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Foreign body found in anterior chamber post-cataract surgery
The patient had no complaints and experienced no inflammation.
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An 80-year-old white female was referred for a cataract evaluation. She described increased difficulty driving at night due to halos and starbursts from oncoming headlights and streetlights. Her right eye was more symptomatic.
The patient’s past ocular history was remarkable for spectacle correction and excision of a squamous cell carcinoma lesion along the lateral aspect of the left lower eyelid margin 10 years prior. She had no history of any other ocular diseases, surgeries or trauma.
Her systemic medical history was positive for hypertension and hyperlipidemia, for which she was taking oral atenolol 25 mg twice a day and oral simvastatin 20 mg once daily at bedtime. Her health history also included surgical excision of malignant melanoma, squamous cell carcinoma and actinic keratosis lesions from her upper limbs. She was also taking a calcium-vitamin D 600 mg/200 IU supplement twice a day and an 81 mg aspirin once daily to maintain bone and heart health. She was allergic to oxycodone and propoxyphene.
Her entering corrected visual acuity was 20/40 with improvement to 20/25+2 on pinhole in the right eye and 20/30+2 with improvement to 20/25 on pinhole in the left eye. Pupils were equal, round and reactive to light with no afferent pupillary defect. Extraocular motilities were full with no restrictions, and visual field was grossly full upon confrontation. Best corrected visual acuity was 20/25 OU with +4.00 -0.50 x 085 OD and +4.50 -0.25 x 063 OS. The brightness acuity test revealed reduced visual acuity in both eyes on all settings, down to 20/70 OD and 20/60- OS with high illumination.
Alexandra Bavasi
All structures of the anterior segment were within normal limits. Intraocular pressures measured 12 mm Hg OD and 11 mm Hg OS. Dilated fundus exam revealed 2+ to 3+ nuclear sclerotic and 1+ cortical cataracts with vacuoles in both eyes. The optic nerves were distinct, well-perfused and had small cup-to-disc ratios. The maculae were flat with no drusen present. The peripheral retina in either eye was flat and intact throughout.
Cataract surgery scheduled
The patient was scheduled for cataract surgery 2 months later. Her right eye was completed first, followed by the left 1 week later.
She returned for her 1-day postop appointment for the right eye with no concerns. She was using her postoperative eye drops as prescribed. Her uncorrected visual acuity was 20/40+2 OD, which was corrected to 20/20 with +1.75 -1.00 x 110. Slit lamp examination of the right eye revealed a clear cornea, trace cells in the anterior chamber and a stable posterior chamber intraocular lens (PCIOL). The superior incision was intact and sutureless, and Seidel’s sign was negative.
The next week, the patient returned for her 1-day postop appointment for the left eye and 1-week postop for the right eye. She had no concerns and was using her eye drops as prescribed. Her uncorrected visual acuity was 20/30 with improvement to 20/20 on pinhole in the right eye and 20/20 in the left eye. The right eye was correctable to 20/20 with +1.00 -0.75 x 110. Slit lamp examination of the left eye revealed trace corneal haze, trace cells in the anterior chamber and a stable PCIOL. The incision was intact and sutureless, and Seidel’s sign was negative. The cornea of the right eye was clear, there were no cells in the anterior chamber, and the PCIOL was stable. The incision was intact and sutureless, and Seidel’s sign was negative. However, we saw a glaring abnormality. An unexpected object was embedded in the incision and extending into the anterior chamber.
Foreign object
A foreign object was seen to have penetrated the external ostium of the superiorly placed scleral tunnel incision. The object was about 4 mm to 5 mm long, curved and tapered in thickness from one end to the other. The thin end of the object was rooted within the incision while the thicker end hovered freely within the anterior chamber above the level of the pupil. The object shifted slightly upon eye movement, but no structures appeared to be compromised.
Initial presentation of thin foreign body 1 week postoperatively. The foreign body was best imaged with iris retro-illumination.
Images: Bavasi A
Neither end of the foreign object appeared to be touching the corneal endothelium or the anterior iris. No part of the object was extending externally from the incision, so no foreign body sensation was noted by the patient. Because she was not experiencing any inflammation, the decision was made to monitor. She was instructed to continue using her postoperative eye drops as prescribed for either eye and to return to the clinic the following week for her scheduled 1-week postop visit for the left eye. She was instructed to come in sooner if she started to experience signs or symptoms of ocular inflammation.
A week later, the patient returned with no concerns. She was happy with her vision and had not experienced any signs or symptoms of ocular inflammation in either eye. She was using her eye medications diligently as prescribed. Her uncorrected visual acuity was 20/30+1 OD and 20/25+1 OS. The right and left eyes were correctable to 20/20 with +1.00 -1.00 x 110 OD and +0.75 -0.75 x 065 OS. Slit lamp examination of the right eye revealed a clear cornea, a deep and quiet anterior chamber and a stable PCIOL. The incision was intact and sutureless, and Seidel’s sign was negative.
The single cilium remained stable in the right scleral tunnel incision. The distal end (tip) of the cilium was secured in the incision while the proximal end (follicle) curved posteriorly toward the iris. It was not abutting any ocular structures and did not appear to be causing any intraocular inflammation. Findings for the left eye were unremarkable.
The patient was educated about the rarity of her presentation and that surgical intervention would be needed to remove the cilium if the eye started to react to it. After the risks and benefits of surgical extraction vs. observation were reviewed with the patient, the decision was made to continue to monitor. The patient was instructed to wean off of her medication as prescribed and to return for her 1-month postop visit.
The patient returned 1 month later with no concerns. She had successfully weaned off of her postop eye drops with no rebound inflammation. Her uncorrected visual acuity was 20/30+1 OD and 20/20-2 OS. Her manifest refraction and final prescription was +1.25 -1.50 x 105 OD and +0.50 -0.50 x 092 OS, with a best-corrected visual acuity of 20/15 in either eye. Slit lamp examination revealed no change since the last visit, and no signs of inflammation were present. The cilium remained inert and stable in the superior incision. Her new spectacle prescription was dispensed and she was scheduled for a comprehensive examination 6 months later.
At the 6-month follow up, the cilium was still present in its original location. There were no signs of inflammation. The patient has not noticed any untoward effects and her best corrected visual acuity in both eyes remains 20/15.
Epidemiology, prognosis, treatment
Cilia present in the anterior chamber after cataract surgery is a rare phenomenon. Surgeons take great care in preventing inoculation of foreign bodies and removing all lens fragments during the procedure. Intraocular nuclear fragments that are mistakenly left behind can cause a serious anterior chamber reaction that can be sight-threatening in some cases. Surgical intervention to remove these fragments is imperative.
However, not all foreign bodies must be removed. There have been many reported cases of traumatic metallic, plastic and autologous foreign bodies that have remained inert for many years. However, any foreign body that causes inflammation or infection requires surgical removal and appropriate medical therapy.
Although intraocular cilia foreign bodies are a rare complication during intraocular surgery, there have been a few reported cases in recent literature. In some cases, intraoperative inoculation of the cilium was suspected, and theories of prevention were speculated. However, other recent cases described similar instances in which the cilium was not present until weeks after the initial procedure.
Case examples
In one such case, the 1-day and 1-week postop examinations were unremarkable. At the 6-week assessment, a cilium was noted to have penetrated the external ostium of the inferiorly located paracentesis incision (Walker, et al.). Similar to this case, the follicle end of the cilium penetrated the incision first. It was speculated that the cilium’s cellular arrangement promoted infiltration into the wound. Cilia, as well as other hair types, are structurally made up of overlapping cells whose free margins are directed toward the distal end. This arrangement may have facilitated the passage through the incision in one direction only: proximal end first.
Appearance of cilium 2 weeks postoperatively.
Another case described an embedded cilium in the clear corneal incision found at the 1-day postop visit (Pham, et al). Again, the follicle tip of the cilium entered the incision first, supporting the theory that the cellular arrangement of cilia may be a contributory factor to postoperative inoculation. The distal end of the cilium protruded from the incision, so it was easily removed with forceps.
In the majority of the reported cases, the intraocular cilium caused no anterior chamber reaction and remained inert. In an unusual case, a cilium was noted in the anterior chamber upon preliminary cataract evaluation (Yalniz-Akkaya). The patient had not seen an eye care clinician since birth. The patient had been struck in the eye with a dining fork about 50 years prior, but no medical attention was sought at the time. The cilium extended from behind the iris at the temporal position, crossed over the pupil and rested nasally at the angle. The anterior chamber was deep and quiet; no inflammation or hyphema was noted. Cataract surgery was cautiously proceeded with, during which the cilium was removed without complication. The cilium had remained inert for years without causing any chronic inflammation.
Another report described a cilium becoming entrapped in the anterior chamber 3 months after cataract surgery (Islam, et al.). The patient remained asymptomatic and was not interested in retrieving the foreign body. He was monitored for 2 more months before being discharged. Four years later, he returned for a follow-up. He had remained asymptomatic without pain, photophobia or monocular diplopia. Again, he declined surgery and opted for annual review.
Despite many reports of inert cilia, the reaction of the eye to intraocular cilia can be variable and unpredictable, ranging from absolute lack of reaction to endophthalmitis. After an uneventful cataract surgery, a patient presented with endophthalmitis 3 days postoperatively (Galloway, et al.). The patient presented with hand-motion visual acuity, and slit lamp examination revealed a fibrinous anterior chamber with hypopyon. Although the fundus view was poor, B-scan ultrasonography showed a severe vitritis with an intact retina. A vitreal sample was taken and the patient was treated in accordance with the standard protocol involving intravenous, oral and topical antibiotics and steroids. Microbiological examination of the vitreal sample revealed no microbes.
Appearance of cilium 2 weeks postoperatively.
After a week of treatment and a decline in inflammation, a curvilinear object was found in the anterior chamber that resembled an eyelash. The cilium was removed, the patient subsequently recovered rapidly, and treatment was tapered. The patient’s vision improved and no sign of intraocular inflammation was evident 5 months after the incident. It was not determined when or how the cilium entered the eye in this case. It could be speculated that the cilium was not autologous, thus causing such a severe reaction. But testing in this area was not performed.
Cases involving endophthalmitis obviously warrant immediate foreign body removal, but cases of subtle, low-grade, chronic inflammation may be more perplexing. Although unrelated to cataract surgery, another unique case reported an instance of an intraocular cilium following a prior traumatic event (Liu, et al.). The patient was not symptomatic, and no anterior chamber reaction was evident. However, the follicle end of the cilium was embedded into the iris while the distal end of the cilium rubbed along the corneal endothelium as the pupil constricted. Specular microscopy revealed lower corneal endothelium cell density and larger average cell size in the affected area.
To prevent further damage to the endothelium or provocation of inflammation, the cilium was removed surgically. Even though the reaction to the cilium was slight, risk of further damage warranted removal.
An intraocular cilium following cataract surgery is a rare phenomenon. In most cases, the autologous foreign body can remain inert in the eye indefinitely. However, serious complications such as endophthalmitis can result. Treatment and management of these cases is debated, as outcomes are variable. It may be generally accepted to monitor patients who are asymptomatic and do not show signs of infection or inflammation. However, removal should be considered if the foreign body is easily accessible or if it is causing any sort of inflammation, be it acute or chronic.
- References:
- Galloway GD, et al. J Cat Ref Surg. 2004;30(2):521-522.
- Islam N, et al. Acta Ophthalmol Scand. 2006;84(3):432-434.
- Liu W, et al. Canadian J Ophthalmol. 2013;48(2):e28-e29.
- Pham TS, et al. Optometry. 2010;81(6):280.
- Walker NJ, et al. J Cat Ref Surg. 2007;33(4):733-734.
- Yalniz-Akkaya Z. J Med Case Reports. 2011;5:527.
- For more information:
- Alexandra Bavasi, OD, is a recent graduate of Pacific University College of Optometry. She will complete a residency in pediatrics, vision therapy and vision rehabilitation at Pacific University. She can be reached at alexandra.bavasi@gmail.com.
- Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, is a Primary Care Optometry News Editorial Board member who practices in Albert Lea, Minn. He can be reached at the Mayo Clinic Health System; skorin.leonid@mayo.edu.
Disclosures: Bavasi and Skorin report no relevant financial disclosures.