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Video Report Minimally Invasive Intraocular Foreign Body Extraction R Maini[1,2] and AI Fernando[1]1. Western Eye Hospital, London NW1 5YE 2. Charing Cross Hospital, London W6 8RF
Correspondence: Mr R Maini Date of acceptance: 21st September 2006 |
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An eight year-old girl sustained a self-sealing penetrating injury with a graphite pencil tip. The anterior chamber foreign body was removed in a minimally invasive fashion through a corneo-limbal incision with viscoelastic endothelial protection. Final visual acuity was 6/5 unaided. |
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[View Video: Fast connection] Note: This video is best viewed in Quicktime Case Report and Technique We present a case of an eight year-old girl who sustained a self-sealing penetrating injury with a graphite pencil tip. She presented to eye casualty the following day complaining of a slightly red and watery left eye. There was no associated blurred vision, photophobia or pain. On examination, visual acuity was 6/5 in her right eye and 6/6+2 in the left eye. Her pupil was round and there was no afferent pupil defect. She had a self-sealing full thickness corneal laceration measuring 2.5mm in length, the graphite tip of the pencil was clearly seen in the anterior chamber adherent to iris at the pupil margin, this foreign body moved in concert with the iris on contraction. There was no associated intraocular inflammation and posterior segment examination was entirely normal The intact intraocular foreign body was removed through a corneo-limbal incision using high molecular weight viscoelastic (Healon GV � Pfizer), and expressed on a Moorfields cystotome and curette (Altomed A2172), using a cyclodialysis spatula to aid corneal endothelial protection (see Video). Intraoperatively a fine dusting of pencil graphite was noted over the anterior surface of the inferior iris, extending onto the trabecular meshwork and anterior chamber angle. The limbal incision was closed with absorbable suture. The pencil tip was sent for microbiological analysis which proved negative. Fortunately she made an excellent post-operative recovery, with minimal intraocular inflammation that settled rapidly, she attained a final unaided visual acuity of 6/5 in the affected eye. Comment Ocular trauma is one of the commonest causes of blindness in the developed world and represents the main cause of blindness in teenagers and young adult males [1]. In general, penetrating ocular injuries have a poor visual prognosis. Prognostic factors and visual outcomes have been evaluated in numerous studies [2, 3] The management of paediatric IOFB and penetrating trauma is particularly complex. Once globe integrity is restored, the visual axis must be cleared and optical corrections must be dispensed to provide optimal vision. This must all be accomplished within the critical period for visual development, if amblyopia is to be prevented. Delayed surgical intervention and inadequate postoperative refractive correction are known to adversely affect visual outcome [4]. The most important prognostic factor is the extent of the initial injury with consequent structural damage. The time interval between presentation and initial injury is also important. Seemingly innocuous trauma resulting in a self-sealing perforation with a retained IOFB and little initial visual acuity loss, may prevent the patient presenting until other complications arise. The presenting visual acuity is thought to be the strongest prognostic indicator in predicting final visual outcome in patients with retained IOFBs [2, 3, 5, 6]. Factors associated with poor visual outcome included the presence of an afferent papillary defect, prolapse of intraocular contents, retinal detachment and vitreous haemorrhage. In our patient, the rapid initial presentation and excellent initial visual acuity were favourable factors. Additionally there was no disruption of the intraocular architecture. Yoshihito et al describe a similar intraocular graphite pencil lead injury where the extraocular wound was promptly treated, but a fragment of graphite remained in the eye for six years without any complications [7]. There was no necrosis, inflammation, infection or ocular siderosis during the six year follow up period. This case illustrates that intraocular graphite may be inert and can remain symptomless even if it remains intraocular for several years. Modern pencil lead is composed of 70% graphite and 30 % clay, with some additives such as liquid paraffin, spindle oil, and silicone oil [8]. Certain kinds of coloured lead pencils are known to cause severe inflammation and necrosis in the orbit and eye [8]. When possible, careful gonioscopy and fundal examinations should be performed preoperatively. If the retina cannot be seen directly, thorough B-scan ultrasonography is necessary. A high index of suspicion must be maintained for suspected IOFBs even if plain x-rays are normal. The plain x-ray detection rate for foreign bodies has been reported as low as 40% and certain objects such as graphite, Perspex and wood have an even worse detection rate [9]. Although magnetic resonance imaging is superior for detecting low�density objects, it is contraindicated where metallic IOFBs are suspected. Computerised Tomography with 1 mm cuts is the preferred investigation under these circumstances. This case highlights the importance of prompt diagnosis and treatment in the management of anterior segment trauma in children in order to optimize the long-term visual prognosis.
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