Retina Today - RETINA PEARLS: Vitrectomy for Removal of Posterior Segment Intraocular Foreign Bodies (January/February 2012)

摘要

In this issue of Retina Today, Lisa C. Olmos, MD, MBA; and D. Wilkin Parke III, MD, provide surgical pearls for performing pars plana vitrectomy to remove an intraocular foreign body. We extend an invitation to readers to submit pearls for publication in Retina Today. Please send submissions for consideration to Ingrid U. Scott, MD, MPH (iscott@psu.edu); or Dean Eliott, MD (dean_eliott@meei.harvard.edu). We look forward to hearing from you. a??Ingrid U. Scott, MD, MPH; and Dean Eliott, MD Intraocular foreign bodies (IOFBs) present unique surgical challenges, particularly when the posterior segment is involved. Risk factors for IOFB after ocular injury include youth, male gender, work-related injury, metallurgy, and battlefield or blast injury. If either traumatic endophthalmitis or traumatic cataract is present, there should be a high index of suspicion for IOFB, and imaging studies should be obtained. Possible consequences of posterior segment IOFB include endophthalmitis, toxicity (such as siderosis or chalcosis), cataract, retinal detachment (RD), intraocular hemorrhage, secondary choroidal neovascular membrane, and sympathetic ophthalmia. The most common intraocular location of a retained foreign body is within the vitreous humor. These cases require vitrectomy with foreign body removal either through the pars plana or anteriorly through the pupil and clear cornea after lensectomy. Retinal or subretinal IOFBs frequently cause widespread hemorrhage and retinal damage and may require retinotomy. Postoperatively, there is a high risk of RD associated with proliferative vitreoretinopathy (PVR). This article presents helpful surgical techniques and reviews the literature on the surgical management of these complex cases. CASE EXAMPLE A 33-year-old man was referred from an outside emergency room with a red, painful left eye (OS; Figure 1). Five days earlier, he presented to the ER after work with mild pain OS. He worked as a furniture mover, and all week long he had been removing chairs that were stapled to the floor. He was diagnosed with a corneal abrasion and started on antibiotic ointment. His pain initially improved, then worsened along with his vision, causing him to seek further care. Upon examination, his visual acuity was 20/20 in the right eye (OD) and light perception OS. Intraocular pressures were 16 and 14 mm Hg, OD and OS, respectively. Ocular examination OD was unremarkable. Slit-lamp examination OS showed 2 to 3+ conjunctival injection and a 0.5-mm hypopyon. The cornea was edematous, and there was a small self-sealing laceration centrally. The view to the fundus was compromised by cloudy media. Computed tomography of the orbits was obtained (Figure 2). The patient was diagnosed with retained IOFB and traumatic endophthalmitis OS. He was told to take nothing by mouth, given topical fortified and oral antibiotics, and taken to the OR emergently the following morning. He underwent 20-gauge pars plana vitrectomy (PPV) and lensectomy with retinectomy for removal of the IOFB and repair of the secondary RD with silicone oil tamponade. The IOFB was identified embedded in the retina just superior to the optic disc and fovea. Fortunately, the macula was spared from direct impact. Perfluorocarbon liquids were used intraoperatively to protect the macula during IOFB removal. The object proved to be magnetic, but it was excessively large and heavy for removal using an intraocular magnet. It also had an irregular, C-shaped contour. The IOFB was therefore grasped with Rappazzo Intraocular Foreign Body Forceps (Storz Ophthalmics), delivered through the pupil, and ultimately externalized via a preplaced limbal clear corneal incision anteriorly. The patient was left aphakic, and the sclerotomies and the corneal incision were sutured. Vitreous cultures were taken, and intravitreal antibiotics were administered. The foreign body was a 12 x 1 x 1 mm magnetic metal o