IOL scaffold technique can be used for retrieval of intraocular foreign body
This method helps prevent slippage of the IOFB into the vitreous.
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Intraocular foreign bodies, or IOFBs, can occur as a result of trauma or accidents. These IOFBs can be metallic or non-metallic. Treatment options depend upon the position or location of the IOFB, the size, the biochemical nature and their relation to surrounding vital structures. Retained IOFB can be a source for vision-threatening complications such as endophthalmitis, photoreceptor damage, retinal detachment, chronic inflammation, cataract and glaucoma. High-velocity objects can penetrate into deeper structures and lodge on the retina or vitreous, while low-velocity objects may settle on the anterior chamber or cornea. In this column, we highlight the application of the IOL scaffold technique for IOFB removal from the vitreous.
Case explanation
An adult man presented with a history of eye trauma followed by visual loss. On clinical examination and ultrasound visualization, there was an IOFB in the mid-vitreous, and he had been referred to us for further management. A thorough preoperative workup was performed to assess the position and relation of the IOFB with the intraocular structures, and IOFB removal by the IOL scaffold method was planned. Because the patient had a coexisting cataractous lens, the procedure was combined with phacoemulsification and IOL implantation. Peribulbar anesthesia was used.
Surgical technique
Under strict aseptic precautions, a clear corneal incision was made, and a continuous curvilinear capsulorrhexis was performed under ocular viscoelastic device. That was then followed by hydrodissection, hydrodelineation and phacoemulsification of the nucleus (Figure 1a). After the lens cortex removal, suturing of the main port with 10-0 monofilament nylon was done. A transconjunctival 23-gauge trocar infusion cannula was introduced in the inferotemporal quadrant. A pars plana sclerotomy for the vitrectomy probe and endoilluminator was made in the superotemporal and superonasal quadrants, respectively. Posterior capsulotomy was performed using the vitrectomy probe. Pars plana vitrectomy was performed with the probe of the Accurus 400VS (Alcon) vitrectomy system. A thorough vitrectomy to free all the vitreous attachments to the IOFB was performed.
The IOFB was localized and removed with an intravitreal magnet and then forceps (Figure 1b). It was then lifted to the anterior chamber and lodged on the iris (Figures 2a to 2c). The infusion was decreased, and the main corneal wound was extended. Meanwhile, the IOFB was noted to dislodge again into the pupillary zone (Figure 2d). A three-piece posterior chamber IOL (6 mm optic diameter) was then placed in the sulcus (Figure 3a) as a scaffold. The IOFB was held over the IOL with the probe via the corneal wound (Figure 3b). The probe was then replaced by forceps, and the IOFB was held with the forceps via the main corneal wound and retrieved through it (Figures 4a and 4b). The IOL was centered, the corneal wound was closed, and the posterior segment was observed to be normal (Figures 5a and 5b). Sclerotomy wounds were closed with polyglactin sutures.
IOFB removal in cataractous eyes
Intraocular foreign body removal can be performed as a lens-sparing or lens-removing procedure. Lens-sparing is not usually recommended in conditions such as coexisting cataractous lens, traumatic cataract and phacodonesis. Many surgeons prefer a simultaneous procedure to remove the lens for better intraoperative visualization and for prevention of lens-induced uveitis. Retrieval of large IOFBs through the sclerotomy port requires extension of the sclerotomy size. Enlargement of the sclerotomy carries the risk for hypotony, vitreous hemorrhage, peripheral vitreous incarceration into the wound intraoperatively and retinal detachment postoperatively. Batman and colleagues showed good visual outcomes after combined clear corneal phacoemulsification with IOFB removal. Combined IOFB removal along with phacoemulsification through a scleral-corneal wound has been reported by Mahapatra and colleagues for large foreign bodies. An anterior capsule preservation technique with a lensectomy procedure has also shown good visual outcome results.
IOL scaffold for IOFB removal
In our case, we used the IOL scaffold technique for IOFB removal. We have used this for removal of nucleus pieces in complicated cataract surgery with posterior capsular rupture. In the case, we created a posterior capsulotomy, and the IOFB was removed via the posterior capsulotomy into the anterior chamber and retained in the anterior chamber until the IOL was placed. The foldable IOL acted as a barrier to the IOFB drop into the vitreous and worked like an artificial posterior capsule. Prevention of IOFB slippage into the vitreous by a simple maneuver is the major advantage of this method.
- References:
- Agarwal A, et al. Retin Cases Brief Rep. 2017;doi:10.1097/ICB.0000000000000296.
- Batman C, et al. J Cataract Refract Surg. 2000;doi:10.1016/S0886-3350(99)00368-5.
- Kumar DA, et al. J Refract Surg. 2012;doi:10.3928/1081597X-20120413-01.
- Mahapatra SK, et al. Indian J Ophthalmol. 2010;doi:10.4103/0301-4738.60077.
- Narang P, et al. Ophthalmology. 2013;doi:10.1016/j.ophtha.2013.05.011.
- Vatavuk Z, et al. Croat Med J. 2004;45(3):295-298.
- For more information:
- Amar Agarwal, MS, FRCS, FRCOphth, is director of Dr. Agarwal’s Eye Hospital and Eye Research Centre. Agarwal is the author of several books published by SLACK Incorporated, publisher of Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at 19 Cathedral Road, Chennai 600 086, India; email: aehl19c@gmail.com; website: www.dragarwal.com.
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