Bilateral iPhone Gorilla Glass Intraocular Foreign Bodies in a Pediatric Patient

Abstract

Purpose:

This report discusses a case of a patient with bilateral intraocular foreign bodies after a bullet shattered his iPhone.

Methods:

A case report is presented.

Results:

The right eye vision was 20/50 and examination disclosed a limbal entry wound at 6:00, dense traumatic cataract, and vitreous hemorrhage. The left eye was 20/40 and an entry wound located roughly 4 mm posterior to the limbus was noted. Fundoscopy revealed multiple refractile particles with preretinal and vitreous hemorrhage. Computed tomography scan demonstrated hyperdensities in the vitreous cavity bilaterally. Globe closure, cataract removal, vitrectomy, and endolaser were undertaken in the right eye, while only globe closure was performed in the left eye. On latest follow-up, the patient had 20/20 corrected vision without inflammation bilaterally.

Conclusion:

A conservative approach led to full visual recovery, despite retained intraocular smartphone Gorilla glass.

Introduction

Cases of intraocular foreign bodies (IOFBs) may result in a spectrum of sequelae, but poor outcomes due to endophthalmitis and retinal detachment have been reported to occur in up to 30% of eyes with retained IOFB, even with prompt surgical management. ^1,2 Adults aged 20 to 40 years are the most likely to present with IOFBs. ³ Ocular trauma is seen in children at an incidence of approximately 15.2 in 100 000 in the United States, yet most of these open-globe injuries do not harbor IOFBs. ^4,5 Few data are available on the epidemiology of IOFBs in children. ⁶ In general, materials such as glass, stone, and plastic are considered inert and are better tolerated intraocularly than vegetative matter or materials with low oxidation-reduction potentials such as iron and copper. ^2,7 Most smartphones are covered in a lightweight, chemically strengthened, damage-resistant glass, known as Gorilla Glass (Corning). ⁸ To the best of the authors’ knowledge, the following represents the first report of a smartphone-glass IOFB. The bilateral nature of the IOFBs and their presentation in a pediatric patient make the management of this case particularly complex.

Methods

Case

A 13-year-old boy presented with blurred vision after a bullet shattered his iPhone screen. Visual acuity (VA) was 20/50 OD and 20/40 OS with normal intraocular pressure in both eyes. On slitlamp examination of the right eye, a limbal laceration at the 6:00 position was noted, as well as diffuse corneal edema and 3+ anterior chamber cell with a less than 1-mm hyphema. There was a traumatic cataract and anterior lens capsule violation with cortical material in the anterior chamber. Fundus examination of the posterior view was not possible.

On examination of the left eye, the conjunctiva was white and quiet with mild inferior corneal edema with 1+ anterior chamber cell and flare. A focal subconjunctival hemorrhage compatible with an entry wound located roughly 4 mm posteriorly to the limbus was noted. The lens was intact. There were preretinal and vitreous hemorrhage and numerous small refractile particles suspended in the vitreous, as well as a large refractile foreign body just above the temporal macula with associated localized hemorrhage (Figure 1).

Figure 1.

Fundus photograph of the left eye at presentation, with fragments of foreign body visualized in the superior arcade.

Computed tomography (CT) of the orbits demonstrated multiple hyperdense IOFBs in both eyes (Figure 2). Preliminary radiology reports suggested that the foreign bodies were metallic in nature; however, clinical history was consistent with shattered glass from the patient’s mobile phone screen caused by a stray bullet (Figure 3).

Figure 2.

Computed tomography without contrast of the brain and orbits demonstrating visible hyperdensities in (A) the right eye and (B) left eye.

Figure 3.

(A) Front and (B) back of the iPhone after being shattered by a bullet.

Surgery in the right eye included corneal wound closure, phacoemulsification, limited pars plana vitrectomy with endolaser to a retinal tear, and injection of intravitreal vancomycin, ceftazadine, bevacizumab, and sub-tenon triamcinolone. In the left eye, the patient underwent globe exploration, closure of the scleral entry wound, and intravitreal injection of vancomycin, ceftazadine, and sub-tenon triamcinolone.

Results

Postoperative optical coherence tomography (OCT) demonstrated an attached macula in each eye, with preretinal IOFBs in the left eye suspended just anteriorly to the temporal macula (Figure 4). Three months after the initial surgery, the patient’s best-corrected VA was 20/20 in both eyes with the right eye aphakic. Residual refractile IOFBs remain in both eyes without evidence of intraocular inflammation, macular edema, or other sequelae, and the patient has resumed all normal activities (Figure 5).

Figure 4.

Optical coherence tomography of the left eye postoperatively, with fragments of foreign body visualized superior to the retina.

Figure 5.

Fundus images 3 months after presentation. (A) Right eye: Remnants of intraocular foreign body inferonasally are shown with resolution of hemorrhage. (B) Left eye: Stable remnants of intraocular foreign body are visualized.

Conclusions

This report presented the first case to our knowledge of an IOFB composed of iPhone glass. This case highlights certain challenges in IOFB management, particularly the importance of determining IOFB composition and the complexities of managing bilateral IOFBs in a pediatric patient.

In cases with unknown IOFB composition or unclear anatomical location, imaging characteristics and measurements, such as radiodensity expressed in Hounsfield units, may guide management. ⁹ A study by Lagalla et al on IOFBs in enucleated pig eyes reported that metallic objects had greater than 3000 H, whereas glass was more likely to have 1000 to 1300 H. ¹⁰ In this case, it was reported the IOFB had approximately 2000 H on CT imaging. This reading was not taken as definitive, because accurate Hounsfield unit determination may have been limited by the small size of the particles. Although the imaging characteristics of the IOFBs were most consistent with metallic composition, the clinical examination and history, including inspection of the patient’s phone, were more suggestive of glass.

Surgical planning hinged on the decision regarding the need for pars plana vitrectomy in both eyes. It was elected to proceed with a relatively conservative approach. Phacoemulsification with limited vitrectomy was undertaken in the right eye. Lens removal was required because the capsule was violated and the presence of exposed cortical material in the anterior chamber was likely contributing to inflammation. A vitrectomy was performed to clear vitreous hemorrhage to further elucidate the nature of the foreign material as well as to assess for the extent of ocular injury. IOFB particulate was found in the vitreous cavity and under the hyaloid. The risk of inducing a posterior vitreous detachment when removing all foreign material was felt to outweigh the potential benefit because under direct visualization intraoperatively, the IOFBs did not appear to be metallic.

In the left eye, given the excellent VA, intact lens capsule, and clear view posteriorly, a minimally invasive approach with globe closure was used to maintain ambulatory vision. Postoperatively in the left eye, OCT imaging demonstrated no retinal involvement of the retained IOFBs that were suspended in the posterior vitreous. This knowledge allowed for further confidence in the choice of careful observation over surgery.

Thus, intraocular foreign material remained in both eyes. Although it was never confirmed with pathology, the presumed material, Gorilla Glass, is a product consisting of alkali aluminosilicate that is strengthened using an ion-exchange process. ¹¹ The substance is lightweight, durable, inert, nontoxic, and marketed as shatter-proof. ¹² It is used in many cellphones, laptop devices, and other portable electronic devices because it is durable and scratch-resistant. ¹³ Generally, most forms of glass are considered to be inert. However, our knowledge of this specific formulation and its reactivity intraocularly is limited. Known indications for removal of an IOFB include potential for retinal toxicity, endophthalmitis, or migration with intraocular damage. ¹⁴ None of these criteria were met in this case, and to date, the retained Gorilla Glass has not led to further sequelae. We will continue close follow-up of this patient to monitor for signs of infection, spontaneous induction of posterior vitreous detachment, and IOFB migration. Furthermore, electroretinography will be used to continue monitoring for subtle retinal damage.

This case of ocular trauma with bilateral iPhone Gorilla Glass IOFBs exemplifies a favorable outcome with a conservative surgical approach in a pediatric patient. CT and OCT imaging were useful adjuncts that were interpreted judiciously in conjunction with the clinical context to guide decision-making.