Retinal Physician

JAN-FEB 2017

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52 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 52 to elevate the IOFB anteriorly enough to use coaxial viewing. After the IOFB is removed, a thorough peripheral reti- nal exam should be performed to look for any tears. If the IOFB was embedded in the retina, laser demarcation of the defect may be required and may be performed before or after removal of the foreign body. Any tears, breaks, or retinal detachments should be treated. If tamponade is required, air, gas, or silicone oil may all be used safely. Scleral Buckle Placement e role of a scleral buckle placement in patients with pos- terior segment IOFBs is unclear. A small study found a 24% reduced risk of retinal detachment in posterior segment IOFB patients treated with a scleral buckle at the time of IOFB removal surgery. However, this difference was not sta- tistically significant. 16 POSTOPERATIVE CONSIDERATIONS Endophthalmitis If the patient is noted to have endophthalmitis before or dur- ing the surgery, a vitreous and vitreous wash culture should be performed to identify the organism and obtain antibiotic sensitivity data. Broad-spectrum intravitreal antibiotics such as vancomycin and ceftazidime should be used. In cases with organic IOFBs, intravitreal antifungals can be used as well. ere are some data that suggest that silicone oil may be a more beneficial tamponade for cases with endophthalmi- tis. 16-18 Even in the absence of endophthalmitis at the time of surgery, prophylactic intraocular injections of broad-spec- trum antibiotics should be considered since they have been shown to decrease the rate of traumatic endophthalmitis. 19 Retinal Detachment Patients treated with IOFB removal should be followed closely in the postoperative period for retinal detachment and PVR. Trauma is a risk factor for the development of PVR. 20 In a study of metallic IOFBs, approximately 27% of patients required additional retinal detachment surgery. 10 Cataract Cataract formation is common after trauma. One study of metallic IOFBs found that 14% of patients who did not have cataract removal at the initial surgery required cataract extraction during a mean follow-up period of 180 days. 10 It is important to assess for factors that may direct the surgeon toward a pars plana approach for cataract removal, including violation of the capsule and zonular dialysis. Other Other common posttraumatic sequelae that need to be mon- itored include high or low intraocular pressure, vitreous hem- orrhage, and pain. 10 Patients with poor vision in the affected eye should be fitted for polycarbonate lenses to protect the better-seeing eye. Conclusion IOFB cases are complex and require a careful history, physical exam, imaging, and presurgical planning. A variety of unique instrumentation and techniques can be used to remove the IOFBs. Patients need to be closely followed for potential post-traumatic complications, including retinal detachment and cataracts. Counseling patients about the uncertain visual prognosis and potential need for additional surgery is crucial. RP REFERENCES 1. Parver LM, Dannenberg AL, Blacklow B, Fowler CJ, Brechner RJ, Tielsch JM. Characteristics and causes of penetrating eye injuries reported to the National Eye Trauma System Registry, 1985-91. Public Health Rep. 1993;108:625-632. 2. Loporchio D, Mukkamala L, Gorukanti K, Zarbin M, Langer P, Bhagat N. Intraocu- lar foreign bodies: a review. Surv Ophthalmol. 2016;61:582-596. 3. Kuhn F, Morris R. Posterior segment intraocular foreign bodies: management in the vitrectomy era. Ophthalmology. 2000;107:821-822. 4. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraor- bital foreign bodies. Ophthalmology. 2002;109:494-500. 5. 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Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML. Low rate of endophthalmitis in a large series of open globe injuries. Am J Ophthalmol. 2009;147:601-608. 16. Azad RV, Kumar N, Sharma YR, Vohra R. Role of prophylactic scleral buckling in the management of retained intraocular foreign bodies. Clin Exp Ophthalmol. 2004;32:58-61. 17. Bali E, Huyghe PH, Caspers L, Libert J. Vitrectomy and silicone oil in the treat- ment of acute endophthalmitis. Preliminary results. Bull Soc Belge Ophtalmol. 2003;288:9-18. 18. Ozdamar A, Aras C, Ozturk R, Akin E, Karacorlu M, Ercikan C. In vitro antimi- crobial activity of silicone oil against endophthalmitis-causing agents. Retina. 1999;19:122-126. 19. Soheilian M, Rafati N, Mohebbi MR, et al. Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection, report 2. Arch Ophthalmol. 2007;125:460-465. 20. Cardillo JA, Stout JT, LaBree L, et al. 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