Long-term corneal complication of retained anterior chamber-angle foreign body

Abstract

A 33-year-old patient referred to the cornea and anterior segment department to evaluate inferior corneal edema related to a retained intraocular foreign body (IOFB) in the anterior chamber-angle. The foreign body, which was a single piece of glass caused by an exploded light bulb twenty years back, was surgically removed; edema resolved and vision improved to 20/30. In the presence of an anterior chamber IOFB; long-term adverse effects should be considered. We would advise removal of the FB regardless of the inertness and location facts, as long as the risk and benefits of the surgical intervention are carefully evaluated.

1. Introduction

Penetrating eye trauma with anterior or posterior chamber intraocular foreign bodies (IOFB) has been reported frequently and may cause devastating sequelae causing loss of vision or globe. At the same time there have been reports of the foreign material staying in the eye for years without causing any complications; surgical intervention was later indicated for delayed sequels (Ray et al., 2004; Staar et al., 1991; Soichiro et al., 2005; Al-Khalaf et al., 2006; Bhaduri and Ghosh, 2003). Other reported cases were stable for a period of time then migrated or caused complications and decreased vision; surgical intervention by removal of the foreign body (FB) yielded good results with improvement in vision (Ray et al., 2004; Staar et al., 1991; Al-Khalaf et al., 2006).

Management of anterior or posterior segment IOFB have largely being dependent on the source, material composition, location of the FB and any associated disturbance in the anatomical structure or physiology on the eye (Ray et al., 2004).

The judgment in few of these cases may be difficult weighing the risks and benefits from the surgery itself versus the complications of leaving the FB in the eye.

We describe a patient with retained glass IOFB in which it was initially stable and encapsulated over the iris but subsequently induced complications and visual symptoms related to localized corneal endothelial trauma.

2. Case report

A 33-years-old patient was referred to King Khaled Eye Specialist Hospital (KKESH) in January 2004 complaining of drop of vision associated with inferior corneal edema and photophobia for the past 9 months. He was treated by his local ophthalmologist as a case of stromal keratitis using topical steroids; with no improvement but detailed examination revealed a glass FB which came to memory again and he was referred for further evaluation and management (Figs. 1a and 1b). Surgical intervention was performed through a superior-temporal limbal approach, protecting the endothelium and the lens with intracameral injection of viscoelastic material. Removal of the FB was smooth as it was freely mobile over the iris near the angle between 5 and 6 o’clock position.

Figure 1a.

Photograph of the affected eye showing corneal edema, localized corneal scar and an inferiorly located anterior chamber foreign body.

Figure 1b.

Gonioscopy photograph showing the inferiorly located anterior chamber angle glass foreign body between 5 and 6 o’clock position.

The history of this patient FB started 20 years earlier when he first presented to KKESH at the age of 13 (November 1984) to manage a corneal ulcer and to evaluate the need to remove a glass IOFB resulted from an exploded light bulb 2 months prior to his presentation. The patient was referred with reduced vision, scar at the area of a full thickness self sealed corneal laceration with corneal infiltrates, anterior chamber FB residing in the angle inferiorly, and inferior corneal edema. The foreign body which was a single piece of glass was confirmed by gonioscopy and ultrasound examination. There were no other IOFBs and the other eye examination was normal.

Ultrasound A scan reported a single high spike around 5 o’clock anteriorly. No acoustic shadowing or reverberations as would be expected in metallic foreign body (Fig. 2).

Figure 2.

Ultrasound A scan showing a single high spike around 5 o’clock anteriorly.

The child was admitted to treat the corneal ulcer. Corneal scrapping for gram and Giemsa stains, culture and sensitivity were obtained. The ulcer was managed medically by debridement and topical fortified antibiotics.

Few days later he was discharged with a clinically healed corneal ulcer, corneal scar at the area of previous trauma, and inferior corneal edema. Uncorrected visual acuity was 20/80. Surgical removal of the FB was not recommended for reasons related to the FB material being inert, location, encapsulation, and the fact that the cornea was infected at the time of admission.

On the latest follow up after the surgical removal, he presented with improved vision to 20/30, normal intraocular pressure, resolved corneal edema, with an area of peripheral anterior synechiae (PAS) at 6 o’clock, and quite anterior segment. Specular microscopy of the affected cornea showed disturbed stroma with enlarged abnormal cells, altered endothelial morphology and decreased density (Fig. 3). Cornea examination was stable until the latest visit to the cornea and anterior segment clinic in November 2009.

Figure 3.

Confocal scanning showing altered endothelium morphology and decreased density.

3. Discussion

Management of anterior chamber intraocular foreign bodies following penetrating eye trauma is variable. The decision would depend on multiple variables related to the facts of the trauma, the extent of the initial injury, and facts related to the FB it self. Of those facts related to the FB are its location, size, material composition, and accessibility. In addition to factors related to disruption of normal eye anatomy or possible structural or visual sequelae or complications that may happen later. All these factors are taken in consideration before electing to observe or remove the FB.

With the presence of advanced surgical instruments and devises, and the improvement in surgical techniques that have improved the surgical outcome and prognosis, the decision to remove intraocular foreign bodies may be easier.

Other factor that should be included in the decision is how feasible for the patient to return to a specialized ophthalmic center if he or she developed later problems, and the availability of continuous clinical examinations to routinely evaluate the eye status.

In our case the presentation was 2 month post trauma, the presence of corneal infiltrates that required medical management have delayed the decision to surgically remove the FB during that first admission. Given the fact that the FB was inert, encapsulated, and entrapped have further supported the decision to leave the FB in the anterior chamber.

The decision to delay the intervention until inflammation and edema have subsided is feasible provided that the patient and the family understands the risk and benefits and are willing to follow up the eye status. The patient failed to attend the given follow-up appointment until he developed eye complaints with drop of vision.

A similar scenario have been previously reported (Staar et al., 1991; Al-Khalaf et al., 2006) where the FB remained stable for years then migrates from its place or caused unpleasant adverse effects mandating removal. On the other hand even this late intervention resulted in favorable structural and visual outcome.

In the presence of an anterior chamber FB; long-term complications should be considered. Management should be modified knowing the possibility of the long-term adverse effects of these FBs. Despite the long duration of the corneal edema it resolved after removal of the FB, but the endothelial damage will always be there. We would advise removal of the FB regardless of its inertness, size, and location facts, as long as the risk and benefits of the surgical intervention are carefully evaluated.

Conflict of intrest statement

The author has no commercial or proprietary interest in any of the products or companies presented in this manuscript.