Twenty-three out of 30 (77%) IOFBs were metallic while 20% were stone, and 3% were wooden foreign bodies. The average size of the IOFB extracted was 2.97 mm. The smallest foreign body was 0.5 mm, and the largest was 8 mm in size. The majority of foreign bodies were in the 1-3 mm size group (40%).
|Figure 4: Computerized tomography scan sagittal view showing foreign body in posterior segment|
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Nineteen out of 30 patients (63%) underwent primary extraction of IOFB that is extraction of IOFB during closure of the entry wound. Eleven out of 30 patients (37%) underwent secondary extraction of IOFB, primary surgery being that of wound closure.
After the surgery of extraction, 17 out 30 patients (57%) did not undergo any further surgery. Twelve out of 30 (40%) required one additional surgery while 1 out of 30 (3%) required two additional surgeries. From the additional surgeries done, 50% were iris claw lens implantation for aphakia, while 33% were retinal detachment surgeries.
At 3 months following IOFB extraction, 9 out of 30 patients (30%) had the best-corrected visual acuity (BCVA) FCCF or worse, while 12 out 30 patients (40%) had vision 6/12 or better [Figure 5], [Table 1] and [Table 2].
|Figure 5: Mean best-corrected visual acuity charted from the time of presentation to 3 months after the extraction of the intraocular foreign body|
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|Table 2: Complications seen at 3 months after the extraction of the IOFB|
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Of the 13 patients who presented with poor vision that is perception of light negative (PL −ve) to FCCF (PL −ve to FCCF), six patients remained in the poor vision group (46.15%), while four patients improved to vision 6/12 or better (30.76%). Of the eight patients presenting with good vision that is 6/12 or better, only one patient regressed to poor vision (FCCF or worse) (12.5%), while four patients retained good vision [Table 3].
|Table 3: Comparing vision at presentation to final vision 3 months postextraction|
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In addition, when the visual outcome was seen in the group with lower vision at presentation (FCCF or worse), the final mean vision was finger counting more than 3 m to 6/60. In comparison, the group which had better vision at the time of presentation (vision more than 6/60), had a final mean vision which was better, that is 6/24-6/18. This difference in visual outcome is statistically significant (P = 0.02) at the end of 3 months. The mean final vision in the small foreign body size group (size ≤3 mm) was 6/24-6/18. The mean vision in the large foreign body size group (size large than 3 mm) was finger counting more than 3m to 6/60. Thus, injuries with larger foreign bodies had poorer visual outcome, which was statistically significant (P = 0.02).
The mean vision in the corneal entry wound group was FCCF to finger counting <3 m. The mean vision in the sclera and limbal entry wound group was projection of light accurate to FCCF. Scleral entry wound had poorer visual outcome, and this was statistically significant (P = 0.02).
The final mean vision in the primary extraction group was 6/24-6/18. IOFB extraction in primary surgery that is during the surgery of entry wound suturing, was associated with better visual outcome, which is statistically significant (P = 0.02).
The final best-corrected vision did not appear to be affected by removal of foreign body later than 1 week after injury (P = 0.33) and larger entry wound size (P = 0.07).
The sample size was inadequate to compute the effect on the final BCVA of the presence of endophthalmitis, nature of the foreign body, and anterior versus posterior segment location.
| Discussion|| |
Most of our patients (53.33%) were in the 15-30 years age group. This is similar to other studies done in other parts of the world; Maneschg et al. (32.29 years), Fonolla et al. (38.7 years), Wickham et al. (34.6 years). ,, Most of the patients in our study were males (90%). This was similar to other studies done, all of which have a male preponderance; Manesch et al. (96.8 %), Fonolla et al. (100%), Memon et al. (90%), Bhattacharjee et al. (all males except one). ,,, This could be related to the fact that majority of the injuries were related to occupational activities of hammering and drilling, jobs which are frequently done by males. None of the workers in our study was wearing protective eye wear, indicating the need for enforcement of workplace safety regulations. Furthermore, in our study, while 87% of the affected were workers themselves, 13% were bystanders, present in the near vicinity of the ongoing activity such as hammering and drilling. Thus indicating a need to separate out areas in which such high risk activities are carried out.
Our study found that the majority of patients presented with vision 6/60 or less (63%). Twenty-seven percent of patients presented with good vision that is vision 6/12 or better.
Fonolla et al. have found that initial visual acuity was below 6/60 in 61.3% of the cases.  Similarly, another study states that the presenting visual acuity was finger counting to perception of light in 78% cases.  Bhattacharjee et al. found that vision on presentation was worse than 6/36 in 88.89% of all eyes. 
Seventy-three percent of our patients had posterior segment IOFBs while 27% of patients had anterior segment foreign bodies.
Further, 47% were located in the vitreous, anterior chamber and intraretinal were 17%, 10% were subretinal, 7% were intralenticular, and 3% of the IOFBs were located in the posterior chamber.
Williams et al. had findings with 61% IOFBs located in the vitreous. 
Napora et al. had different findings with 46.1% of IOFBs in the anterior segment, 44.2% in the vitreous, and the rest in the posterior part of the globe. 
The rate of endophthalmitis in our study was found to be was 17%. The reported rate of endophthalmitis following penetrating ocular trauma varies from 2% to 13.5%. ,,,
In Falavarjani et al.'s study, 19.1% achieved a vision of 6/12 or better.  George et al. found that vision was no perception of light in 29%. George et al. and Thoongsuwan et al. found that visual outcome was 6/18 or better in 50% and 48.2%, respectively which was similar to what we have found. , Greven et al., however, reported that the final visual outcome was 6/12 or better in 71% of patients. 
Poor vision at presentation was found in our study to be predictive of poor final vision. It has been stated as a poor prognostic factor by a number of researchers. ,,,,, We also found in our study that foreign body size >3 mm was associated with poorer visual outcome which is statistically significant (P = 0.02).
Similar outcome was found by Strmen et al.  Several other studies in the literature have proposed larger foreign body size as poor prognostic factor. ,,,,
We compared the visual outcome in both the groups undergoing extraction within 7 days of injury and after 7 days, and found that there was no statistical difference (P = 0.94).
This is in concordance with previous studies done by George et al., Ahmadieh et al. and Falavarjani et al.,, Akesbi et al., however, found that visual outcome was better if the foreign body was removed within 1 week after injury.  We found that entry wound through the sclera and limbus was associated with worse visual outcome when compared with the entry through the cornea (P = 0.02).
A similar finding was noted by Valesova et al. in 2003 where scleral entrance wound was a negative prognostic factor. 
In a previous study, Erakgun has not found any association of visual outcome with entry wound location.  On the other hand, Akesbi et al. stated that the sclera or sclera corneal entry are associated with a good prognosis. 
In our study, sclera entry has worse prognosis, most likely because in our study the corneal entry wounds were mostly those that came to lie in the anterior chamber or the lens, while the sclera entry foreign bodies required posterior segment surgery for removal.
The drawback of this study was that the subjects were followed up only till 3 months after the surgery of extraction. At this time, a few patients still had treatable complications such as aphakia, vitreous hemorrhage, and epiretinal membranes, and would be likely to show improvement in vision on further follow-up. Second, the surgeries of extraction were done by different surgeons; however, all the operating surgeons had similar qualifications and years of experience.
| Conclusion|| |
Our study found that 30% of patients with IOFB injuries had poor visual outcome (FCCF or worse). The outcome was worse if there was poorer vision at presentation, scleral entry wound, larger foreign body size; and if extraction was done as a secondary procedure. The above conclusions of the study can help predict prognosis in patients with IOFB and will aid in counseling of the patients. It was found that the affected individuals were young males in the economically productive age group, most of who were injured in the workplace while working without wearing protective goggles. This highlights the importance of preventive measures to avoid ocular morbidity.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]