|Year : 2021 | Volume
| Issue : 3 | Page : 360-361
When iron hits; iris safeguards, lens surrenders
Prateek Jain, Anshuman Pattnaik
Department of Community Ophthalmology, Global Hospital Institute of Ophthalmology, Sirohi, Rajasthan, India
|Date of Submission||13-Jan-2021|
|Date of Acceptance||21-Apr-2021|
|Date of Web Publication||08-Dec-2021|
Dr. Prateek Jain
Global Hospital Institute of Ophthalmology, Abu Road, Sirohi - 307 510, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jain P, Pattnaik A. When iron hits; iris safeguards, lens surrenders. Kerala J Ophthalmol 2021;33:360-1
Foreign body (FB) penetrating the eye to a variable depth is a frequently observed problem in the ophthalmology outpatient department. This article narrates two cases with metallic intraocular FB (IOFB) of which one was safely removed, while the other was referred to a higher center.
Case 1 [Figure 1] shows a 25 year-old-male laborer who presented with diminished vision, pain, redness, and watering in the left eye (LE) after having injury while grinding an iron rod 1 day back. Best-corrected visual acuity was finger-count 5 m. Slit-lamp examination (SLE) revealed diffuse conjunctival congestion and self-sealed (Seidel's negative) corneal tear with the iron particle in the anterior chamber (AC). AC showed Grade-4 flare and cells. The iron particle was adherent to iris by fibrous membrane. Fortunately, the lens was clear with an intact anterior capsule. Fundoscopy and B-scan revealed a normal posterior segment. Orbital computed tomogarphy (CT) ruled out any other FB or damage. Inside OT, under sub-tenons block, the iron particle was mobilized after breaking surrounding adhesions and oriented such that it could be taken out from the same entry without the creation of another port. Copious viscoelastic was used to avoid collateral damage to the lens and endothelium. The sharp iron particle (4 mm × 6 mm) was extracted out and corneal tear was repaired with (10-0) nylon sutures. Uncorrected visual acuity at postoperative day-7 was 6/12 [Figure 2].
|Figure 1: Intraoperative photographs. (a) Iron particle adherent to iris. (b) Iron particle being mobilized and re-oriented with a spatula after adhesiolysis. (c) Iron particle being extracted out from the same entry wound. (d) Iron particle being shown after extraction|
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|Figure 2: Slit-lamp photograph: Above - Preoperative: Diffuse conjunctival congestion with self-sealed corneal tear and iron particle with surrounding exudative membrane in anterior chamber. Below: postoperative day-7: Quiet eye with intact corneal suture and well-formed anterior chamber|
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Case 2 [Figure 3] illustrates a poor 45-year-old-male presented with diminished vision and pain in LE after getting injured while hammering a chisel 6 h ago. Visual acuity was an accurate perception of light but an inaccurate projection of rays. SLE revealed diffuse conjunctival congestion and full-thickness (Seidel's positive) vertical corneal tear involving visual axis with tiny FB particles lying at the edge. Shallow AC, traumatic mydriasis, sphincter tear, and traumatic cataract were noted. Close examination revealed incomplete bisection of the lens which was suggestive of FB having penetrated into the vitreous cavity. X-ray orbit showed the presence of intra-ocular radio-opaque particle. B-scan was deferred because of poor wound integrity. Noncontrast head CT orbit was advised, but the patient refused. Careful SLE helped catching the trajectory of FB and thus timely referral of the patient to a higher center.
|Figure 3: (a) Slit-lamp photograph at × 10: Vertical full thickness corneal tear and traumatic cataract. (b) Positive Siedel's test confirming aqueous leak. (c) Slit-lamp photograph at × 25: Showing corneal foreign body, sphincter tear and partially bisected lens. (d) Orbital X-ray: Revealing presence of metallic foreign body (in red circle)|
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During penetrating trauma, the direction and site of impact, along with the mass and velocity of the FB, determines its final position inside the eye. Objects with lower mass (usually nonmetallic) and lesser velocity seem to remain in AC. In contrast, objects with greater mass (metallic) come to lie more commonly in the posterior segment. Such cases occur when there is splashing of the FB, commonly seen during drilling.
Orbital X-ray is helpful to detect radio-opaque FBs, but CT-Scan is the preferred modality as it provides more information such as size, shape, and localization of the FB. Magnetic resonance imaging is not used for metallic-IOFB as it can dislodge the FB and cause further destruction. B-scan is usually avoided in open globe injuries. Ultrasound biomicroscopy is used when FB in the angle is suspected.
Siderosis bulbi is a degenerative change caused by Iron FB, occuring 2 months to 2 years after injury where iron undergoes electrolytic dissociation producing ions which combine with intracellular proteins and cause degeneration.
Prompt management including timely removal of FB is of paramount importance, but wearing protective eye gear is the first step in avoiding such injuries.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors acknowledge the guidance of Dr. V C Bhatnagar, Head of Department and Medical Superintendent, Global Hospital Institute of Ophthalmology.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]