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Intraocular Foreign Body Induced Anterior Uveitis in a Child

Duke University Eye Center, Durham, NC, USA

Correspondence: Sharon F. Freedman
Duke University Eye Center, Box 3802, DUMC, Durham, NC 27710 Email: freed003@mc.duke.edu

Date of acceptance: 15th October 2006

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Introduction

We present a case of a 13 year old myopic white female with anterior uveitis and steroid-responsive glaucoma in her right eye. Seven months prior to presenting at our institution, she was evaluated for a corneal abrasion and right eye pain that developed immediately after her face was scratched by a tree branch.

Despite healing of the epithelial defect, over the next few weeks, our patient continued to be photophobic and had conjunctival injection in the right eye with an anterior chamber reaction of 15 cells per high powered field (hpf) with minimal flare. Her vision, intraocular pressure (IOP), and posterior segment exam were all reportedly normal as was the examination of her left eye.

Prednisolone acetate 1% drops were started and titrated to maximum dose of eight times a day to control the anterior uveitis. Although her symptoms and inflammation in the involved right eye resolved with this treatment, the IOP increased to 31 mmHg

Case Report

The eye was treated with dorzolamide/timolol maleate (Cosopt) and brimonidine tartrate 0.15% (Alphagan P), and a taper of topical prednisolone was attempted. The IOP did decrease, but the anterior chamber inflammation markedly increased over several weeks. With subsequent increased frequency of topical prednisolone application, the IOP once again rose to ~30 mmHg. This cycle of increased IOP but decreased iritis on more frequent topical steroid vs. lower IOP but increased iritis with attempted steroid taper was repeated several times over the next few months, despite topical anti-glaucoma therapy.

The patient�s past medical history was remarkable for chicken pox at age 2 years, and occasional knee or ankle pain after vigorous exercise over the past year. She denied any recent antecedent febrile illnesses, and did not have any gastrointestinal complaints. She was not sexually active. A previous systemic work-up including lyme titer, sedimentation rate, c-reactive protein, rheumatoid factor, HLA-B27, and antinuclear antibody were all negative. The patient�s left eye was always asymptomatic and normal on examination.

The patient was referred to our institution for persistent anterior uveitis with elevated IOP in her right eye. Corrected visual acuity was 20/20 OU. IOP measured 32 mmHg OD and 18mmHg OS. Slit lamp biomicroscopy of the right eye showed un-inflamed conjunctiva and sclera, and a clear cornea of normal diameter without keratic precipitates. The anterior chamber was deep without flare, and with 1 cell per high powered field. No iris nodules or atrophy were noted. The lens and anterior vitreous were also clear and the posterior segment was normal. Examination of the left eye was normal. Gonioscopy of the right eye demonstrated a small convex area of iris adhering to the angle at 6:30-o�clock (anterior synechia).

After reasonable control of IOP and uveitis was achieved by her ophthalmologist for four months, uveitis again flared; at this point, a new iris mass appeared in the inferior temporal anterior chamber, which seemed to slowly enlarge over two months.

The patient was then referred back to our institution for evaluation and biopsy of the iris/angle mass OD. Gonioscopy, however, suggested the possibility that the iris elevation/mass was actually a foreign body. (Figure 1) This suspicion was confirmed when gonioscopic surgical removal of the mass revealed a firm object consistent with a piece of wood from the tree branch that had stuck her face and right eye 15 months earlier (Video).

In the operating room under general anesthesia, the inferior temporal angle was visualized using a Goldmann four-mirror lens. A conjunctival peritomy was then made superotemporally and a microvitreoretinal blade was used to make a paracentesis at the surgical limbus at 10 o�clock. After viscoelastic was instilled in the eye, a diamond dusted intraocular forceps was placed though the paracentesis to grasp the angle mass. As the forceps was being removed some of the foreign object fell back into the anterior chamber. The diamond dusted forceps was again used to remove the object from the anterior chamber. The specimens were sent to microbiology and pathology respectively for further identification. The four-mirror lens was again used to verify that suspected foreign body had been entirely removed with only some anterior synechia left in its place. The anterior chamber was then irrigated and the scleral and conjunctival wounds were sutured closed.

Microbiologic analysis of the removed object did not yield any organisms and only demonstrated white blood cells. After surgery, steroids were tapered over 8 weeks and discontinued, as were all pressure-reducing medications. The vision remained 20/20 and the IOP returned to normal in the right eye. The uveitis resolved completely, although the trace lens opacity persisted, as did the small anterior synechia in the inferotemporal angle (Figure 2).

Comment:

The surgical removal of the foreign body from our patient�s right eye was curative. This case points out that history is key in determining the etiology of uveitis. It also demonstrates that small intraocular foreign bodies may penetrate the globe unrecognized, and remain buried in the ciliary body/iris tissue for some time, producing inflammation in the anterior segment. In this respect, gonioscopic assessment of the anterior chamber angle is an invaluable part of the ocular examination. Further, we note that when elevated IOP occurs in the setting of uveitis requiring steroid therapy, it can be difficult to determine whether IOP elevation is secondary to uveitis or rather is steroid-induced. Children have shown marked IOP elevation to topical steroids, which should therefore be used judiciously when needed. [1,2]

References

• Biedner, BZ et al. Intraocular pressure response to corticosteroids in children. Br. J. Ophthalmol. 1980. June; 64(6) 430-1.
• Ohji, M et. al. Marked intraocular pressure response to instillation of corticosteroids in children. Am. J. Ophhalmol. 1991. Oct 15; 112(4) 450-4.