Open Globe Management

Alessandro A. Castellarin, MD; Dante J. Pieramici, MD

Disclosures

Compr Ophthalmol Update. 2007;8(5):111-124. 

In This Article

Intraocular Foreign Body: Established Role of Pars Plana Vitrectomy

Intraocular foreign bodies represent 18-41% of open globe injuries, with hammering being the most common cause.[37] The main goal in managing IOFBs is to treat and prevent associated conditions, such as endophthalmitis, retinal detachment, and late metallosis.[36] A posterior segment IOFB has a 68% chance of causing one retinal lesion and a 21% chance of resulting in two or more retinal lesions.[37]

It is essential to rule out the presence of an IOFB with an accurate history and clinical examination. In suspected cases with ocular media opacities limiting adequate evaluation, a CT scan should be ordered. Acute IOFBs are more of an emergency than non- IOFB open globe injuries, as they carry a significantly greater risk of developing endophthalmitis. In general, removal is considered in the acute setting to reduce this risk. Chronic IOFBs (present > 48 hours) are unlikely to develop endophthalmitis, and their removal is less urgent and, in some instances, unnecessary. Risk factors for endophthalmitis in the setting of IOFB include time of removal (3.5% if < 24 hours, 13.4% if > 24 hours), wound > 5 mm, rural settings, posterior segment involvement, lens injury, and intravenous (IV) antibiotic therapy not started within 24 hours.[37] We favor the use of intravitreal antibiotics at the time of primary removal in the case of acutely presenting IOFBs.

In general, eyes with IOFB tend to do better than perforating or ruptured globes, unless the IOFB is a BB or pellet. As is true of most eye injuries, when posterior segment structures are involved, particularly those located in the posterior pole, the prognosis worsens.

Before the advent of vitrectomy, all magnetic foreign bodies were often removed using an external magnet with variable success. Today, in the modern ophthalmic operating room, there is no need for external magnetic removal of posterior segment IOFBs. We would argue that PPV and internal removal offer a number of advantages, although a retrospective review comparing internal versus external approaches found no statistical difference in outcomes.[38] First, internal removal allows for the most controlled and predictable extraction of magnetic and nonmagnetic foreign bodies.

Second, for reasons previously discussed, removal of the vitreous, blood, associated cytokines, and infectious organisms should be beneficial in the injured eye. Third, direct treatment of associated retinal pathology, such as retinal tears, is facilitated.

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