A 43-Year-Old Man with a 30-Year History of a Retained Glass Intraocular Foreign Body Presenting with Retinal Detachment

Introduction

Open globe injury (OGI), which means full-thickness defects of the eyewall, is a major risk factor for ocular morbidity and blindness [1]. Intraocular foreign bodies (IOFBs) are foreign objects inadvertently penetrating and lodging within the eye, and account for 16–41% of OGI cases [2]. IOFBs typically result from high-velocity trauma, such as industrial accidents or explosions, and require prompt diagnosis using imaging (eg, computed tomography [CT] or B-scan ultrasound) and surgical management to prevent severe complications like endophthalmitis or retinal detachment [3]. Retinal detachment is typically caused by retinal breaks, tractional forces, or exudative processes, and its management often involves surgical interventions such as scleral buckling or vitrectomy [4]. IOFBs are usually seen in the posterior segment of the eye (58–88%), followed by anterior chamber (10–15%) and lens (2–8%) [5]. Retained IOFBs increases the risk of severe complications, emphasizing the urgent need for diagnosis and treatment to prevent permanent vision loss or blindness [2]. However, not all IOFBs can be diagnosed during the initial clinic visit, particularly in cases where patients have experienced a small, high-velocity projectile penetrating the eyeball under explosive conditions without evident symptoms [6,7]. Moreover, small inert IOFBs composed of materials like glass, porcelain, stone, and plastic, if not causing anatomical interference, may be well tolerated for an extended duration without giving rise to substantial inflammation and infection [8]. Ray et al reported 3 cases of retained glass intraocular foreign bodies (IOFBs), all of which were intentionally left intraocular. In 1 case, the IOFB remained asymptomatic for 6 years until complications developed, necessitating vitrectomy [9]. This report describes the case of a 43-year-old man with a 30-year history of a retained glass intraocular foreign body, presenting with retinal detachment.

Case Report

A 43-year-old man was admitted on July 19, 2018, with a chief concern of a dark shadow accompanied by floaters and decreased vision in the right eye for 3 days. The symptoms began abruptly without any apparent trigger or associated discomfort. The patient’s medical history revealed an explosion injury to the right eye at the age of 13, caused by placing a firecracker in a small glass bottle, 30 years ago. Immediate surgical treatment was administered at the time, but specific details were unavailable. The right eye had remained asymptomatic until the recent onset of visual disturbances.

The best-corrected visual acuity (BCVA) was 20/500 in the right eye and 20/20 in the left eye. Mild conjunctival congestion was observed in the right eye, along with a leukoma at the 8 o’clock limbus (Figure 1A, white square). A small piece of shiny glass was identified in the upper-central region of the corneal stroma (Figure 1A, 1B, white arrow). The anterior chamber depth and angle were normal, but the pupil was slightly oval and had a delayed light response. A small hole was noted at the 8 o’clock position near the pupillary margin of the iris (Figure 1A, white circle). The lens displayed mild opacity, and the vitreous cavity appeared hazy. Fundus examination revealed long-standing atrophic lesions from 12 to 2 o’clock (Figure 1C) and a half-disc-sized retinal hole at the 9 o’clock position in the peripheral retina. The inferior temporal retina was elevated from 6 to 11 o’clock, with macular involvement (Figure 1C). Intraocular pressure (IOP) was 14.2 mmHg in the right eye and 16.0 mmHg in the left eye. No abnormalities were detected in the left eye.

B-scan ultrasonography confirmed the presence of an IOFB, showing a bright echogenic acoustic signal (Figure 2A, arrow) with a comet-tail artifact in the echolucent vitreous of the right eye (Figure 2A, square). A hyperechoic undulating membrane indicated the presence of retinal detachment (Figure 2B).

The patient underwent surgical intervention under retrobulbar anesthesia, which included a standardized three-port pars plana vitrectomy without chandelier assistance or bimanual technique. The procedure involved extraction of the IOFB, retinal reattachment, photocoagulation, and silicone oil tamponade. Due to the mild lens opacity, which did not interfere with the surgery, only vitrectomy was performed, and the lens was preserved. Triamcinolone acetonide was injected during vitrectomy to enhance visualization of the vitreous. An irregular, triangular glass foreign body, approximately 1 papillary diameter in size, was successfully extracted through a pars plana incision using intraocular claw forceps (Figure 3). During the procedure, an area of lattice degeneration was observed in the 6–8 o’clock region of the peripheral retina, with tight vitreous adhesion. Extensive efforts were made to shave the vitreous in this area. Besides photocoagulation, silicone oil was used as a tamponade to ensure retinal stability.

Postoperatively, the patient was prescribed a regimen of Levofloxacin, TobraDex, and Pranoprofen eye drops. At the 1-week follow-up, the retina was flat with visible laser spots, and the BCVA improved to 20/40. The IOP was 13.2 mmHg in the right eye. The retina remained stable and well-attached during subsequent follow-ups at 1 month, 3 months, and following silicone oil removal.

Discussion

The unique scenario of this case highlights the challenges associated with historical ocular injuries. This report emphasizes that any OGI should be thoroughly evaluated to exclude the possibility of an IOFB. The decision for early intervention to remove a glass IOFB must balance the risks of surgical removal against the need for close long-term follow-up. If complications such as retinal detachment occur, they can be managed using standard surgical approaches.

Injuries leading to IOFBs typically stem from OGI and carry the potential for significant visual impairment. Timely detection and removal of IOFBs play a crucial role in mitigating the risk of severe complications, underscoring the importance of prompt and thorough intervention in such cases [2]. According to a recently published systematic review, early vitrectomy is associated with better postoperative visual acuity and a higher rate of retinal reattachment [10]. In this case, the presence of a glass IOFB eluded detection and extraction during the initial treatment, likely due to several factors.

Firstly, the glass foreign body went unnoticed during the initial examination. The challenges in identifying IOFBs can arise from obscured visibility caused by factors such as a hazy medium, including hyphema and vitreous hemorrhage, or extensive damage to the cornea. Hence, it becomes imperative to exercise meticulous care in examining every patient with an OGI, especially those due to high-risk occurrences like explosions, hammering, or while using metal power tools. The presumption that an IOFB may be present should guide a comprehensive and thorough assessment to ensure early detection and appropriate intervention, minimizing the potential complications associated with such injuries [11]. Secondly, as details of the procedure conducted 30 years ago were not available, we speculate that surgeon at the primary examination consciously decided against its removal. Typically, early surgical intervention is recommended for patients with IOFBs to minimize the risk of severe complications, such as endophthalmitis. However, in this case, the patient likely exhibited no apparent signs of infection, and the glass fragment may have demonstrated notable stability and immobility in successive examinations during the follow-up 30 years ago. The decision to retain the glass foreign body intraocularly thus may have been based on the observed inert nature of the material and the perceived low risk of endophthalmitis. Thirdly, considering that the initial surgical intervention was conducted in 1970, it is conceivable that the limited availability and use of vitrectomy procedures, coupled with constrained therapeutic techniques at that time, might have influenced the decision-making process. Despite the doctors’ observation of the IOFB in the posterior part of the eye, the prevailing circumstances may have necessitated leaving the glass foreign body in situ, as the available options for safe and effective removal were likely restricted by the technological and procedural constraints of that era.

Thus, due to these factors, the foreign body persisted in the eye until recently. Remarkably, over the past 30 years, the presence of the IOFB did not induce any significant intraocular abnormalities. It was only with the recent onset of retinal detachment that the patient sought medical attention, marking the first instance of a discernible complication linked to the retained foreign body.

This scenario underscores the critical importance of early detection of IOFBs. Generally, the identification of IOFBs is facilitated by assessing the mechanism of injury, which may include a penetrating wound with an iris defect, the presence of a focal cataract, and other indirect clinical manifestations [12]. Our approach in managing this case centered on identifying the presence of the retained intraocular foreign body. We performed a comprehensive ocular examination, carefully noting the mechanism of injury and signs indicative of a penetrating injury.

IOFBs can be difficult to identify, despite meticulous examination. To further validate our initial observations, we strategically considered multiple imaging modalities, each offering unique strengths. B-scan imaging provided real-time visualization, capturing the hyperechoic nature and comet-tail effect characteristic of glass IOFBs, as evident in our case. While B-scan is rapid and cost-effective, its application may be limited in eyes with fresh OGI due to the potential risk of exacerbating the injury. Computed tomography (CT), offering high-resolution capabilities crucial for precise localization of IOFBs, has emerged as the primary choice for detection of IOFBs. Objects can be differentiated according to their Hounsfield units (HU). Modjtahedi et al [13] reported that the HU of metallic IOFBs (brass, copper, silver, steel, and lead) ranged from 3000 to 3100 HU. Non-metallic objects, like polyvinyl chloride pipe (484 HU) and plastic eyeglasses (123 HU), had low HU value, and wood even had negative HU values from −371 to −102.5 HU. Various types of glass IOFBs produce different attenuation signals, and the HU of bottle glass and windshield glass were 2096 HU and 2700 HU, respectively. Magnetic resonance imaging (MRI) is a high-resolution modality effective for nonmagnetic IOFBs. Glass foreign bodies appear hypointense on T2-weighted MRI, providing valuable insights, particularly for smaller IOFBs (<0.5 mm) that might be missed by other modalities [14]. However, it is essential to note that MRI is not suitable for metal IOFBs due to safety concerns, as the strong magnetic fields pose potential risks.

In the present case, B-scan ultrasonography was a judicious choice, offering confirmation of IOFB presence without the risk of exacerbating the OGI. The strengths of B-scan ultrasonography in providing real-time imaging and avoiding pressure on the eyeball made it a suitable and safe for our diagnostic strategy. Once our findings were corroborated, we proceeded with the appropriate management of the patient, aligning our interventions with the confirmed diagnosis to ensure effective and targeted care.

We believe that the retinal detachment was caused by the glass IOFB from 30 years ago. During the surgery, a retinal hole at 9 o’clock and extensive old lesions from 12-2 o’clock on the peripheral retina were observed. There was no obvious proliferation or traction along the posterior surface of the vitreous. These findings, combined with his symptoms at began just 3 days before, suggested that the rhegmatogenous retinal detachment (RRD) was newly developed; perhaps the hole was a filtering lesion and the origin of the RRD. The glass foreign body recently detached from the inner wall of the eye, resulting in retinal laceration and detachment. This is consistent with the absence of significant intraocular complications over the past 30 years and the recent onset of retinal detachment.

Previous reports have described retained glass foreign bodies in the anterior chamber [7], lens [15], vitreous [16], and retina [17]. Intraocular glass has been retained from weeks to 21 years [7,9]. Management approaches for IOFBs vary depending on patient presentation, zone of injury, type of material, and associated ocular pathologic features, from a watch-and-wait stance to surgical extraction [9,17]. Gopal et al reported one of the largest series of glass IOFBs cases, in which 51 eyes were included [17]. Thirty-nine eyes had foreign bodies in the posterior segment, with IOFBs located intraretinally in 11 eyes, and in the vitreous cavity in 28 eyes. Eight eyes did not undergo surgery, leaving the glass in the position, and no complications occurred within an average of 31 months’ follow-up. In another glass IOFBs series, Ray et al reported 3 cases with retained glass foreign body intraretinally, which were initially stable but subsequently migrated and caused severe complications, including retinal laceration and loss of vision [9]. One of the cases in that series was quite similar to ours, in which the glass IOFB localized intraretinally with fibrosis around it, until 6 years later, when the glass dislodged from its original position and migrated into the vitreous. Surgical removal of the glass foreign body through a pars plana vitrectomy was recommended. The authors stated that the decision to perform early removal of glass IOFBs must be weighed against the potential hazards, and the need for close follow-up for patients with retained glass IOFBs.

For IOFBs management, the most important consideration is comprehensive anatomical reconstruction and minimization of possible complications in the future [11]. Mester et al proposed, based on their findings, that in eyes with signs of endophthalmitis following injury, urgent surgical intervention is imperative [11]. This intervention should encompass both globe repair and prompt removal of IOFBs without any delay. This recommendation underscores the critical nature of timely and comprehensive surgical measures in cases where endophthalmitis is indicated, emphasizing the need for immediate attention to mitigate the risk of severe complications.

In cases where the patient exhibits no significant signs of infection and the IOFBs do not pose a threat to critical anatomical structures, a viable option is to perform a clean closure of the entry wound. This approach is coupled with close observation, and a secondary surgery is considered a few days later. Given that many IOFBs are in the posterior segment, vitrectomy often becomes a necessary component of surgical intervention. Notably, with the continual advancement of vitreoretinal surgical techniques, even inert glass IOFBs in the posterior segment are typically removed, underscoring the proactive nature of modern surgical approaches in addressing potential complications [9]. Importantly, the risk of endophthalmitis may not be mitigated unless infected vitreous is effectively removed during the surgical intervention. If the surgeon is not well-versed in vitrectomy techniques, it is advisable to refer the patient to a specialist with expertise in this area. Following the surgical procedure, regular and vigilant follow-up is imperative. This is essential to monitor and address potential complications that may still emerge, such as endophthalmitis, retinal detachment, and proliferative vitreoretinopathy.

Glass IOFBs are less common than other types of IOFBs and their prevalence has been reported to be 2.8–17.6% in several series [5]. In cases of OGI resulting from explosions, a meticulous examination is imperative, presuming the potential presence of an IOFB. It is crucial to recognize that IOFBs, particularly in the context of explosions, may not exhibit immediate signs of inflammation, infection, or other complications, remaining latent for extended periods, even decades. The decision to perform emergency removal of IOFBs must be carefully weighed against potential hazards, considering factors such as the inert nature of the material and the absence of immediate complications. If the decision is made to leave the IOFB in the eye, regular and vigilant follow-up for patients becomes essential. This ongoing monitoring is crucial to detect any latent complications that may arise over time, ensuring timely intervention if needed and optimizing the long-term ocular health of the patient.

Conclusions

Patients with OGI should be examined carefully to rule out the possibility of an IOFB. Glass IOFBs can remain asymptomatic for decades but can lead to sudden complications. The decision to perform early surgical intervention to remove a glass IOFB must balance the risks of the procedure against the necessity of close long-term follow-up. If complications such as retinal detachment occur, they can be managed using standard surgical approaches.