Surgical Technique
Edited by George A. Williams
A Simple Alternative Method for Extracting Multiple Intraocular Foreign Bodies
P
The 13 eyes had the following similar features: corneal entry wound, traumatic cataract, multiple IOFBs, and no evidence of intraocular infection. Data on age, activity at the time of injury, clinical features, visual acuity, surgical techniques, and final visual acuity assessment were recorded and analyzed. Written consent was obtained from all participants. Thirteen eyes underwent combined surgery; 5 of them received corneal transplants, lensectomy, and pars plana vitrectomy, and the other eight eyes underwent lensectomy and pars plana vitrectomy. All study procedures adhered to the recommendations of the Declaration of Helsinki. Institutional review board/ethics committee ruled that approval was not required for this study.
enetrating injuries of the globe are a major cause of visual loss worldwide, and are often associated with intraocular foreign bodies (IOFBs). The deficiency of adequate occupational health and safety training results in a high incidence of IOFB injuries in China, and these injuries pose significant threats of the loss of vision.1,2 Prompt and proper interventions, such as surgical repair of penetrating injuries and extraction of IOFBs, are crucial for the recovery of useful visual function but pose significant challenges to ophthalmologists.3 Clinically, IOFBs can be generally divided into magnetic or nonmagnetic materials. Magnetic IOFBs can be extracted by a strong magnet used intravitreally or through an indirect external extraction method.4 Nonmagnetic IOFBs may require vitrectomies or the use of intravitreal forceps.5–7 These methods are suitable for a single IOFB or magnetic IOFBs; however, the application of these methods for multiple IOFBs, which often occur after severe injuries like those because of explosions, is limited. Herein, we present our methods and experiences of handling multiple IOFBs using a simple and novel technique.
Surgical Technique Primary closure was already achieved following injury before our surgery. Thirteen eyes had lensectomy performed after a standard three-port pars plana vitrectomy, and if possible, taking care to leave behind an adequate lens capsule for an intraocular lens. A thorough vitrectomy was completed with scleral depression to release all vitreous attachments adherent to the IOFBs. Multiple IOFBs were freed from the vitreous. A 20-gauge intravenous catheter (hollow tube without a needle) was inserted into the vitreous through the pars plana sclerotomies, and a finger was placed on the external joint, which was not to open to the atmosphere (Figure 1). The catheter was handheld and directed toward the IOFBs, then removed the finger which was placed on the external joint, and the IOFBs were sucked up one by one by the catheter at the drop between intraocular pressure and atmospheric pressure. For larger IOFBs, the tip of the catheter was cut into three parts to splay and enlarge the diameter of the tip. The smaller IOFBs were removed first, then the larger IOFBs were removed. The catheter was inserted into the vitreous and the tip was divided into three parts with the help of an optical fiber that was guided by the other hand. Once the IOFB had been sucked up into the catheter, the optical fiber was used
Patients and Methods A series of 13 operations were performed between January 1, 2003 and December 1, 2012 on 11 patients with multiple IOFBs because of explosion injuries. These patients were retrospectively reviewed (Table 1). All operations were performed by the same surgeon. From the Department of Ophthalmology, Medical School of People’s Liberation Army, General Hospital of People’s Liberation Army, Beijing, China. None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.retinajournal.com). Reprint requests: Yifei Huang, MD, PhD, Department of Ophthalmology, General hospital of People’s Liberation Army, No. 28 Fuxing Road, Haidian District, Beijing, China; e-mail: [email protected]
405
406
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2014 VOLUME 34 NUMBER 2 Table 1. Ocular Characteristics, Surgical Manipulations, and Visual Outcomes of Traumatized Eyes
Patient No.
Gender
Age, years
Unilateral Versus Bilateral
1
M
34
Bilateral
2 3 4
M F M
27 22 51
Unilateral Unilateral Bilateral
5 6 7 8 9 10 11
M M M M M M M
29 47 41 33 43 21 23
Unilateral Unilateral Unilateral Unilateral Unilateral Unilateral Unilateral
No. in and out Sclerotomy Manipulations for Extracting Multiple IOFBs Initial BCVA HM (OD) HM (OS) CF 1 foot LP LP (OD) CF 1 foot (OS) CF 0.2 foot HM 20/600 HM LP CF 1 foot HM
2 (OD) 2 (OS) 2 2 2 (OD) 1 (OS)
No. IOFBs
Final BCVA
13 (OD) CF 1 foot (OD) 6 (OS) 20/100 (OS) 9 20/60 11 20/320 10 (OD) HM (OD) 5 (OS) 20/200 (OS)
2 2 1 2 3 1 2
7 10 6 11 14 5 9
20/200 CF 1 foot 20/400 CF 0.5 foot CF 1 foot 20/160 20/500
BCVA, best-corrected visual acuity; CF, counting fingers; F, female; HM, hand motion; LP; light perception; M, male; OD, right eye; OS, left eye.
to push the IOFB deeper into the catheter to ensure its removal. Because of the elasticity of the sclerotomy, it was easy to pull the catheter out without enlarging the pars plana sclerotomy (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A206).
Results The details of the gender and age of the patients involved in this study, numbers of in and out sclerotomy manipulations to remove the IOFBs per eye, the numbers of IOFBs per eye, and the final best-correct visual acuity at 3 m postoperation are given in Table 1. The mean age at the time of injury was 33.7 ± 10.5 years. There were 10 men (90.9%) and 1 woman (9.10%). Of the activities at the time of injury, mining was the most common activity and accounted for 54.5% of the injuries, setting off firecrackers accounted for 36.4%, and tire inflation accounted for 9.10%. The number of in and out sclerotomy manipulation for IOFB extraction was 1.8 ± 0.5 and the number of IOFBs was
Fig. 1. A. A 20-gauge hollow IV catheter without needle. Black arrow points to the external joint that can be closed with a finger to generate a pressure drop between the atmosphere and intraocular pressure. B. The tip of the catheter was cut into three parts in the direction perpendicular to the horizontal plane of the tip (sketch).
8.9 ± 2.9. The nature of the IOFBs was stone (76.9%), concrete (15.4%), and metal (7.70%). The exact nature of the stone and metal involved was uncertain. All of the final best-corrected visual acuities of the 11 patients were better than their initial acuity assessments. All IOFBs were successfully removed during the surgeries in all cases without enlarging the sclerotomy. There was no slippage during the extraction of the IOFBs with the catheter. No major intraoperative or postoperative complications were encountered, and intraocular manipulations were easily performed.
Discussion Intraocular foreign bodies generally result in a poor prognosis because IOFBs may transport bacteria into the eyeball, which can lead to endophthalmitis, or the IOFB itself may cause ocular siderosis and chalcosis because of metal properties.8–10 The management of posterior segment IOFBs requires vitrectomy combined with extraction of the
407
SURGICAL TECHNIQUE
foreign body, either by an intravitreal magnet or by other equipment.11 There are a number of techniques and types of equipment that can be used for IOFB extraction such as different kinds of foreign body forceps. All the methods have their limits. A magnet is suitable for magnetic IOFBs, and the other equipments are suitable for a single IOFB but not for multiple IOFBs because they can only remove, at most, two IOFBs at a time. Multiple IOFBs are common, especially after severe injuries that are because of, for example, explosions. Our team previously reported that, of 1421 eyes with IOFB in China, multiple IOFBs were present in 318 cases (22.38%).1 Our catheter technique is suitable for multiple IOFBs; furthermore, this technique is simple and can reduce the numbers of in and out sclerotomy manipulations for extracting multiple IOFBs. The principle of this catheter technique is the same as that of the Charles fluted needle that is, both take the advantage of the drop of the pressure. When the Charles fluted needle is introduced into the vitreous cavity through a pars plana sclerotomy, the closure of the exit port by the surgeon’s finger prevents the flow of fluid or gas from the eye. The removal of the finger allows egress of the fluid along the needle and through the exit hole, which is provided by the infusion of gas or fluid to maintain the intraocular pressure above atmospheric presssure.12 With the same principle, the catheter could extract multiple IOFBs at the same time. We also found out that this method was efficient and widely applicable for the removal of multiple IOFBs with a range of diameters that were larger than that of the vitreous cutter probe. Even if the sizes of the IOFB are bigger than the catheter, this method can still be used after the enlargement of the tip of the catheter. Furthermore, the drop between intraocular pressure and atmospheric pressure ensured that the IOFBs did not easily drop out of the catheter and avoided damage to the retina. Because of the smooth surface of the catheter and the elasticity of the tissue around the sclerotomy, it was easy to pull the catheter out without enlarging the incision. The ideal instrument for IOFBs removal must be able to grasp and extract foreign bodies in a controlled and safe manner when the IOFBs are of diverse size, shape, and properties.13
The pen type or butterfly type catheter with a long and broad needle hub is easy to grip and control, and can prevent any instability during extraction. Gently tapered catheter tips can provide smooth insertion into the sclerotomy. In conclusion, we believe that our method is a useful choice for the extraction of multiple IOFBs. QUN WANG, MD YIFEI HUANG, MD, PHD LIQIANG WANG, MD, PHD YI YAO, MD References 1. Zhang Y, Zhang MN, Jiang CH, et al. Intraocular foreign bodies in China: clinical characteristics, prognostic factors, and visual outcomes in 1,421 eyes. Am J Ophthalmol 2011; 152:66–73. 2. Yeh S, Colyer MH, Weichel ED. Current trends in the management of intraocular foreign bodies. Curr Opin Ophthalmol 2008;19:225–233. 3. Jonas JB, Knorr HL, Budde WM. Prognostic factors in ocular injuries caused by intraocular or retrobulbar foreign bodies. Ophthalmology 2000;107:823–828. 4. Chow DR, Garretson BR, Kuczynski B, et al. External versus internal approach to the removal of metallic intraocular foreign bodies. Retina 2000;20:364–369. 5. Camacho H, Mejía LF. Extraction of intraocular foreign bodies by pars plana vitrectomy. Ophthalmologica 1991;202:173– 179. 6. Hickingbotham D, Parel JM, Machemer R. Diamond-coated all-purpose foreign-body forceps. Am J Ophthalmol 1981;91: 267–268. 7. Soheilian M, Abolhasani A, Ahmadieh H, et al. Management of magnetic intravitreal foreign bodies in 71 eyes. Ophthalmic Surg Lasers Imaging 2004;35:372–378. 8. Ahmed Y, Schimel AM, Pathengay A, et al. Endophthalmitis following open-globe injuries. Eye (Lond) 2012;26:212–217. 9. Archer DB. Dermot Pierse lecture. Injuries of the posterior segment of eye. Trans Ophthalmol Soc UK 1985;104:597– 615. 10. Mester V, Kuhn F. Ferrous intraocular foreign bodies retained in the posterior segment: management options and results. Int Ophthalmol 1998;22:355–362. 11. Joondeph HC, Joondeph BC, Mulcahy T. Comparison of three permanent intraocular magnets. Retina 1992;12:270–272. 12. McLeod D, Leaver P. Modified Charles flute needle. Br J Ophthalmol 1981;65:69. 13. Eckardt C, Eckert T, Eckardt U. Memory snare for extraction of intraocular foreign bodies. Retina 2006;26:845–847.
Edited by George A. Williams
A Simple Alternative Method for Extracting Multiple Intraocular Foreign Bodies
P
The 13 eyes had the following similar features: corneal entry wound, traumatic cataract, multiple IOFBs, and no evidence of intraocular infection. Data on age, activity at the time of injury, clinical features, visual acuity, surgical techniques, and final visual acuity assessment were recorded and analyzed. Written consent was obtained from all participants. Thirteen eyes underwent combined surgery; 5 of them received corneal transplants, lensectomy, and pars plana vitrectomy, and the other eight eyes underwent lensectomy and pars plana vitrectomy. All study procedures adhered to the recommendations of the Declaration of Helsinki. Institutional review board/ethics committee ruled that approval was not required for this study.
enetrating injuries of the globe are a major cause of visual loss worldwide, and are often associated with intraocular foreign bodies (IOFBs). The deficiency of adequate occupational health and safety training results in a high incidence of IOFB injuries in China, and these injuries pose significant threats of the loss of vision.1,2 Prompt and proper interventions, such as surgical repair of penetrating injuries and extraction of IOFBs, are crucial for the recovery of useful visual function but pose significant challenges to ophthalmologists.3 Clinically, IOFBs can be generally divided into magnetic or nonmagnetic materials. Magnetic IOFBs can be extracted by a strong magnet used intravitreally or through an indirect external extraction method.4 Nonmagnetic IOFBs may require vitrectomies or the use of intravitreal forceps.5–7 These methods are suitable for a single IOFB or magnetic IOFBs; however, the application of these methods for multiple IOFBs, which often occur after severe injuries like those because of explosions, is limited. Herein, we present our methods and experiences of handling multiple IOFBs using a simple and novel technique.
Surgical Technique Primary closure was already achieved following injury before our surgery. Thirteen eyes had lensectomy performed after a standard three-port pars plana vitrectomy, and if possible, taking care to leave behind an adequate lens capsule for an intraocular lens. A thorough vitrectomy was completed with scleral depression to release all vitreous attachments adherent to the IOFBs. Multiple IOFBs were freed from the vitreous. A 20-gauge intravenous catheter (hollow tube without a needle) was inserted into the vitreous through the pars plana sclerotomies, and a finger was placed on the external joint, which was not to open to the atmosphere (Figure 1). The catheter was handheld and directed toward the IOFBs, then removed the finger which was placed on the external joint, and the IOFBs were sucked up one by one by the catheter at the drop between intraocular pressure and atmospheric pressure. For larger IOFBs, the tip of the catheter was cut into three parts to splay and enlarge the diameter of the tip. The smaller IOFBs were removed first, then the larger IOFBs were removed. The catheter was inserted into the vitreous and the tip was divided into three parts with the help of an optical fiber that was guided by the other hand. Once the IOFB had been sucked up into the catheter, the optical fiber was used
Patients and Methods A series of 13 operations were performed between January 1, 2003 and December 1, 2012 on 11 patients with multiple IOFBs because of explosion injuries. These patients were retrospectively reviewed (Table 1). All operations were performed by the same surgeon. From the Department of Ophthalmology, Medical School of People’s Liberation Army, General Hospital of People’s Liberation Army, Beijing, China. None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.retinajournal.com). Reprint requests: Yifei Huang, MD, PhD, Department of Ophthalmology, General hospital of People’s Liberation Army, No. 28 Fuxing Road, Haidian District, Beijing, China; e-mail: [email protected]
405
406
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2014 VOLUME 34 NUMBER 2 Table 1. Ocular Characteristics, Surgical Manipulations, and Visual Outcomes of Traumatized Eyes
Patient No.
Gender
Age, years
Unilateral Versus Bilateral
1
M
34
Bilateral
2 3 4
M F M
27 22 51
Unilateral Unilateral Bilateral
5 6 7 8 9 10 11
M M M M M M M
29 47 41 33 43 21 23
Unilateral Unilateral Unilateral Unilateral Unilateral Unilateral Unilateral
No. in and out Sclerotomy Manipulations for Extracting Multiple IOFBs Initial BCVA HM (OD) HM (OS) CF 1 foot LP LP (OD) CF 1 foot (OS) CF 0.2 foot HM 20/600 HM LP CF 1 foot HM
2 (OD) 2 (OS) 2 2 2 (OD) 1 (OS)
No. IOFBs
Final BCVA
13 (OD) CF 1 foot (OD) 6 (OS) 20/100 (OS) 9 20/60 11 20/320 10 (OD) HM (OD) 5 (OS) 20/200 (OS)
2 2 1 2 3 1 2
7 10 6 11 14 5 9
20/200 CF 1 foot 20/400 CF 0.5 foot CF 1 foot 20/160 20/500
BCVA, best-corrected visual acuity; CF, counting fingers; F, female; HM, hand motion; LP; light perception; M, male; OD, right eye; OS, left eye.
to push the IOFB deeper into the catheter to ensure its removal. Because of the elasticity of the sclerotomy, it was easy to pull the catheter out without enlarging the pars plana sclerotomy (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A206).
Results The details of the gender and age of the patients involved in this study, numbers of in and out sclerotomy manipulations to remove the IOFBs per eye, the numbers of IOFBs per eye, and the final best-correct visual acuity at 3 m postoperation are given in Table 1. The mean age at the time of injury was 33.7 ± 10.5 years. There were 10 men (90.9%) and 1 woman (9.10%). Of the activities at the time of injury, mining was the most common activity and accounted for 54.5% of the injuries, setting off firecrackers accounted for 36.4%, and tire inflation accounted for 9.10%. The number of in and out sclerotomy manipulation for IOFB extraction was 1.8 ± 0.5 and the number of IOFBs was
Fig. 1. A. A 20-gauge hollow IV catheter without needle. Black arrow points to the external joint that can be closed with a finger to generate a pressure drop between the atmosphere and intraocular pressure. B. The tip of the catheter was cut into three parts in the direction perpendicular to the horizontal plane of the tip (sketch).
8.9 ± 2.9. The nature of the IOFBs was stone (76.9%), concrete (15.4%), and metal (7.70%). The exact nature of the stone and metal involved was uncertain. All of the final best-corrected visual acuities of the 11 patients were better than their initial acuity assessments. All IOFBs were successfully removed during the surgeries in all cases without enlarging the sclerotomy. There was no slippage during the extraction of the IOFBs with the catheter. No major intraoperative or postoperative complications were encountered, and intraocular manipulations were easily performed.
Discussion Intraocular foreign bodies generally result in a poor prognosis because IOFBs may transport bacteria into the eyeball, which can lead to endophthalmitis, or the IOFB itself may cause ocular siderosis and chalcosis because of metal properties.8–10 The management of posterior segment IOFBs requires vitrectomy combined with extraction of the
407
SURGICAL TECHNIQUE
foreign body, either by an intravitreal magnet or by other equipment.11 There are a number of techniques and types of equipment that can be used for IOFB extraction such as different kinds of foreign body forceps. All the methods have their limits. A magnet is suitable for magnetic IOFBs, and the other equipments are suitable for a single IOFB but not for multiple IOFBs because they can only remove, at most, two IOFBs at a time. Multiple IOFBs are common, especially after severe injuries that are because of, for example, explosions. Our team previously reported that, of 1421 eyes with IOFB in China, multiple IOFBs were present in 318 cases (22.38%).1 Our catheter technique is suitable for multiple IOFBs; furthermore, this technique is simple and can reduce the numbers of in and out sclerotomy manipulations for extracting multiple IOFBs. The principle of this catheter technique is the same as that of the Charles fluted needle that is, both take the advantage of the drop of the pressure. When the Charles fluted needle is introduced into the vitreous cavity through a pars plana sclerotomy, the closure of the exit port by the surgeon’s finger prevents the flow of fluid or gas from the eye. The removal of the finger allows egress of the fluid along the needle and through the exit hole, which is provided by the infusion of gas or fluid to maintain the intraocular pressure above atmospheric presssure.12 With the same principle, the catheter could extract multiple IOFBs at the same time. We also found out that this method was efficient and widely applicable for the removal of multiple IOFBs with a range of diameters that were larger than that of the vitreous cutter probe. Even if the sizes of the IOFB are bigger than the catheter, this method can still be used after the enlargement of the tip of the catheter. Furthermore, the drop between intraocular pressure and atmospheric pressure ensured that the IOFBs did not easily drop out of the catheter and avoided damage to the retina. Because of the smooth surface of the catheter and the elasticity of the tissue around the sclerotomy, it was easy to pull the catheter out without enlarging the incision. The ideal instrument for IOFBs removal must be able to grasp and extract foreign bodies in a controlled and safe manner when the IOFBs are of diverse size, shape, and properties.13
The pen type or butterfly type catheter with a long and broad needle hub is easy to grip and control, and can prevent any instability during extraction. Gently tapered catheter tips can provide smooth insertion into the sclerotomy. In conclusion, we believe that our method is a useful choice for the extraction of multiple IOFBs. QUN WANG, MD YIFEI HUANG, MD, PHD LIQIANG WANG, MD, PHD YI YAO, MD References 1. Zhang Y, Zhang MN, Jiang CH, et al. Intraocular foreign bodies in China: clinical characteristics, prognostic factors, and visual outcomes in 1,421 eyes. Am J Ophthalmol 2011; 152:66–73. 2. Yeh S, Colyer MH, Weichel ED. Current trends in the management of intraocular foreign bodies. Curr Opin Ophthalmol 2008;19:225–233. 3. Jonas JB, Knorr HL, Budde WM. Prognostic factors in ocular injuries caused by intraocular or retrobulbar foreign bodies. Ophthalmology 2000;107:823–828. 4. Chow DR, Garretson BR, Kuczynski B, et al. External versus internal approach to the removal of metallic intraocular foreign bodies. Retina 2000;20:364–369. 5. Camacho H, Mejía LF. Extraction of intraocular foreign bodies by pars plana vitrectomy. Ophthalmologica 1991;202:173– 179. 6. Hickingbotham D, Parel JM, Machemer R. Diamond-coated all-purpose foreign-body forceps. Am J Ophthalmol 1981;91: 267–268. 7. Soheilian M, Abolhasani A, Ahmadieh H, et al. Management of magnetic intravitreal foreign bodies in 71 eyes. Ophthalmic Surg Lasers Imaging 2004;35:372–378. 8. Ahmed Y, Schimel AM, Pathengay A, et al. Endophthalmitis following open-globe injuries. Eye (Lond) 2012;26:212–217. 9. Archer DB. Dermot Pierse lecture. Injuries of the posterior segment of eye. Trans Ophthalmol Soc UK 1985;104:597– 615. 10. Mester V, Kuhn F. Ferrous intraocular foreign bodies retained in the posterior segment: management options and results. Int Ophthalmol 1998;22:355–362. 11. Joondeph HC, Joondeph BC, Mulcahy T. Comparison of three permanent intraocular magnets. Retina 1992;12:270–272. 12. McLeod D, Leaver P. Modified Charles flute needle. Br J Ophthalmol 1981;65:69. 13. Eckardt C, Eckert T, Eckardt U. Memory snare for extraction of intraocular foreign bodies. Retina 2006;26:845–847.
