Retinal Physician

JAN-FEB 2017

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50 R E T I N A L P H Y S I C I A N . C O M | J A N U A R Y / F E B R U A R Y 2 0 1 7 R E T I N A L P H Y S I C I A N | J A N U A R Y / F E B R U A R Y 2 0 1 7 50 Echography is not routinely used in the presence of an open globe due to the risk of expulsion of intraocular con- tents. However, if performed gently, it is useful for localiza- tion and identification of IOFBs, especially those located by the ciliary body, which may be harder to identify on exam. 8 Plain x-ray is rarely used for IOFBs, but it is an option in cases where there is no access to a CT. Many IOFB materials are identifiable using x-ray, including metal, glass, slate, and polyvinyl chloride.6 Magnetic resonance imaging is usually avoided in open globes due to the concern for a ferromag- netic IOFB. PRE-OPERATIVE MANAGEMENT Initial Treatment All patients should be started on broad-spectrum systemic and frequent topical antibiotics. A Fox shield should be placed to protect the eye from further damage. Tetanus immuniza- tion history should be obtained, and tetanus toxoid or tetanus immune globulin should be administered if necessary. e patient should be placed on nil per os (NPO) status in prepa- ration for surgery. Any pain and nausea should be addressed, and the medical clearance for surgery should be obtained. Counseling After the presence of the IOFB is confirmed, the manage- ment plan should be discussed with the patient and family. Patients with better presenting vision are more likely to have better visual outcomes than those with worse presenting vision. 9,10 Nevertheless, even patients with good presenting vision need to be counseled on the unpredictable final vision due to potential vision-threatening sequelae (eg, retinal detachment or endophthalmitis). ere have been conflict- ing findings on the association between visual outcomes and IOFB features. 5 However, anterior chamber IOFBs are asso- ciated with better visual outcomes than posterior segment IOFBs. 5 e patient also should be informed that multiple surgeries could be needed to address all sequelae of the ocular trauma. Timing Generally, it is thought that an acute IOFB should be removed as soon as possible and that delaying surgery could result in higher rates of endophthalmitis and proliferative vit- reoretinopathy (PVR). However, a study by Colyer and col- leagues from the Walter Reed Army Medical Center showed that delayed IOFB removal (median time to IOFB removal was 21 days) with a combination of systemic and topical antibiotic coverage can result in similar visual outcomes as cases with prompt removal of IOFBs. However, those IOFBs could have potentially been sterilized by the heat from the exploding ordnance. 11 Treating patients with intravitreal broad-spectrum antibiotics as prophylaxis for endophthalmi- tis is another option for those who have a delay in surgical management (eg, due to other traumatic injuries). Anesthesia General anesthesia has traditionally been used for OGIs. However, in select cases of IOFBs local anesthesia with seda- tion might be an option. 12,13 SURGICAL MANAGEMENT Closure of the Entry Wound Closure of the entry wound is usually the first step of surgical management. While corneal wounds are easily identified, a conjunctival peritomy is needed to identify the full extent of most scleral wounds. Corneal wounds are often closed with 10-0 nylon suture and sclera can be closed with 9-0 or 8-0 nylon sutures. Buried sutures often improve the postopera- tive comfort of patients. Anterior Chamber IOFBs When removing an anterior chamber IOFB without involve- ment of the crystalline lens, care should be taken to protect the corneal endothelium and lens using viscoelastic. A para- centesis can be made in a location that allows for easy access to a foreign body. e viscoelastic cannula can be used to help orient the foreign body for easier removal. e paracen- tesis can then be enlarged to accommodate IOFB removal. Figure 4. Fundus photo demonstrating inferotemporal large metal intraocular foreign body embedded in the retina of the right eye with an associated retinal detachment. Figure 5. Coronal computed tomography scan demonstrat- ing temporal intraocular foreign body in the le eye. UPDATE ON THE MANAGEMENT OF INTRAOCULAR FOREIGN BODIES

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