Embedded metallic foreign body in the sclera

[Richard_Hom]

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A 21 year old HM presented to the clinic from the emergency room as the last patient of the day with a laceration of the left outer lid of about 4 mm wide and a retained metallic foreign body in the sclera about 3-4 mm above the limbus at 12:00 in the left eye.

Physical examination shows Vision in each eye being 20/20 and the anterior chamber is quiet. The left iris is in normal position and undistorted. Applanation pressures are OD 14mm Hg and OS 18 mm Hg.

Dilated fundus examination reveals no intraocular metallic foreign bodies.

It appears that the metallic FB went through the upper lid and ended up in the sclera.

The outer lid was sutured by the emergency room physician.

Question(s):

1. Under what conditions would you need to suture the inner palpebral conjunctival side of the lid?
2. Would you require forced irrigation through the lid to cleanse the wound site prior to suturing the outer lid?
3. How would you determine the depth of the FB? Can it be done optically? must imaging be done?
4. If removal resulted in blood loss but not aqueous, does this indicate that penetration did not occur?
5. If removal resulted in both blood loss and aqueous, would you suture in the OR or in the office?
6. Does the sclera require any additional care or follow-up as would a rust ring of the cornea?


Regards,
Richard_Hom

 

[Andrew_Doan]

1. Under what conditions would you need to suture the inner palpebral conjunctival side of the lid?

We don't suture the inner palpebral conj. It will heal well with only external closure. Unless the lac involves the lid margin, simple closure with 7-0 Vicryl is good.


2. Would you require forced irrigation through the lid to cleanse the wound site prior to suturing the outer lid?

Irrigation with normal saline should be performed before wound closure. It's also a good idea to make sure the patient's tetanus shot is current.

3. How would you determine the depth of the FB? Can it be done optically? must imaging be done?

Plain film xrays or a CT scan of the orbits should be performed to r/o multiple FBs. The depth of the FB is difficult to judge optically, and the patient should be taken to the OR to remove the FB and determine if closure of the sclera is needed.

4. If removal resulted in blood loss but not aqueous, does this indicate that penetration did not occur?

Not necessarily. Blood loss could result from penetration of the vascular ciliary body or choroid. From your description, the injury was 4 mm from the limbus, which places this injury near the ora serrata. Usually 3.5 mm from the limbus will still place a wound in the pars plana, but with an elongated piece of metal, if one end is seen at ~4 mm from the limbus, then where is the other end of the FB posteriorly? The ora serrata begins at about 6-7 mm from the limbus, so if the FB is 2-4 mm long (assuming that the FB had to be large enough to cause a 4 mm lid lac), then the scleral wound may be very close to the peripheral retina. A thorough peripheral retinal exam is needed to rule-out any retinal tears, which should be treated with cryo or laser demarcation. A peripheral exam will require scleral depression, but this should not be done until an open globe is ruled-out. In addition, a penetrating wound at this position would not result in loss of aqueous, but rather there would be loss of vitreous. Vitreous may also "plug" the wound. I've seen a case where a penetrating wound was missed, and the patient developed severe endophthalmitis because the vitreous acted like a wick.

5. If removal resulted in both blood loss and aqueous, would you suture in the OR or in the office?

I would only repair this in the OR because the patient will require a peritomy and take down of the conjunctiva and Tenon's for exploration of the sclera and repair of the scleral laceration. Trauma that is forceful enough to penetrate the lid and lodge a metal FB in the sclera requires careful surgical exploration and repair. Also, if the wound occured at 3-4 mm from the limbus, then there would be vitreous loss and may require a vitrectomy and evaluation by a retina surgeon.


6. Does the sclera require any additional care or follow-up as would a rust ring of the cornea?

If there's a scleral laceration, then it requires primary closure. This must be done in the OR after taking down the conjunctiva and Tenon's. There's usually no additional care of the sclera after surgical closure.

 

[daredevil_2010]

Hey you probably know my brother. He graduated from Hopkins in 2001 as well... I think. And went into Optho. He stayed at Wilmer.

 

[Andrew_Doan]

Originally posted by daredevil_2010
Hey you probably know my brother. He graduated from Hopkins in 2001 as well... I think. And went into Optho. He stayed at Wilmer.

I know both guys who stayed at Wilmer. There was a MD-PhD and a MD. They are both very nice! 😉