Penetrating ocular trauma with retained intraocular foreign body (IOFB) is a relatively common cause of avoidable blindness. IOFB is associated with 18%-41% of penetrating ocular injuries (1) Most of these injuries are workplace related (2). Young working age males are affected by a large majority (1). These patients need thorough evaluation and treatment on a priority basis to reduce visual morbidity.

Following article describes Do’s and Don’ts of a patient with IOFB.

Dos

1. Take detailed history including medico legal aspects of trauma, circumstances of trauma, type of IOFB etc,
2. Medico legal formalities must be completed at time of first contact
3. History of systemic diseases should be elicited to r/o uncontrolled hypertension, diabetes mellitus, hyper or hypothyroidism etc. They may have implications in planning anesthesia and intraocular surgery
4. Make sure visual acuity is evaluated and documented before proceeding with clinical evaluation
5. Detailed documentation of each examination, pre and post operatively, must be made and stored. These might be necessary at latter date if the surgeon is summoned as expert witness in the court of law
6. External examination to rule out orbital and adnexal involvement like retrobulbar or periorbital hematoma, orbital fractures, lid tear with special attention to canalicular tear.
7. Detailed clinical examination must be done to assess entry wound, associated anterior segment trauma, corneo-scleral wound, presence of traumatic cataract and media opacity
8. If fundus can be seen, characteristics of IOFB like size and shape, its location inside the eyeball, whether embedded in ocular coats should be documented
9. CT scan of orbits should be done for each patient. When ordering the scan, make sure to mention 1 mm sections with axial and coronal scans taken. Most CT scan centers scan at 5 mm sections unless specified. One may not be able to locate the IOFB if it is present between the cuts. Axial and coronal sections help to locate the number and location of IOFB precisely in relation to other ocular structures, which helps in planning the surgery
10. Intraoperatively, the anterior segment should be reconstructed at outset. Lensectomy with vitrectomy cutter or phacoemulsification for removal of crystalline lens can be done if IOFB is large and the surgeon feels it may need removal through limbal route. Anterior capsular rim can be preserved for placement of IOL in sulcus at latter date
11. Thorough vitrectomy and removing all vitreous adhesions to IOFB is a must before attempting IOFB removal. If IOFB is encapsulated, the fibrous capsule can be cut using vitreous scissors or vitrectomy cutter. Inadequate vitrectomy at the time of IOFB removal can lead to vitreoretinal traction and retinal tears.
12. If IOFB is not easily visible intraoperatively, usually these IOFB are lodged in vitreous skirt close to pars plana. These can be visualized by performing thorough base excision with external depression. Chandelier light source can be used for additional illumination in these cases.
13. PVD can be induced after IOFB is removed as posterior hyaloid acts as cushion and helps to protect retina
14. A bubble of PFCL should be used to avoid retinal trauma in macular area should IOFB slip back and fall during removal from ocular coats
15. In case the IOFB is embedded in the retina, before its removal, a barrage laser should be done around the IOFB. If haemorrhage develops after the IOFB is removed from the retinal surface, a laser around consequate break may be difficult to barrage.
16. Various types of instruments have been described for removal of the IOFB from the eye (3).This author has described ‘Claw’ forceps with 4 retractable prongs, for removal of a large non magnetic IOFB from vitreous cavity without slippage (4)

Don’ts

1. Avoid contact method of IOP evaluation in case of open globe injury
2. Avoid putting excessive pressure on eyeball with ultrasound probe while performing B-Scan USG
3. Do not order MRI when metallic IOFB is suspected
4. Do not give plan surgery under local anesthesia when dealing with OGI, GA is preferred as there is no undue pressure on the eyeball.
5. Do not postpone removal of IOFB to second stage surgery unless absolutely necessary
6. Do not start surgery without surgical planning and availability of necessary instrumentation required to remove IOFB. While majority of IOFB are small in size and magnetic in nature, large non magnetic IOFB can be difficult to remove unless surgery planned in advance and necessary instrumentation is available at hand
7. Do not promise excellent anatomical or visual prognosis preoperatively

References

1. Loporchio D, Mukkamala L, Gorukanti K, Zarbin M, Langer P, Bhagat N, et al. Intraocular foreign bodies: A review. Surv Ophthalmol. 2016;61:582–96.
2. Hapca MC, Muntean GA, Dragan IAN, Vesa SC, Nicoara SD. Outcomes and prognostic factors following pars plana vitrectomy for intraocular foreign bodies-11-year retrospective analysis in a tertiary care center. J. Clin. Med. 2022;11:25
3. Yang D, Yuan AE, Chee YE. Vitrectomy Instrumentation: Scissors, Forceps, Picks. Operative Techniques in Vitreoretinal Surgery. 2022 May 21:276.
4. Bapaye M, Shanmugam MP, Sundaram N. The Claw: A Novel Intraocular Foreign Body Removal Forceps. Indian Journal Of Ophthalmology 66(12), 1845-1848

Links to Youtube Videos

This video shows collection of videos with IOFBs in different ocular coats

1. Industrial eye injury with IOFB
2. A Collage of IOFBS