DEPARTMENT OF OPHTHALMOLOGY
FACULTY OF MEDICINE PADJADJARAN UNIVERSITY NATIONAL EYE CENTER CICENDO EYE HOSPITAL BANDUNG
Case Report : Intralenticular Metal Foreign Body Removal by Phaco- Aspiration : A Case Report
Presenter : Intan Ekarulita Supervisor : Budiman, MD
Has been reviewed and approved by Supervisor of Cataract and Refractive Surgery
Budiman, MD
Monday, July 5th 2021 08.15 – 9.00 A.M
Intralenticular Metal Foreign Body Removal by Phaco-Aspiration: A Case Report
Abstract
Introduction: Intralenticular foreign body (ILFB) is included as a rare case of intraocular foreign body (IOFB), constitute only 3.76%. It may have fewer complications than other IOFB, however metallic ILFB can cause cataract and siderosis bulbi, a sight threatening condition.
Purpose: To present a rare case of metallic foreign body in the lens.
Case report: A 31-years-old male came to Cicendo Eye Hospital with complain of sudden left vision loss while nailing wood to the wall at 3 weeks before. Visual acuity of the left eye was hand movement with normal ocular pressure. The biomicroscopic examination full-thickness corneal wound at the temporal area was revealed. Seidel test did not indicate any wound leakage. The iris was normal and anterior chamber was deep with minimal cells. The lens appeared cloudy with anterior capsule rupture. The Schedel examination was normal. B-scan ultrasonography found intralenticular was detected. One week after lens aspiration and intraocular lens (IOL) implantation, left visual acuity became 0.5 and 1.0 with pinhole.
Conclusion: Metallic foreign body can penetrate and isolated in the lens then lead to cataract formation. Cataract accompanied by capsular tear require certain surgical lens extraction technique.
Keywords: intrelenticular foreign body, metallic, traumatic cataract.
I. INTRODUCTION
Intraocular foreign body (IOFB) is a division of ocular trauma that can lead to blindness or other severe ocular complication. Retained IOFB occurs in 18-41%
of ocular trauma cases, leading to a wide range of ocular damage and vision outcomes. The previous observational study fron Duan F et al. reported the most common type IOFB was metal (78.5%). The most common location of IOFB was vitreous cavity (74.3%). Intralenticular foreign body (ILFB), foreign body in the lens, was reported as a rare case with prevalence rate 3.76%. Through slit-lamp examination and confirmed with B-scan ultrasonography or computed tomography, the foreign body usually detected. Manifestations that may occurs depend on size, chemical contents, and existence of capsular tear. The larger size of ILFB will tear lens capsule then cause extensive cataract and lead to sudden visual loss. Early surgical intervention for the ILFB is indicated in the presence of cataract, lens subluxation, anterior uveitis, and glaucoma.1-3 In this case, we reported a rare case of metal ILFB without involving the posterior capsule of the lens and discuss clinical management and prognosis.
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II. CASE REPORT
A 31-years-old male experienced sudden left vision loss after saw sparks while nailing wood in the wall at 3 weeks before. He admitted no pain and have a minimal eye redness on the left eye. The nail appeared intact with no missing parts.
He visited a local ophthalmology clinic and diagnosed as traumatic cataract. He was referred to Cicendo Eye Hospital and underwent to do some examinations. Bare visual acuity was 0.32 for right eye (RE) and hand movement (HM) for left eye (LE). Best corrected visual acuity (BCVA) was 1.0 for RE and revealed no visual improvement for LE. Intraocular pressure (IOP) was 15 for RE and 11 for LE.
Under slit-lamp examination, a full-thickness corneal wound with complete epitelized was revealed. Seidel test performed and found no wound leakage. The anterior chamber was deep with minimal cells. The iris was normal. The lens was cloudy with anterior capsule tear was revealed. Fundus examination could not be performed because the axis visual is too cloudy.
Foreign body was not seen through Schedel x-ray examination. B-scan ultrasonography was performed and showed retained foreign body in the lens Figure 2.1 Clinical pictures of the patient on first examination. A) Anterior chamber
picture from the RE with dilated pupil. B) Anterior chamber picture from the LE revealed 1mm entry wound in corneal (black arrow) and lens mass that indicated anterior capsule tear (blue arrow). C) B-scan ultrasonography was showed there was a retained ILFB without posterior capsule tear. D) Schedel AP and lateral radiology x-ray revealed no IOFB.
Source from : Cicendo Eye Hospital
A B
C
D
without posterior capsule tear and intravitreal foreign body. The patient was diagnosed as traumatic cataract, ILFB, and epitelized corneal laceration in LE.
Topical Levofloxacin was required to adminitered 6 times daily before surgery.
Two days later, the patient received elective exploration, lens aspiration, and IOL implantation. Tropicamide and phenylephrine hydrochloride were instilled to dilate the pupil, however left pupil was only mid-dilated. Adrenaline was injected to the anterior chamber after doing 2.75 mm insicion with keratomy. Ophthalmic trypan blue solution was injected to stain anterior capsule. The ophthalmic viscoelastic device (OVD) was applied to fill the anterior chamber. Continuous curvilinear capsulorhexis (CCC) was performed by making a flap in the area away from the torn capsule then continued with hydrodissection and hydrodelineation.
The ILFB was still unvisible. Using irrigation/aspiration probe with parameter Figure 2.2 Pictures of the left eye patient during the surpery. A) A/I probe was place
away from the anterior capsule tear with vacuum 450-630mmHg, aspiration rate 40 cc/min, and 85cmH2O irrigation. B) Lens debulking to secure area of ILFB then continue aspirating with vacuum 250-400 mmHg and lowered aspiration rate. C) Once the ILFB clogged the tip of the A/I probe, decrease the aspiration rate and more irrigate. D) When the ILFB was placed in the anterior chamber, viscoelastic was injected in the bag to prevent ILFB from falling posteriorly.
Source from: Cicendo Eye Hospital
A B C D
A B
C D
vacuum 450-630 mmHg, irrigation 85 mmHg, and aspiration rate 40 cc/min, was aspirating lens away from suspected ILFB area. Forceps and OVD were used to maneuvers ILFB into the anterior chamber, however ILFB was too deep. Then OVD was injected behind the lens to secure foreign material from falling posteriorly. It was continued to aspirate all lens material carefully so as foreign material not to be sucked through the probe. Once the foreign material closed the tip of the probe, suspend aspiration and continue with low irrigation. The 2.0 mm metal foreign body was seen and extracted throught corneal insicion. The foldable IOL was implanted in the bag vertically, then injected myoticum and continued with hydrosuture. The topical levofloxacin 6 times daily, topical prednisolone acetate 6 times daily, and ciprofloxacin 500 mg b.i.d were prescribed to left eye patient.
Visual acuity in one day after surgery was 0.32 for RE and 0.9 for LE. The IOP was 15 mmHg for RE and 10 mmHg for LE. Under biomicroscopy examination, corneal was revealed 1 mm epitelized full thickness wound without oedema. The anterior chamber was deep with minimal flare and cells. The iris and pupil were normal. The IOL appeared to be installed properly in the bag. Post- operative treatments were continued. Visual acuity in one week after surgery was 0.32 and 1.0 with pinhole for RE, 0.6 and 1.0 with pinhole for LE. The IOP was 14 mmHg for RE and 13 mmHg for LE. The other examniation still showed the same
Figure 2.3 Metallic foreign body what was evacuated from lens of the left eye. The size is 2 mm.
Source from: Cicendo Eye Hospital
results. Prednisolon acetate was tappered off fashion for 6 weeks after surgery.
Prognosis ad vitam, functionam, and sanactionam were bonam.
III. DISCUSSION
The possibility of IOFB should be thoughly investigated by asking the detail of injury mechanism, onset, material, size of the material, and the symptoms after injury in every case of trauma to estimate the diagnosis and prognosis. The cases of ILFB constitute 5-10% of IOFB cases. The diagnosis of ILFB should be considered in case of self-sealing corneal wound. Foreign material passed through the cornea and sometimes through the iris, then through the anterior capsule, and finally localized in the lens. 2,3 Because the patient did not come at the day of injury, entry wound might be not seen and unconsidered as an ILFB case by the previous ophthalmologist. In this case, the patient had possibility metal ILFB as he complained sudden left vision loss after saw sparks while nailing the wood on the wall. In examination, the corneal wound scarring was aligned with anterior capsule torn and also according to the injury mechanism. The material is notable factor because Abram p et al. reported that metallic IOFBs conferred a higher endophthalmitis risk compare to glass or plastic material. In this case, the patient complained no pain and no eye redness since the day of injury what indicate the foreign body isolated in the lens as a barrier to trigger inflammatory response in the eye.
Figure 2.4 Clinical picture of patient’s eye after 1 week surgery.
IOL was placed in the bag of LE.
Source from: Cicendo Eye Hospital
When an IOFB cannot be found during ophthalmologic evaluation, additional examination is required, including radiography, ultrasonography, ultrasound biomicroscopy, computerized tomography (CT) scanning, and magnetic resonance imaging (MRI). Previous study reported most ILFB were detected by slit-lamp examination (85%), some by B-scan ultasonography or CT scan (14%), and few were comfirmed only after operation (7%).4,5 In this case, foreign body cannot be found through slit-lap examination, it also could not be identified by Schedel AP/Lateral radiolody x-ray, but B-scan could instead provide a ILFB image. We didn’t request CT scan for this patient as Loporchio et al. argued that CT-scan cuts miss small IOFB.3
The study from Rofagha et al. reported size of ILFBs what less than 2 mm would be manifest as zonal cataracts for minimal capsular tear on the lens might self-seal, whereas those of 3 mm of larger may lead to large opacity. In case of localized lens damage and does not involve the visual, the best policy is to wait and let the foreign body remain in situ. It has been reported that the anterior capsule has a healing capacity if there is a small breach, however, it requires careful follow up in order to monitor for siderosis bulbi. The epithelial proliferation rapidly restores its continuity, limiting the free passage of ions and fluids that may progress to the development of cataract. If there were presences of glaucoma, uveitis, or the visual acuity is compromised by cataract formation induced by the ILFB, removal of the cataract and ILFB is necessary.3,6-9 In this case, there was no sign of siderosis bulbi, but the lens was fully opacificated even size metal ILFB was 2 mm only. It resulted from rapid progressivity of distrubed lens metabolism after penetrating ILFB at 3 weeks before. The patient was indicated to undergo lens extraction to clear visual axis.
According to alogarithm for the management of IOFB that was published by Jung et al., treatment surgical choices of traumatic cataract that caused by IOFB were phacoemulsification and extracapsular cataract extraction (ECCE), depend on posterior capsule condition. Therefore, posterior capsule tear was better to identified before surgery to determine the management of lens extraction.Arora R et al. mentioned 2/8 cases of ILFB with posterior capsule tear that only was found
during operative, so that co-existent posterior capsule tears need to be anticipated and dealt with when encountered. In consideration of patient’s age, in case of soft lens, phaco-aspiration could be used to evacuate the lens.7,10,11 This case was suggested no posterior capsule tear based on B-scan ultrasonography. The foreign body was isolated in the lens and found no patology in the posterior segment therefore, the patient was planned to do cataract extraction with phaco-aspiration technique.
Tri-combined operations (removal of foreign body, lens extraction, and IOL implantation) was reported Lin et al as a technique that could be used while the foreign body was found. The tools that may be used to create manuever ILFB into the anterior chamber were magnet, forceps, and viscoelastic. When removal of foreign body could not be performed first, phacoemulsification with lens debulking could be used to mobilize the embedded foreign body. As a pre-existing traumatic posterior capsule tear is still possible, a minimal and gentle aspiration or nuclear expression is recommended.7,10 During our operation, ILFB was seemed too deep
Figure 3.1 Alogarithm of surgical management for IOFB Source from: Jung at al
and difficult to removed by forceps, then phaco-aspiration and lens debulking was performed. The capsulorrhexis, hydrodisection, and hydrodilineation was performed minimal and starting from the area fas from capsule torn. The vacuum was in a range of 450-630 mmHg at first aspiration. The OVD was injected behind the debulked lens to secure the isolated foreign body for falling to posterior. Then continued with phaco-aspiration for finding the foreign body, lower vacuum was set when the aspiration tip near the area of the capsule torn. When foreign body was found, OVD injection could be performed in the bag to keep the foreign body stay floating in the anterior chamber then it can be evacuated.
Previous studies reported material, size wound size, loaction, and surgical time as several factors related to the visual outcome. The other factors that considered may be associated with visual outcome was time interval between the injury and the ILFB removal. The ILFB extraction should be performed as soon as the diagnosis is made to rescue visual function and avoid further damage. However, some studies reported no statistical association between the intervention time and the final best corrected visual acuity.1,5,7 According to Ocular Trauma Score (OTS), this case was 70 and has a 40% chance to achieve visual outcome more than 20/40.
Visual acuity one week after surgery was achieved 1.0 with pinhole. The foreign body of our patient what isolated in the lens and did not cause any inflammation or toxic reactions would explain the visual outcome in one day and one week after surgery that was achieved 1.0 with pinhole.
IV. CONCLUSION
Intralenticular foreign body is a rare case and should be excluded whenever there is a self sealed corneal wound following to a penetrating injury of the eye. A foreign body isolated in the lens may lead to structural damage depend on size, chemichal contained, and existence of capsule tear. The management of traumatic cataract with ILFB is foreign body evacuation and cataract extraction. The time and surgical options depend on posterior capsule conditions and operator preference.
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