44-year-old Hispanic male who reports three-day history of stucco solution in his left eye while working on construction site. He complained of redness, tearing, and pain with resolving photophobia
Six months prior to this presentation, the patient reported that he was hammering porcelain tile when felt something went into his left eye
He was examined and treated at that time at an outside hospital with topical antibiotics, corticosteroids, and cycloplegics for two weeks, but then had a lack of follow-up
His vision slowly declined gradually over three months and then then remained stable but very poor in the left eye
20/20 OD, Light perception OS. Pupils reactive OD, and Fixed/dilated and white OS with a 2+ rAPD OS. IOP 13 OD and 0 OS by applanation (4 by Tonopen)
pH of the left eye was within normal limits
Additional Exam Findings
Corneal endothelial pigment, 3+ cell and 1+ flare in the anterior chamber. Seidel negative.
Given the constellation of findings there is really only one thing that unifies all of them, so a good differential diagnosis was difficult to construct:
Chemical alkali injury to the left eye
Intraocular foreign body left eye
Traumatic cataract left eye
Retinal Detachment causing hypotony left eye/li>
(much less likely):
External alkali chemical injury from stucco solution (general with a pH of 13)
Ceramic intraocular foreign body (IOFB) – chronic in nature
Patient found to have an occult chronic IOFB with associated traumatic dense white cataract and retinal detachment–likely chronic in nature given the diffuse retinal thickening, chronically poor vision, and history of previous trauma six months prior
IOFB was likely self-sealing leaving behind a full thickness stromal scar pigmented by either blood or iris pigment with an associated transillumination defect just posterior to the scar delineating the path of the projectile
IOFB and retinal detachment likely caused anterior segment inflammatory reaction observed on slit lamp examination
This was confirmed with computed tomography imaging as the foreign body was not found on B-scan ultrasound likely given its small size, anterior location, and the limits of resolution of the standard B-scan ultrasound probe
Given the relative lack of vitritis and deep boring pain, foreign body was likely not causing any severe inflammatory/infectious reaction posteriorly. Additionally, per patient report, the composition of the foreign body was porcelain, a material known to be relatively inert (along with glass, rubber, coal, silver, silver, gold)
For patient’s resolving chemical injury, aggressive lubrication was prescribed after adequate copious irrigation of the surface with normal saline had been performed.
Erythromycin ointment was added given the remaining unknown contaminants of the stucco solution
For patient’s inflammation, prednisolone acetate QID was prescribed for the left eye
After thorough discussion of the situation, surgery for IOFB removal was discussed and a joint decision was made to defer surgery for the time being
Prognosis and Future Directions
Data is currently equivocal on incidence of endophthalmitis based on time to IOFB removal
Outcomes can be largely variable depending on composition of IOFB (inert materials are less likely to cause inflammatory and oxidative injury compared to materials such as tin, iron, copper, and vegetable matter) and nature of injury (i.e. heat sterilized projectiles having less infectious burden than farm/wood injuries)
However, there are often other factors to consider when determining how urgently to take a patient to surgery for primary open globe closure +/- IOFB removal including hemodynamic stability of patient, presence of other life-threatening injuries, presence of active signs of infection in the eye, and availability of appropriate OR personnel and equipment
Certain factors have been shown to portend an overall worse prognosis including increased size and mass of IOFB, worse presenting visual acuity, the presence of a relative afferent pupillary defect (RAPD), hammering of metal on metal injury, vitreous hemorrhage, retinal detachment and hyphema
Other factors tend to produce better overall outcomes including older patient age, better presenting visual acuity, and normal lens at presentation
Prognosis of our patient was poor given that he was younger, already had an RAPD, retinal detachment, and worse presenting visual acuity
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