FIBERGLASS INTRAOCULAR FOREIGN BODY WITH NO INITIAL OCULAR SYMPTOMS David Mostafavi, MD, Kenneth Olumba, MD, Eric M. Shrier, DO

Purpose: To report a case of an occult intraocular foreign body missed on initial presentation. To our knowledge, this is the first reported case of fiberglass as an intraocular foreign body. Methods: A case report in which the clinical presentation of the patient was documented by color anterior segment and fundus photographs, optical coherence tomography (OCT), and computed topography (CT) of the orbit. Results: A 34-year-old male was referred for the evaluation of an acute unilateral preretinal hemorrhage of undetermined origin. Three months before his presentation, he had a foreign body sensation while cutting fiberglass, which lasted for several hours. He denied having any visual complaints until his presentation 3 months later. On anterior examination, a small paracentral corneal scar was noticed. There was no cell or flare. A small iris defect inferior nasal with an adjacent area of broad based peripheral anterior synechia on gonioscopy was noted. On funduscopy, a large subretinal elevation with an underlying hemorrhage adjacent to the disk with a white foreign body partially imbedded in the retina was seen. A vitreous hemorrhage was overlying the macula. Because there were no signs of infection or inflammation, surgical intervention was avoided. Barrier laser was performed around the subretinal elevation. Conclusion: Occurrence of intraocular foreign bodies, although not uncommon, has a varying presentation. Most often devastating and dramatic, clinical signs may not be obvious or appreciated on thorough examination, especially when the offending object is very small. Intraocular foreign bodies composed of inert material (i.e., glass/fiberglass) can leave the eye without inflammation, further making the diagnosis difficult. RETINAL CASES & BRIEF REPORTS 8:10–12, 2014

was missed on initial examination by the referring institution. To our knowledge, this is the first reported case of fiberglass as the IOFB.

From the Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, New York.

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etained intraocular foreign bodies (IOFBs) are relatively uncommon events. Clinical signs may not be always obvious on initial examination, especially with high velocity, small projectiles. Small IOFBs that do not result in infection and are composed of inert materials, which do not result in significant inflammation, can occasionally be missed on initial examination.1 We report a case of retained intraocular (presumed) fiberglass occurring with no initial visual change or discomfort before 3 months. The IOFB

Case Report A 34-year-old otherwise healthy Hispanic man was referred to the Kings County Department of Ophthalmology (Brooklyn, NY) for the evaluation of a unilateral preretinal hemorrhage of undetermined origin. Patient noted decreased vision in left eye upon awakening the morning before. He specifically denied having any pain or photopsias. On further questioning, he recalled an event approximately 3 months ago in the same eye while cutting fiberglass without eye protection. He vehemently denied that he had vision change at the time; however, he stated that he had foreign body sensation for several hours. No medical treatment was sought at that time. On our initial examination, vision was 20/20 in the right eye and counting fingers at 2 feet in the left eye. Extraocular muscle movement was full, and intraocular pressure was within normal limits in both eyes. On anterior examination, a small paracentral

None of the authors have any financial/conflicting interests to disclose. Reprint requests: David Mostafavi, MD, Department of Ophthalmology, SUNY Downstate Medical Center, 451 Clarkson Avenue, E Building, 8th Floor, Suite C, Brooklyn, NY 11203; e-mail: [email protected]

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FIBERGLASS INTRAOCULAR FOREIGN BODY

Fig. 1. A small, paracentral corneal scar delineating corneal entry of IOFB.

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Fig. 3. Adjacent area of broad based peripheral anterior synechia on gonioscopy.

corneal scar was noticed (Figure 1). There was no cell or flare. A small iris defect inferior nasal (Figure 2) with an adjacent area of broad based peripheral anterior synechia on gonioscopy (Figure 3) was noted. On funduscopy, a large subretinal elevation with underlying hemorrhage adjacent to the disk with a white foreign body partially embedded in the retina was seen (Figure 4). A vitreous hemorrhage was overlying the macula. No anterior or posterior inflammation was noted. B-scan ultrasound was inconclusive for a retained foreign body. Computed tomography orbits delineated a possible radiolucency nasal to the disk (Figure 5). Optical coherence topography performed 6 months after presentation delineated a likely granuloma in the area of the IOFB (Figure 6). Because there were no signs of infection or inflammation, surgical intervention was avoided. Barrier laser was performed around the subretinal elevation. Vision improved to 20/100 after 2 weeks, with noticeable improvement of the vitreous hemorrhage. No sign of infection or inflammation was present on the last follow-up examination 8 months later. Final visual acuity was 20/30 in the affected eye.

Discussion Retained IOFBs are common events, which can be easily missed on clinical examination leading to ocular

Fig. 2. A subtle, small iris defect inferior nasal.

Fig. 4. A large subretinal elevation with underlying hemorrhage adjacent to the disk with a white foreign body partially embedded in the retina.

Fig. 5. Computed tomography orbits showing a possible radiolucency nasal to the disk.

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RETINAL CASES & BRIEF REPORTS´  2014  VOLUME 8  NUMBER 1

Fig. 6. Optical coherence tomography showing a likely granuloma in the area of the IOFB.

complications and legal dilemmas. Zhang et al1 reported 1,421 eyes with retained IOFBs in a span of 5 years in China. Although labor laws reduce the commonality of IOFBs in the United States, cases of missed IOFBs have been previously reported.2 Fiberglass is an inert polymer composed of glass, plastic, and silicone oxide, which is commonly used in sporting equipment.3 The difficulties of ascertaining intraorbital fiberglass by imaging have been shown before.4 Ultrasound biomicroscopy has been reported as a valuable tool in the diagnosis of nonmetal IOFBs.5 To our knowledge, this is the first reported case of IOFB composed of fiberglass. Because of its location and possible risk of further dislocation intrasclerally by exploration, conservative management of observation was chosen. One limitation of our report is that the composition of the offending IOFB rests solely on history because gross or histopathology confirmation of the foreign body was not possible. A high index of suspicion is necessary to diagnose occult IOFB when signs are minimal given absent of

inflammation or infection. High-speed machinery with ocular complaints should also prompt careful ocular examination given that a self-sealing wound can occur, demonstrated by our aforementioned case. Key words: intraocular foreign body, fiberglass, occult. References 1. Zhang Y, Zhang M, Jiang C, Qiu HY. Intraocular foreign bodies in China: clinical characteristics, prognostic factors, and visual outcomes in 1421 eyes. Am J Ophthalmol 2011;152:66–73. 2. Mete G, Turgut Y, Osman A, et al. Anterior segment intraocular metallic foreign body causing chronic hypopyon uveitis. J Ophthalmic Inflamm Infect 2011;1:85–87. 3. Hall G, Benger RS. Missed diagnosis of an intraorbital foreign body of surfboard origin. Ophthal Plast Reconstr Surg 2004;20: 250–252. 4. Chen CS, Davis GJ, Selva D. Orbital foreign body misdiagnosed as superior orbital rim fracture. Clin Experiment Ophthalmol 2002;30:295–296. 5. Kaushik S, Ichhpujani P, Ramasubramanian A, Pandav SS. Occult intraocular foreign body: ultrasound biomicroscopy holds the key. Int Ophthalmol 2008;28:71–73.

Fiberglass intraocular foreign body with no initial ocular symptoms.

To report a case of an occult intraocular foreign body missed on initial presentation. To our knowledge, this is the first reported case of fiberglass...
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