|Year : 2015 | Volume
| Issue : 2 | Page : 60-62
Open globe injury with intraocular foreign body and traumatic cataract
Classified Specialist (Ophthalmology), Military Hospital, Jodhpur, Rajasthan, India
|Date of Web Publication||22-Mar-2016|
Dr. Santosh Kumar
Military Hospital, Jodhpur - 342 010, Rajasthan
Source of Support: None, Conflict of Interest: None
Penetrating ocular trauma is an important cause of visual loss in children and young adults. The fate of the traumatized eye depends on the treatment adopted, with early reporting and appropriate surgical management reducing the visual loss. With the use of modern diagnostic techniques, surgical approaches, and rehabilitation, many eyes can be salvaged with retention of vision. We report a patient who presented with sudden visual loss, corneal laceration, large foreign body, and who subsequently developed a traumatic cataract. Following a successful management, the patient's visual acuity improved from 1/60 at presentation to 6/9 at discharge.
Keywords: Intraocular foreign body, open globe injury, traumatic cataract
|How to cite this article:|
Kumar S. Open globe injury with intraocular foreign body and traumatic cataract. Afr J Trauma 2015;4:60-2
| Introduction|| |
Penetrating ocular trauma is an important cause of visual loss in children and young adults. The fate of the traumatized eye depends on the treatment adopted with early reporting and appropriate surgical management reducing the visual loss. It has been estimated that 90% of all ocular injuries are preventable.  With the use of modern diagnostic techniques, surgical approaches, and rehabilitation, many eyes can be salvaged with retention of vision.
| Case Report|| |
A 23-year-old male presented to the emergency department following a trauma, right eye, of about 4 h duration. The patient was working on a heavy military vehicle, and some metallic part of the vehicle hit his right eye. This was followed by severe pain, watering, sudden loss of vision, and difficulty in opening the affected eye. The patient reported to the local primary health center wherein a provisional diagnosis of severe injury, right eye, with presumably a metallic foreign body was made. He received injection Tetanus Toxoid and stat dose of injection cefotaxime 1 g. The patient was transferred urgently to our eye center. On examination, the visual acuity (VA) in the right eye was 1/60, and there was associated corneal laceration of about 4 mm in length in paracentral part at 2'O clock with embedded metallic foreign body whose outer end was seen at the corneal surface. The foreign body had injured other intraocular structures including iris and lens. There was also associated hyphema and shallow anterior chamber (AC). The left eye was essentially normal with VA of 6/6 and intraocular pressure of 16 mmHg as measured with a noncontact tonometer.
The patient underwent immediate corneal repair along with the removal of large foreign body under general anesthesia. The foreign body measured 7 mm in length [Figure 1]. The AC was reformed with air through a side port entry [Figure 2]. Intraoperatively, the patient also had immature traumatic cataract whose extraction was deferred to allow it to mature and more importantly for ocular inflammation to subside [Figure 3]. The specimen of the metallic intraocular foreign body was sent for microscopy, culture/sensitivity, which was later reported as sterile.
Postoperatively, the patient was treated with intravenous cefotaxime 1 g 12 hourly for the next 5 days, along with tablet prednisolone 50 mg orally daily, on a tapering basis for the next 4 weeks. Furthermore, the patient had topical 1% prednisolone 2 hourly, 0.5% moxifloxacin 6 hourly, 2% homatropine 8 hourly, and 0.5% timolol 12 hourly. Topical timolol and homatropine were given for 1 week, whereas topical prednisolone and moxifloxacin were given for 4 weeks in tapering doses.
After 4 weeks, when ocular inflammation stabilized, the patient had cataract surgery. Preoperatively, ultrasonography (USG) B-scan was done to rule out any remaining foreign body and any retinal pathology. The USG B-scan was essentially normal. The patient underwent phacoemulsification with hydrophobic acrylic foldable intraocular lens (IOL) implantation. Postoperatively, the patient was treated with topical 1% prednisolone 2 hourly along with 0.5% moxifloxacin 6 hourly, which was tapered over a period of 4 weeks. The patient was reviewed weekly and at the end of 4 weeks VA was 6/18 which improved to 6/9 with refraction of −0.75/−1.5 cyl × 110° by spectacle correction [Figure 4].
|Figure 4: Follow-up at 4 weeks postcataract surgery with posterior chamber intraocular lens|
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| Discussion|| |
Ocular trauma is a common cause of monocular blindness and visual impairment worldwide with about 1.6 million people being bilaterally blind and a further 19 million suffering from monocular blindness.  It is more commonly seen in males (male to female ratio 4:1) and at a much younger age (average age, 36 years) than in females (average age, 73 years).  The cornea and corneoscleral regions are the most common sites of injury due to the greater exposure of these structures to impact.  The most common causes of ocular injuries are either work-related or chance events. 
Ocular trauma can cause cataracts.  The methods used to evaluate the visual outcome in eyes managed for traumatic cataracts, and senile cataracts are similar, but the damage to other ocular tissues due to trauma may compromise the visual gain in eyes operated on for traumatic cataracts. Hence, the success rates may differ between the eyes with these two types of cataracts.
In our case, an intraocular foreign body was present as up to 40% of eyes with open-globe injuries are known to be associated with at least one foreign body.  In these cases, early primary surgical repair under general anesthesia is preferred,  and same was followed in our case. Postoperatively, the patient was managed with prophylactic systemic antibiotics and steroids in high doses to prevent endophthalmitis and to control ocular inflammation, respectively. , In a case of ocular injury, ocular inflammation needs to be controlled at the early stage to prevent irreversible damage to ocular tissue and loss of vision. Systemic steroids were, hence, preferred over nonsteroidal anti-inflammatory drug (NSAID) due to their better and faster anti-inflammatory effects as compared to NSAID. The antifungal treatment was not given, as the fungal pathogens were not suspected since it was a metallic foreign body and not a vegetative one. Furthermore, the report of microscopy and culture/sensitivity was sterile. The management of traumatic cataract after a gap of 4 weeks was to stabilize the internal milieu, which led to an excellent visual recovery. The VA of the patient improved from 6/18 to 6/9 with a refraction of − 0.75/−1.5 cyl × 100° spectacle correction. The residual refractive error could be explained by corneal astigmatism caused due to corneal repair and possibly inadequate IOL power. We were able to successfully manage our case because the timely operative intervention was done, and all possible precautions were taken to prevent any probable complications.
| Conclusion|| |
Penetrating ocular injury includes a challenge to salvage useful vision in injured eye. Prevention, early presentation, and proper management help to save vision and early rehabilitation of the patient. In this particular case, the injury occurred at a remote place far from our hospital. The importance of medical and paramedical staff at primary healthcare center cannot be ignored as they were the first to diagnose the condition correctly and made immediate referral to our center without any delay. They also ensured that the patient was kept nil orally so as to allow early surgical intervention. This shows the importance of an early evacuation in all these cases, which is of paramount importance in ensuring a successful outcome.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]