From the Editor-in-Chief

Photo courtesy of Kevin Caldwell Photography.

Your internist colleague stops you in the corridor and says, “I’ve got something in my eye. Can you take a look?” You instantly understand and agree—ophthalmologists get a lot of requests for curbside consults for subconjunctival hemorrhage, chalazion, conjunctivitis, etc—and moments later, you lift the lid and extract the offending eyelash from the fornix, delighted to be available and helpful.

You have just participated in one of the most common experiences in our specialty. Two, actually: the removal of an eyelash, for sure; and correctly understanding one of the most inaccurate uses of a preposition in medicine. We all know that our colleague’s in the eye meant on the eye; something truly in the eye is serious business and is reserved for the most highly trained vitreoretinal specialists.

Intraocular foreign bodies are a world unto themselves, and it would be impossible to list the many objects—from nail slivers to stone fragments to thorns—that have found their way into the eye. Until the modern era, all but the smallest and most innocuous were fatal to useful vision. Without vitreoretinal surgery and its magical tools, and lacking modern antibiotics, there simply were no pathways to successfully navigate the damage from the initial injury, frequent secondary infection or toxicity, and the obligate trauma of removal.

The first serious attempts involved magnetic extraction in the nineteenth century. In his 1881 treatise, ¹ Dr M. Macdonald McHardy of King’s College Hospital of London recounts in detail his series of patients undergoing magnetic extraction. He describes his brilliant, if unsettling, extraction of a metal fragment from the eye of a blacksmith who sustained a powerful blow after striking cast iron with a steel chisel and hammer.

The patient’s pain, already excruciating on presentation, increased dramatically as soon as the electromagnet was brought near the eye, and further worsened over the several minutes of magnetic application required to bring the fragment into visible contact with the iris. Ether anesthesia was administered, and additional manipulation with the magnet successfully retrieved the 2 × 5-mm metal sliver from the eye.

Dr McHardy’s report indicates that the patient retained light-perception vision and was so pleased with the result, despite cataract and synechiae, that he requested (understandably!) no further surgery. Incidentally, the pain test for the presence of magnetic foreign bodies in eyes clouded by hemorrhage and cataract was briefly used as a diagnostic test, but mercifully gave way to more sophisticated metal locators and ultimately radiography.

For all the damage and suffering they have caused, intraocular foreign bodies have also played a leading role in vision restoration. We return to London, this time in 1940. The famous insights by Sir Harold Ridley regarding the tolerance of acrylic windshield fragments in the eyes of Royal Air Force pilots shot down during the Battle of Britain led to his transformational—and initially much derided—development of intraocular lens implants. The link between this small cadre of injured pilots and the millions of grateful patients undergoing cataract surgery with intraocular lenses each year is as inspirational as it was tenuous and unexpected.

The present issue of JVRD includes the case of a unique patient who sustained bilateral intraocular Gorilla Glass (Corning, Inc) foreign bodies after a bullet shattered his mobile phone. Indeed, apart from this amazing report by Drs Meghana Kalavar, Alexandra Levitt, Nimesh A. Patel, Kevin Clauss, Kenneth C. Fan, Nicolas A. Yannuzzi, and Audina M. Berrocal, it is difficult to imagine another event in which a bullet striking so close to both eyes would not be fatal. Remarkably, both eyes were returned to 20/20 visual acuity (VA); surgery was required in one eye for vitreous hemorrhage, and the retained Gorilla Glass, unreactive so far, is being managed by careful observation.

Drs Tyler Pfister, Carisa Bohnak, and Shriji Patel present a remarkable series of 32 cases of wood-related open-globe injuries. Despite a substantial incidence of associated retinal detachment, intraocular hemorrhage, and endophthalmitis, their expert management resulted in 20/50 or better VA in 41% of eyes.

This issue also contains a case report by Drs Anh D. Buia, Anna L. Diep, Qiyin Lin, Donald S. Minckler, Andrew W. Browne, and Angeline L. Wang in which a patient presented with reduced vision, cataract, paralytic mydriasis, and intraocular discoloration in association with a nail fragment embedded in the sclera 8 months prior. These physicians most skillfully employed optical coherence tomography angiography, electroretinography, color vision testing, and other multimodal tests to document changes on presentation and after removal, signaling yet another saltation in the diagnosis and management of intraocular iron.

Also in this issue, and continuing our chance minitheme of substances in the eye, is an exciting description of a novel, biodegradable vitreous substitute for retinal tamponade, a large series of cases of macular edema managed with invitingly named “slurry” intravitreal triamcinolone, and a refined method for implantation of an intravitreal fluocinolone acetonide implant. There are also articles with new observations on the effects of coexisting diabetic retinopathy on macular hole repair, a review of 14 patients with incontinentia pigmenti highlighting the importance of fluorescein angiography and laser photocoagulation, and other offerings for your education and enjoyment.

In the end, intraocular foreign bodies are not so foreign. Whether as exotic as Gorilla Glass or as common as wood, they derive from objects that surround us in our environment or are personal items we carry lovingly and use frequently. Sooner or later, they all seem to find an unwelcome presence in our eye—yes, in our eye. Keeping them out—or only on!—remains a priority.

Donald J. D’Amico, MD
Editor-in-Chief
Journal of VitreoRetinal Diseases