Ocular trauma is a leading cause of noncongenital monocular blindness in children, and it imposes a significant economic burden on society [
This was a retrospective study designed to assess the characteristics and surgical outcomes of posterior segment IOFB injuries in children and possible prognostic factors for visual outcome. The posterior segment is the back two-thirds of the eye that includes the vitreous, retina, choroid, and optic nerve. Inclusion criteria were consecutive patients aged less than 16 years who were admitted to the Eye, Ear, Nose and Throat Hospital between January 2014 and December 2017 for posterior segment IOFB injuries. Exclusion criteria were patients older than 16 years or patients with only anterior segment or intraorbital foreign bodies. Patients with suspected IOFB preoperatively were also excluded with no final evidence of IOFB after imaging test or surgical treatment. The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Ethics Committee of the Eye, Ear, Nose and Throat Hospital. Informed consent was obtained from each patient’s parents.
At presentation to the hospital, a detailed medical history was collected from each child and their guardians, and each child underwent a complete ophthalmologic examination including assessment of visual acuity (VA), pupillary reflex evaluation, slit-lamp examination, and fundus examination. The interval between IOFB injury and surgery, type of injury, number of IOFBs, IOFB type and size, entry site of the IOFB, concomitant ocular injuries, presence of endophthalmitis, IOFB extraction route, and details of vitrectomy were recorded. Computed tomography (CT) of the orbits without contrast was performed preoperatively to confirm and localize the IOFBs. Helical CT was performed through the orbits in three planes (axial, sagittal, and coronal) with slice thickness of 0.75 mm. If the primary wound entry had already been closed, B scan ultrasonography was also used to confirm and localize the IOFB and evaluate the vitreous and retina. Ultrasound biomicroscopy was used to evaluate the IOFBs if CT indicated the presence of an IOFB in the ciliary body. The International Society of Ocular Trauma Classification [
Postoperative follow-up visits were scheduled at 1, 7, and 14 days and 1, 2, 3, 6, 12, 24, and 36 months after surgery for each patient and included VA testing, intraocular pressure measurement, and a comprehensive ophthalmic examination. VA values obtained from the Snellen eye test were converted into the logarithm of the mean angle of resolution (logMAR) units for analysis. The VAs for hand motion, light perception, and no light perception were assigned logMAR values of 2.6, 3, and 4, respectively. Follow-up was scheduled after any additional surgeries.
The diagnosis of endophthalmitis was based on the clinical findings of presence of corneal edema, anterior chamber cells, hypopyon, and inflammation in the vitreous. The diagnosis of panophthalmitis was based on the ophthalmic examination findings of presence of corneal edema, hypopyon, severe vitritis, and edema of the eye walls, as well as an obvious elevation in white blood cell counts. Topical levofloxacin 0.5% and tobramycin 0.3% eye drops were applied preoperatively every 30 minutes to eyes with suspected infection. Intravitreal injections of ceftazidime (2.25 mg/0.1 ml) and vancomycin (1 mg/0.1 ml) were administered to eyes with endophthalmitis after the initial surgery to remove the IOFB. Intravenous ceftazidime (50 mg/kg twice daily) was administered for 3 days postoperatively to patients with endophthalmitis or panophthalmitis. The white blood cell count of patients with panophthalmitis was measured every other day until it decreased to within the normal range. The antibiotic therapy was adjusted accordingly when microorganisms were detected in cultures of vitreous samples or extracted IOFBs. Patients with no signs of infection did not receive intravitreal or systemic antibiotics. Topical prednisolone acetate 0.1% and levofloxacin 0.5% eye drops three times daily for 4 weeks postoperatively were prescribed for all eyes.
All patients with IOFBs received surgical treatment within 1 day after admission to our hospital. Conventional three-port 20-gauge pars plana vitrectomy (PPV) was performed. An undiluted vitreous sample from eyes with suspected endophthalmitis was obtained at initiation of PPV for Gram staining and culture. Media opacities including hyphema, hypopyon, or traumatic cataract were removed prior to performing core vitrectomy. If the IOFB was suspended in the vitreous gel, adhesions surrounding the IOFB were dissected around the perimeter, and the IOFB was then extracted via scleral or limbal incision. After removal of an intravitreal IOFB, artificial posterior vitreous detachment was performed. However, if there were significant signs of vitritis or retinitis, excision of the hyaloid face was performed with extreme caution or even deferred for subsequent surgery. If retinal impact sites were present, with or without the IOFBs embedded in the impact sites, vitreous-retina adhesion around these areas was eliminated thoroughly, and the area around the retinal impact sites was treated with laser photocoagulation before removal of the IOFB.
The extraction strategy for the IOFBs was determined preoperatively, based mainly on the size and composition of the IOFB. Ferromagnetic IOFBs were removed bimanually using an intraocular magnet and forceps. Nonferrous or organic IOFBs were removed using foreign body forceps, and heavier-than-water liquid was introduced if necessary to protect the macula. Where possible, smaller foreign bodies were removed after enlargement of the sclerotomy site. Large IOFBs were removed via a new limbal incision.
After extraction, the IOFB was sent for microbiological culture, the limbal incision or enlarged scleral incision was sutured, and a complete retinal examination using scleral depression was conducted. If rhegmatogenous retinal detachment (RRD) was present, PPV using perfluoropropane or silicone oil tamponade was performed. The decision to use gas or oil tamponade was made by the surgeon, based on issues including the severity of endophthalmitis and the number and location of retinal breaks. The postoperative face-down position could not be accomplished by the children and thus was not mandatory. Removal of the silicone oil was scheduled for 3 months after the primary vitrectomy. Aphakic eyes with a postoperative VA better than 20/200 received intraocular lens implantation at least 3 months after successful vitrectomy.
Evisceration was indicated in cases of panophthalmitis. The cornea was excised completely following peritomy, and the intraocular contents and IOFB were removed using an evisceration spoon. The IOFB was sent for microbiological culture to detect pathogens, and the contents of the eye were sent for histopathological examination. Any remaining pigment was removed by scrubbing with cotton-tipped applicators soaked in 95% alcohol. Irrigation was then performed to remove the residual pigment and alcohol. A scleral shell was envelope-sutured, Tenon’s capsule was closed, and the conjunctiva was sutured with burying of the knots. A conformer was then placed inside the eyelid. A hydroxyapatite implant was planned at least 3 months after the infection had subsided.
Statistical analysis was performed using SPSS for Macintosh (version 21, SPSS Inc., Chicago, IL, USA). Fisher’s exact test was used for comparisons of categorical variables. The preoperative and postoperative best-corrected visual acuity (BCVA) values were compared using the nonparametric Wilcoxon matched-pairs signed-rank test. A two-tailed
Eleven eyes in seven boys (63.6%) and 4 girls (36.4%; mean age 6.8 ± 3.0 years; range 2–12) were included in the study (Table
Demographic characteristics of subjects with posterior segment IOFBs.
Subject | Sex | Age (years) | Eye | Interval between accident and surgery (days) | Initial VA | Nature of IOFB | IOFB size (mm) | Location of IOFB | Distance of IOFB to limbus (mm) |
---|---|---|---|---|---|---|---|---|---|
1 | F | 2 | OS | 2 | NA | Pencil tip | 5∗1∗1 | Ciliary body | 5 |
2 | M | 10 | OD | 0.5 | 20/200 | Wood from playground | 2∗2∗1.5 | Vitreous | 14 |
3 | F | 5 | OD | 1 | HM | Pencil tip | 2∗2∗1 | Retina | 16 |
4 | M | 9 | OD | 5 | 20/63 | Iron from playground | 4∗2∗2 | Retina | 13 |
5 | M | 6 | OD | 50 | 20/20 | Pencil tip | 3∗2∗1 | Ciliary body | 6 |
6 | M | 6 | OS | 1 | NLP | Stone in mud, from exploding fireworks | 6∗6∗4 | Vitreous | 15 |
7 | M | 12 | OD | 0.5 | 20/160 | Iron from playground | 5∗3∗3 | Retina | 16 |
8 | F | 6 | OD | 1 | 20/200 | Pencil tip | 2∗2∗1 | Vitreous | 16 |
9 | M | 8 | OS | 2 | LP | Plastic pieces of fireworks | 3∗2∗1, 6∗5∗1 | Anterior chamber, vitreous | 16 |
10 | F | 8 | OS | 5 | HM | Iron from hairpin | 4∗2∗2 | Vitreous | 13 |
11 | M | 3 | OD | 6 | NA | Iron from playground | 3∗1∗1 | Vitreous | 5 |
IOFB: intraocular foreign body; VA: visual acuity; OS: left eye; OD: right eye; NA: not available; HM: hand motion; NLP: no light perception; LP: light perception.
The median interval from injury to IOFB removal was 2 days (mean 6.7, range 0.5–50) This was irrespective of the presence of vitritis (2.1 ± 1.7 days in 5 eyes with endophthalmitis or panophthalmitis versus 10.6 ± 19.4 days in 6 eyes with no signs of infection;
All injuries were type C IOFB according to the International Society of Ocular Trauma classification system and the OTS score was evaluated for each patient (Table
Ocular injuries and OTS in subjects with posterior segment IOFBs.
Subject | Wound entrance | Length of wound (mm) | Anterior chamber and iris | Cataract | Vitreous opacity | Retina | OTS |
---|---|---|---|---|---|---|---|
1 | Cornea | 1 | — | Y | Endophthalmitis | RRDa | NA |
2 | Cornea | 3 | — | Y | Endophthalmitis | — | 3 |
3 | Cornea | 5 | Iris incarceration | Y | Vitreous hemorrhage | Retinal hole | 3 |
4 | Cornea | 2 | Iris penetration | Y | — | Retinal hole | 4 |
5 | Sclera | NA | — | — | — | — | 5 |
6 | Cornea | 10 | Hypopyon, iris dialysis | Y | Panophthalmitis | — | 1 |
7 | Sclera | 3 | — | Y | Vitreous hemorrhage | Retinal hole | 4 |
8 | Cornea | 5.5 | Iris incarceration | Y | — | Retinal hole | 4 |
9 | Cornea/sclera | 7 | Iris incarceration | Y | Endophthalmitis | — | 1 |
10 | Cornea | 2 | Hypopyon | Y | Endophthalmitis | RRD† | 1 |
11 | Cornea | 3 | — | Y | — | — | NA |
IOFB: intraocular foreign body; OTS: ocular trauma score; RRD: rhegmatogenous retinal detachment; NA: not available. †Injury during IOFB removal.
The OTS was available in 9 children. As shown in Table
Comparison of the ocular trauma score (OTS) predictions with the actual visual outcomes.
Actual visual outcomes | |||
---|---|---|---|
Vision survival | No vision | ||
OTS predictions | Vision survival (LP or better) | 6 | 0 |
No vision (NLP or enucleation) | 2 | 1 | |
Minimal to severe vision loss | Profound vision loss | ||
Minimal to severe vision loss (20/20∼3/60) | 6 | 0 | |
Profound vision loss (worse than 3/60) | 1 | 2 |
OTS: ocular trauma score; LP: light perception; NLP: no light perception.
The IOFBs were located in the retina in three eyes (27.3%), ciliary body in two eyes (18.2%), and vitreous in six eyes (54.5%). The composition of the IOFB was iron in four eyes, graphite in four eyes, wood in one eye, stone in one eye, and plastic (two pieces) from a fireworks explosion in one eye. In the eye with panophthalmitis, the IOFB was a stone thrown up with mud by exploding fireworks.
The IOFBs were removed via the scleral incision in PPV in 8 (72.3%) of 11 eyes, via limbal incision after extraction to the anterior chamber in 2 eyes (18.2%), and by evisceration in 1 eye (9.1%). A single IOFB was present in 10 eyes (90.9%) and multiple IOFBs in 1 eye (9.1%). The size of the IOFB varied from 2 × 2 × 1 mm to 6 × 6 × 4 mm, and the mean length was 3.8 ± 1.5 mm.
As shown in Table
Surgeries, complications, and follow-up of subjects with posterior segment IOFBs.
Subject | Primary surgery | IOFB extraction route | Additional surgery | Complications | Final VA | Follow-up (months) |
---|---|---|---|---|---|---|
1 | LC, PPV, SO | Planar | Retinotomy, SO (3 times) | Glaucoma, RRD | LP | 42 |
2 | LC, PPV | Planar | IOL implantation | — | 20/25 | 35 |
3 | LC, PPV, C3F8, | Planar | IOL implantation | — | 20/32 | 26 |
4 | LC, PPV, C3F8, | Planar | IOL implantation | IOP increase | 20/100 | 22 |
5 | Anterior PPV | Planar | — | — | 20/20 | 22 |
6 | Evisceration | Evisceration | Hydroxyapatite implantation | — | NLP | 22 |
7 | LC, PPV, C3F8, | Planar | RGP | IOP increase | 20/100 | 20 |
8 | LC, PPV | Planar | IOL implantation | — | 20/32 | 13 |
9 | LC, PPV | Limbal | RGP | — | 20/40 | 9 |
10 | LC, PPV | Limbal | SO removal | IOP increase | HM | 8 |
11 | Anterior PPV | Planar | — | — | NA | 3 |
LC: lensectomy; PPV: pars planar vitrectomy; SO: silicone oil tamponade; RRD: rhegmatogenous retinal detachment; VA: visual acuity; LP: light perception; NLP: no light perception; HM: hand motion; IOL: intraocular lens; IOP: intraocular pressure; C3F8: perfluoropropane; RGP: rigid gas-permeable lens; NA: not available.
The mean follow-up period was 20.2 (range 3–42) months. Preoperative and final VA data were available for 9 and 10 eyes, respectively (Tables
Cultures of vitreous samples or extracted IOFBs were positive in only two eyes (one for
The predictors of the final VA are summarized in Table
Predictors of final visual outcomes in subjects with posterior segment IOFBs.
Variable | VA ≥ 20/200 | VA < 20/200 |
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Endophthalmitis or panophthalmitis | 2 | 3 | 0.1667 |
None | 5 | 0 | — |
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Presence | 0 | 3 | 0.0083 |
Absence | 7 | 0 | — |
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Positive | 1 | 1 | 1.000 |
Negative | 6 | 2 | — |
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Vitreous | 3 | 2 | 1.000 |
Retina or ciliary body | 4 | 1 | — |
VA: visual acuity; RRD: rhegmatogenous retinal detachment; IOFB: intraocular foreign body.
IOFBs are seen most often in adults and most frequently occur at work sites [
We found that IOFB injuries in children occurred most commonly in the playground, where six children were injured by IOFBs composed of iron, wood, plastic, or stone. One child developed panophthalmitis 1 day after he lit a firework buried in a pile of stones in the playground, an injury that could have been prevented by parental supervision or by wearing protective glasses. To our surprise, our study revealed school as the next most common site for IOFB injury. Four eyes of four children were penetrated by sharp pencils, and the graphite lead remained in the eye after the pencil was removed, which is rarely seen in adults with IOFB. In fact, ocular injuries caused by pencils are not rare in children and include penetration of the eye wall, traumatic cataract, endophthalmitis, and pencil lead retained in the anterior chamber [
IOFBs were composed of plastic, wood, or pencil lead in six eyes in our study. This supports the suggestion that 50% of IOFBs are not detectable on plain radiographs and is in agreement with the recommendations of other reports that thin-slice CT of the orbits might be preferable [
The IOFB was pencil lead in four of the present patients, and was located in the ciliary body in one eye, retina in one eye, and vitreous in one eye. It is debatable whether an IOFB of graphite pencil lead should be removed. Its main component, graphite, can remain inert in the eye for long periods [
During the follow-up period, the VA improved in 5 (of 9) children, and 7 (of 9) children had a final VA better than 20/100. In our study, the OTS sensitivity and specificity to predict visual outcomes was high, which may provide prognostic information in children with open globe injuries, consistent with other studies [
The presence of RRD during surgery was a predictor of VA. RRD can be induced during vitrectomy, especially in the presence of severe vitritis and retinitis [
The limitations of this study included the relatively small sample size and lack of a control group, preventing the performance of some statistical analyses and obtaining statistically significant differences. Thus, more studies with larger sample sizes are warranted.
In conclusion, the clinical features of pediatric posterior segment IOFBs were unique, including the IOFB composition and the setting where the injury occurred. The visual prognosis was favorable in this case series, and a poor visual outcome was associated with retinal detachment during removal of IOFB.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no conflicts of interest.
Ting Zhang and Hong Zhuang contributed equally to this work.
This research was supported by the National Natural Science Foundation of China (81700861) and the grant from Science and Technology Commission of Shanghai Municipality (16411953700).