Endoscopy-assisted removal of angle foreign body presenting as persistent localised corneal oedema

Abstract

A 20-year-old man presented to us with injury to the left eye by a glass bulb 3 weeks ago. The acute injury resolved with a peculiar residual localised corneal oedema in the inferior one-third of the cornea. This localised oedema in absence of any evidence of a localised visible injury to the cornea indicated towards a possible retained foreign body. The foreign body visibility was equivocal on gonioscopy. Subsequently via a limbal incision, an endoscope was introduced into the anterior chamber. The endoscopic view revealed the glass foreign body lodged into the inferior angle of the eye which was removed with the help of an intraocular forceps. Over the next week, the corneal oedema resolved completely.

Background

Penetrating ocular trauma is associated with multiple ocular comorbidities. Of which, anterior chamber angle foreign body is most likely to be missed to detect. Approximately 15% of all intraocular foreign bodies (IOFBs) are detected to be have anterior chamber angle foreign bodies.¹ The severity of injury depends on factors that include size and composition of the foreign body, force of entry into the eye, location of the resulting wound and the final location of the foreign body.² To date, there had been several reports describing anterior chamber foreign bodies. In some cases, the area of penetration and the IOFB itself may not be easily detected. To our knowledge, there have been no reports demonstrating the application of endoscopic technique in the removal of embedded anterior chamber angle foreign body which was equivocal on gonioscopic view.

Case presentation

A 20-year-old man presented to us with injury to the left eye by a glass bulb 3 weeks ago. The acute injury resolved with a peculiar residual localised corneal oedema in the inferior one third of the cornea (figure 1). This localised oedema in absence of any evidence of a localised visible injury to the cornea indicated towards a possible retained foreign body.

Figure 1.

Slit lamp photo depicting localised corneal oedema inferiorly.

Investigations

The foreign body visibility was equivocal on gonioscopy. So an endoscopic procedure was planned to aid in the detection of the foreign body.

Treatment

The endoscopic view revealed a glass foreign body lodged into the inferior angle of the eye (figure 2), which was subsequently removed using an intraocular forceps (video 1). The endoscopy system used included 23G endoscope (E2 Laser and Endoscopy System; Endo Optiks, Little Silver, New Jersey, USA). The probes are available in 18G, 19G, 20G and 23G and can be autoclave sterilised. The console has laser treatment capability with endoscopic imaging. It also includes a video camera with is high resolution, 175 or 300 W xenon light source and an 810 nm diode laser. The endoscopic view allows for a panoramic intraocular view of the entire retina, a close-up (down to 0.75 mm) and also a very magnified view of pathology. The in-built video adapter has capabilities of optimum zoom and also has an option of manual focus of the endoscopic image.

Figure 2.

Endoscopic view of the retained glass foreign body.

video 1.

Download video file ^{(9.1MB, mp4)}

DOI: 10.1136/bcr-2019-233419.video01

The anterior chamber was filled with a cohesive viscoelastic to maintain the chamber. From a superior limbal 23G entry, the endoscope was introduced to examine the angle of anterior chamber inferiorly. Scanning across the inferior angle, the glass foreign body was located at the 6 o cock position. Using an intraocular forceps in the other hand, the foreign body was retrieved from the limbal entry.

Outcome and follow-up

After performing endoscopy-assisted foreign body removal, a patient was prescribed regular postoperative medications and advised to follow up after 1 week. Over the next week, the corneal oedema resolved completely (figure 3).

Figure 3.

Slit lamp photo depicting resolution of corneal oedema post foreign body removal.

Discussion

Anterior chamber IOFB after penetrating trauma is a condition which needs thorough clinical examination and appropriate management. Management of theses cases depends on the type and extent of the injury, type and composition of the foreign body itself. In the literature, there are few cases were reported with foreign body in anterior chamber angle. It may be difficult to detect the foreign body on first clinical examination but always we need to rule out retained foreign body. Therefore, gonioscopy should be performed to rule out any angle foreign body unless there is no contraindication. Our patient had peculiar inferior residual localised corneal oedema after initial injury resolution. A similar case was reported by Han et al³ where they had a retained graphite anterior chamber foreign body masquerading as stromal keratitis. Initially, they treated the case as herpetic stromal keratitis for 3 months then they noticed a graphite foreign body in the anterior chamber angle and on repeated history taking, revealed that the patient had injury to the eye with a pencil earlier.

In another report by Jastaneiah et al,⁴ they described a case of persistent corneal oedema with blurred vision. They initially diagnosed it as stromal keratitis and started on topical steroid drops, there was no clinical improvement but on further detailed examination they noticed a glass foreign body. Past medical records of the patient revealed that the patient presented 20 years ago with a corneal ulcer and glass IOFB resulting from an exploded light bulb. At that visit, the corneal ulcer was medically managed and the FB was not removed. At the latest visit, the FB was removed surgically following which the corneal oedema resolved completely. In a report by Xiao-Qiang et al,⁵ they reported a case with a foreign body in anterior chamber angle. They performed surgery to remove the foreign body, which was unsuccessful. With the assistance of an endoscope, they successfully removed the foreign body from the angle 5 days after the initial intervention. These scenarios allude to the fact that that endoscopy usage in foreign body removal from angle of anterior chamber is more convenient than the conventional surgical technique and precise localisation of the foreign body can be achieved. With this technique, we can reduce surgical trauma and the need for multiple surgeries.

Learning points.

• In cases of localised corneal oedema in absence of any evidence of a localised visible injury to the cornea should investigate for possible retained foreign body.

• Gonioscopy is essential in detecting embedded foreign body in angle structures.

• Endoscopic removal of foreign body from the angle of anterior chamber is a convenient and quick technique.