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A man in his late 30s presented to our ophthalmology outpatient department with a history of trauma to the right eye (RE) with a metallic foreign body, thought to be iron, following hammering a metallic sheet. He underwent an orbital X-ray immediately at a local hospital (figure 1A) but no obvious intraocular foreign body (IOFB) was reported on imaging. However, based on clinical history and mode of injury, he was operated on for IOFB removal through the anterior chamber route at that hospital. As no IOFB could be located during the surgery, he was subsequently referred to us for a second opinion. At presentation to us, his best corrected acuity was 20/20 bilaterally. RE slit-lamp examination revealed a small self-sealed limbal wound, and a full-thickness iris hole with visible lens edge at 4-30 o’clock position without any obvious IOFB (figure 1B,C). Based on a strong clinical suspicion, a meticulous dilated fundus evaluation with gentle scleral indentation, and ocular ultrasound was performed, but no IOFB could be located. In the absence of ultrasound biomicroscopy (UBM) at our institute, indirect gonioscopy was performed with Goldmann three-mirror lens. Surprisingly, an IOFB could be seen behind the iris hole, at inferonasal ciliary sulcus (figure 2A). A non-contrast CT (NCCT) of orbit also confirmed the presence of the IOFB (figure 2B). Surgical removal of IOFB through an anterior limbal route was planned. After securing an anterior chamber maintainer inferotemporally, iris hooks were applied carefully in the inferonasal quadrant avoiding any trauma to the crystalline lens. An initial attempt to retrieve the IOFB directly with an intraocular magnet failed. Subsequently, the IOFB was directly visualised under scleral indentation at the inferonasal quadrant and exteriorised through a limbal incision by a bimanual handshake technique (figure 2C,D). The key steps of the surgery have been shown in online supplemental video 1. Postoperative recovery was uneventful with a visual acuity of 20/20 at 3 months.
Supplementary video
(A) Orbital X-ray done elsewhere with no obvious evidence of IOFB. (B) RE anterior segment slit-lamp photo in diffuse illumination showing a self-sealed limbal wound (blue arrow) and an iris hole (yellow arrow). (C) RE anterior segment slit-lamp photo in retro illumination showing iris hole (yellow arrow) and visible lens edge. IOFB, intraocular foreign body; RE, right eye.
(A) Indirect gonioscopy with Goldmann three-mirror gonioscopy lens revealing a linear IOFB lodged at inferonasal ciliary sulcus (red arrow). (B) NCCT orbit confirming the presence of IOFB in the RE (yellow arrow). (C) Intraoperative image (surgeon’s view) showing IOFB lifted in the anterior chamber with the help of an IOFB forceps (blue arrow). (D) Intraoperative image (surgeon’s view) showing the exteriorised IOFB (blue arrow). IOFB, intraocular foreign body; NCCT, non-contrast CT; RE, right eye.
IOFB at or near the ciliary body region constitutes about 5% of all IOFB cases.1 If not timely treated, it can cause grave intraocular complications including retinal toxicity and secondary glaucoma.1 Due to its particular anatomic location with no direct visibility, IOFB at the ciliary sulcus or ciliary body region poses a significant diagnostic and management challenge.2 3 While ocular ultrasonography and CT scan may fail to precisely locate IOFB at this region, anterior segment Optical coherence tomography (OCT) also has a limited role in detecting IOFB posterior to the iris plane.2–4 Ultrasound biomicroscopy may be an indispensable tool in the localisation of an occult IOFB in such a location.4 In the absence of UBM, gonioscopy may be a simple, readily available and economical method, as illustrated in the current case. However, small encapsulated IOFB in the ciliary sulcus and concurrent corneal scar at the entry wound may create challenges for gonioscopic detection. Surgical removal of IOFB at these locations can be done internally (through pars plana or endoscopic vitrectomy with zonulectomy), externally (through scleral flaps) or by direct visualisation (through the anterior chamber route).2 3 5 In the current case, the IOFB was directly visualised by scleral indentation and extracted through a limbal incision in a similar fashion to that described by Ji et al.2 In conclusion, strong clinical suspicion, meticulous ancillary ocular examinations and simple yet innovative surgical methods can be appropriate and cost-effective in managing IOFB at the ciliary sulcus, particularly in the setting of resource constraint.
Learning points
Clinical cues like a self-sealed wound and an iris hole should arouse a high index of suspicion for an intraocular foreign body (IOFB), even if the initial imaging modality fails to detect it.
Gonioscopy can be an important clinical tool to detect IOFB located at the ciliary sulcus or ciliary body area in the absence of ultrasound biomicroscopy.
Scleral indentation-assisted direct visualisation and extraction through the limbal route can be a cost-effective and safe option for removing IOFB from the ciliary sulcus.
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Supplementary materials
Supplementary Data
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Footnotes
Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: AN: Conceptualisation, Design, Literature search, Data acquisition and analysis, Manuscript preparation and review. RS: Conceptualisation, Design, Definition of intellectual content, Literature search, Data analysis, Manuscript preparation, editing and review. SJ: Literature search, Data acquisition and analysis, Manuscript preparation, editing and review. AA: Conceptualisation, Design, Manuscript editing and review. The following authors gave final approval of the manuscript: AN, RS, SJ, AA.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.