Lecture: Tips and Tricks for Intraocular Foreign Body Removal

>> DR. NIMESH PATEL: Hello, everybody, welcome to the webinar. It’s about 45 minutes of talk and open for questions. However, if you like, feel free to ask questions in the Q&A throughout the webinar. I have it open, so I can try to answer them in real time. Just to introduce myself, I’m a specialist in adult and pediatric retina at the Harvard Medical School, Massachusetts Eye and Ear, and Boston Children’s Hospital in Boston, USA. I’ve trained in Miami where I was the Director of Ocular Trauma. Many of these cases I saw there and did surgery there as well. I guess without further ado, we’ll get started. I’ll try to share my screen here. Okay. Andy, are we all good there? >> Yes, perfect. >> DR. NIMESH PATEL: Okay. So let’s get started. We’ll talk about tips and tricks for intraocular foreign body resume. We have a variety of different IOFBs as well as different surgical techniques. And we’ll go over how to manage them, some of the perils and pitfalls, what things can be done differently, in some of these videos. So the objective is to be case-based. We’re trying not to be too theoretical here. We’ll go over actual surgical videos. Part of the difficulty with intraocular foreign bodies is making sure you have the right instrumentation and finding out what exactly will help you get the case done. What are the surgical approaches, how big a wound to make, where to make it. Again, we welcome discussion, feel free to put the Q&As in. So let’s just go through the first video here. And I’ll pause them as we go along. So this is the patient presenting one month after having a drill bit in the eye. So my first tip for intraocular foreign bodies is, don’t miss it. It’s very common, we just published a case series of 14 cases of missed intraocular bodies. They presented to a variety of clinics including emergency rooms and two ophthalmologists. These are high risk medical legal cases, depending on where you work, where sometimes it can be very subtle to catch that there was an intraocular foreign body. In this case you can see there was a peripheral iris translumination defect. The patient said he felt something hit his eye, but otherwise things look quite normal, there was no sign of infection. But it’s important to have a high index of suspicion in cases with high velocity trauma, particularly with metal and drilling. So this is the ultrasound here. So not only did he have an intraocular foreign body but he actually had a retinal detachment. That’s, again, a sign of chronicity. We always recommend getting a CT scan in cases of suspected open globe injuries for these reasons. Oftentimes, this can help identify the foreign body. Another tip here is that you can use the CT scan to identify the relative size. If you can see here relative to the size of the globe, you can already estimate that this is going to be quite a significant sized IOFB. You can even measure it on the CT scan. And this could be about at least four to six millimeters, at least half the size of the cornea. Then you’re going to know that depending on the shape, you’re going to need a large wound to remove it. In cases of retinal detachment with intraocular foreign body, I usually place a scleral buckle. It’s hard to know if this is necessary or not. Usually these are young patients with firmly attached hyaloids and you may not be able to remove it all. Therefore a buckle in the case of an IOFB with detachment can help prevent vitreous contraction and further problems down the road. So here first we perform a vitrectomy. And we can see the foreign body sitting on the back of the eye. I’ll often use per floor on to step stabilize the macula especially if the retina is detached because you don’t want the retina coming up out of the wound. Sometimes Perfluoron can protect the macula. Not all the time can you get the foreign body up in one go, and it can drop down again. This can help protect the retina and the macula from damage. There are cases where you can use Perfluoron to float the IOFB up closer to the wound so you don’t actually have to pick it up off the retina itself with forceps. Here is the sclerotomy that we make. Oftentimes I’ll usually make the sclerotomy with a keratome. I find it makes a nice large wound that’s very uniform. Sometimes if you’re using an MVR blade and really sawing the tissue, it may be more difficult to remove. One tip is to always make the wound a little bit bigger than you need. I find that sometimes if the wound is too small, it will often get caught and then fall back down and add difficulty to the surgery. Most of the time, even if the wound is two, three millimeters larger than you need, it’s still quite easy to close, if it’s a nice wound in the radial, in the sclera. So here we pick it up with forceps. But right away we can see it’s quite large and it’s in the wrong orientation to be able to remove without hitting the lens. At this point you have a couple of options. One is to actually remove the lens. The other is to see if there is a better way to orient this that we can remove it without hitting a lens. I always try to spare the lens if possible. And you can see what we do here. So then what we do is we place a chandelier in the eye and then use two hands. And that way we can orient it with the soft tip so that the long axis is parallel with the wound. And that way it can be removed, even a large intraocular foreign body, without touching the lens. I usually use Vicryl suture to cover the sclerotomy. We then finish the vitrectomy and tighten the scleral buckle. We mark with diathermy, fill the rest of the Perfluoron, drain from the peripheral break, and laser there. It’s kind of difficult to know whether to place oil or gas in these situations. I usually tend to lean oil, if there was a chronic detachment. These are high risk cases for peripheral vitreal retinopathy. So I usually will try to place oil to at least stabilize the eye. This patient did well and was 20/70 under oil. So some of the tips on this case is, number 1, like we said, don’t miss the foreign body. The chandelier can allow for a bimanual approach to help orient it so you don’t hit the lens. And if you can spare the lens, that’s really nice, if possible. So I think we can move on. I don’t see any questions in the chat currently, is that correct, Andy? >> Yes. >> DR. NIMESH PATEL: Okay, good. So the next case is to try an external approach for iris intraocular foreign bodies. So one tip is that oftentimes, the foreign body may actually hide itself in the iris. So there’s a couple of foreign bodies here. You can see this one is in the cornea. So we pull that one out directly. But when there’s a blast injury, there may be multiple foreign bodies. And you have to look for fragments. We noticed during this case there was actually some in the iris. We had tried to, again, pick it out. Now this patient is aphakic so we don’t want to damage the lens if possible. However it was very much caught within the eye stromal tissue. One embedded in there, it’s very hard to slide out. One tip is to make a keratome wound. You can see here I was trying to pull it and not being very successful. So what you can do is actually externalize the iris itself out of the corneal wound and just transect a small piece of it. Usually this will not cause much of a problem. It’s very similar in a way which peripheral iridotomies are done sometimes in glaucoma surgery. This can help remove the foreign body and prevent future things like siderosis or complications from having a foreign body in the eye that gets missed. So that’s our tip number 2. So in this case, I would say that the iris can hide foreign bodies in the eye. So make sure to at least palpate the iris sometimes with forceps in cases where there’s been multiple blast injuries. Another tip here is to leave viscoelastic in the anterior chamber. In this case, there’s a fairly large central corneal wound that is irregularly shaped. Even with closing with a suture, it sometimes can leak postoperatively. I like to leave viscoelastic in the eye for all open globes, because one of the difficulties postoperatively is a flat chamber or low pressure. If we can maintain pressure and give time for the wound to seal, that will prevent a lot of problems like hypopyon. High pressure is usually transitory and can be managed with eyedrops and burping viscoelastic out the wound. But that’s very uncommon. I’ll place a bandage contact lens to help seal the wound. I usually don’t remove this until one week after surgery. And of course like we showed in the video, a tip is to remove the iris and externalize it to see if that can be helpful in removing foreign bodies from there. Okay. We have a couple of questions here. So should we inject intravitreally antibiotics in case 2. A good question. I think it’s very controversial. Oftentimes we find that in high velocity injuries, there’s low rates of endophthalmitis. So often I will not inject antibiotics. However, if there’s been a chronic foreign body or the globe has been open for a long time, then it may make sense. In case 1, where it was self-sealed and there was a month of symptoms, I don’t think it’s necessary. In case 2, you probably would, I think, with an open globe. And having multiple injuries in the eye, it could make sense. It also depends where you live. Sometimes if you’re operating in a very sterile environment, then it may not be necessary. If you’re worried about the cleanliness of the surgery and the patient after going home, it could be more worthwhile to do the antibiotics. The one tip I always think about with antibiotics is, I think there is a chance of hemorrhagic occlusive retinal vasculitis with vancomycin. And I think that’s especially prevalent when there’s silicone oil in the eye. So I would just caution, when doing silicone oil and injecting vancomycin, remember that the concentration is much higher than what we normally use. And I have seen cases where silicone oil was used and injection of vancomycin was given in intraocular foreign body cases and you get hemorrhagic occlusive retinal vasculitis. So I do not inject antibiotics unless there’s infection at the time of surgery. Another question is, can you leave wood in the eye. We usually do not leave wood in the eye, the reason being there’s very high risk for fungal endophthalmitis which is very difficult to manage. We have left glass. We had a patient with a shattered iPhone and multiple glass fragments and we were able to get some out but not all, and the patient did well leaving them in the eye. But I would not leave wood. The type of viscoelastic I tend to leave in the eye is, I usually used to use Viscote or Helon. I usually don’t use Helon 5 or one of the thicker viscoelastics. Any one can actually work. The question is, are the iris foreign bodies appear on B skin? They can be, but it’s actually quite challenging to find them. Sometimes there’s a lot of hyperreflectivity on the ultrasound, and it’s difficult to understand if they’re in the iris, in the sclera, especially in the peripheral iris, or in the angle. I think ultrasound can be quite challenging to determine the exact location of the foreign bodies. Okay. Let’s move on. And we have about 11 cases, so we have plenty to go. This is one of our discussion questions. Does the vitreous need to be lifted in all intraocular foreign body cases? Let’s see if everyone has a poll. Andy, do we have an answer to the poll question? >> Yes. Coming shortly. >> DR. NIMESH PATEL: Okay, 52 to 48, slight winner for yes. And I think everybody’s correct, because I think the answer remains, it depends. And we’ll go through a case and show you. This is a patient with a peripheral nail injury. I usually try to spare the lens, like I said. This one had a perforation of the anterior capsule. We did remove the cataract. I usually prefer — and you can see the capsule is perforated there. I usually prefer phacoemulsification for lens removal. I know you can use the fragmatome. I find the phacoemulsification is more efficient at removing the lens. I also find sometimes if there’s not too much damage to the anterior capsule, you can make a nice capsule rhexis and preserve the sulcus for a secondary future lens. So here you can see a large nail inside the eye, underneath the retina. And I think the tendency here is to say, let me just go quickly grab it out the eye, tunnel down and get it. But sometimes if the foreign body is trapped underneath the hyaloid, it won’t come very easily. In these cases you do need to lift the vitreous gel. I like to use a flex cutter at the macula. I find many of these are young patients, and that’s the easiest spot to initiate the vitreous detachment. I usually make a ring and then start to propagate it from there. That way it can all come in one piece. As you can see here, and much easier. As we start to strip the vitreous more peripherally, you can see that we are able to get to the foreign body. But it’s still not free. Only when we really peel the vitreous off the area of local retinal detachment does the nail fall out. Once we lift the vitreous, then we’re able to grasp it with a foreign body. I would suggest in an aphakic patient, it’s really the easiest way to remove the foreign body is through an anterior wound. There’s a technique called the iris shell technique where you can place the foreign body on the iris as a good place to store it until you can reorient it. The other option here is, again, to use two hands to orient it out a small wound. So we were able to get this large nail, as you can see here in a second, out of just the corneal wound that we used for the phacoemulsification. We didn’t enlarge it at all, just turned it around, got it in the right plane with two hands, and then straight out the corneal wound. Again, we’ve completed the peripheral vitrectomy, drained from the break, made a peripheral iridotomy because we’re using a tamponade. In this case, because it was localized, fresh, and superior, we decided to use gas. And this patient, again, also did well. So the tip on this case is, yes, you do need to lift the vitreous if the foreign body is under. Now, there are some exceptions to this rule. If you can tunnel down quickly and get the foreign body out of, and the vitreous is very adherent, sometimes you’re better off using the vitreous to keep the retina attached and not use a retinal break. So clear some vitreous around, remove the foreign body, then you don’t necessarily have to lift the hyaloid. Here you can use small, clear corneal wounds for removal. Okay. Let’s take a look at some of the questions. So how to approach an intraocular body in a perforating injury. So if there’s a perforating injury, I usually like to close the corneal wound first or whatever the perforating injury was. If it’s through and through completely perforated through the whole eye and it goes through the — and it goes through the back of the eye into the orbit, I usually consult the plastics colleagues. But many of them do not necessarily have room in the orbit. Do you use magnetic devices? Yes. And we’ll show a case of that. How can insect hairs be removed from the cornea? So that can be used just — I usually use tires, same as we would use for sutures, I have seen that before. And do you do under general anesthesia? It depends. So it depends if on your anesthesiologist, sometimes they tend to use propofol, in that case you can do under local anesthesia. These are often not very painful surgeries if it’s a clear corneal wound, it’s very similar to just a retinal detachment repair and local anesthesia is okay. If you feel like the anesthesiologist is not keeping the patient very deep, then you can try general anesthesia. Would the iris need suturing if cutting a piece of it out? Not all the time. The iris stroma is very elastic. Even if you remove a small piece, sometimes it’s not always full thickness. You don’t always have to actually cut the whole iris out. Sometimes you can just take a lamellar cut of the iris such that it’s not — such that it’s not an actual full thickness part of the iris so it may not need to be repaired. I believe the name of the instrument was the reposi forceps to remove out of the cornea on the third case. Does the penetration in the vitreous humor get fully healed? Yes, it usually does with surgery. And the question is did we remove the capsule in case 3, what was the rationale. Yeah, the reason we removed the capsule is that it was completely torn from the posterior anterior and it didn’t really look like it was going to have enough support to do a sulcus lens in the future. If that’s the case, some of these cases are high risk for proliferative vitreoretinopathy and the capsule can often serve as a scaffold. So I would usually in that case remove the capsule. I have a few preferred techniques of secondary lens, including the scleral sutured lens. If you’re placing a scleral sutured lens, you want the capsule removed. It’s nice to do everything on surgery 1 so when you come back for the secondary lens you know, okay, there’s no capsule, there’s no vitreous, and it’s very easy to do the secondary lens and have a good outcome. And do you have to do laser before removing the foreign body? The answer is no, especially if there’s a detachment, you can just do the fluid air exchange. And is there a risk of retinal detachment during IOFB removal. And I think the answer is yes, if you have to lift the vitreous and it’s very sticky. So in those cases I usually do not lift it, if it’s very adherent and I think there’s a risk for retinal breaks. Okay. Let’s move on. The next one is to watch out for intraocular eyelashes. This was a 4-year-old patient, a pediatric patient. I find this happens more in pediatric patients, maybe it’s because their eyelashes are longer. We use viscoelastic to sweep the iris back inside the eye. Then we noticed these eyelashes inside. And it’s important to remove these because oftentimes they are quite inflammatory. And you’ve got to check the angle. You see there’s even another one here inside the eye. So my tip here is, in pediatric patients, you have to be very careful about eyelashes in the eye. I’m not sure what it is about the pediatric patients, but I’ve seen it quite a few times. Maybe it’s their eyelashes are longer. Potentially it’s that they rub their eyes a little bit more. But these are things to monitor as well. So this one is a little bit more simple, but this is just to show that you have to check for eyelashes. Then also just to look at the angle in general, in intraocular foreign body cases. Many times there are foreign bodies that can slip to the angle of the patient sitting up. Most of the time they will usually fall with gravity. I will at least take a good look with the angle, sometimes even using a gonioprism to check, especially if you can’t find the foreign body. Sometimes they hide in the angle and also the sulcus. Okay. The question is why was there an eyelash in the eye. It’s not clear. I think sometimes what happens is that the patient rubs their eye when they have pain, especially pediatric patients, and potentially then an eyelash can somehow slip onto the surface of the eye and then migrate into the eye. To be honest, I don’t have a good opinion of how can an eyelash get in such a small wound. Okay. Next case. The phaco can help with a soft intraocular foreign body. So this is a case where an Ozurdex implant has migrated. This is an aphakic patient. These can be quite challenging to remove. One of the reasons you do have to remove them is they can cause corneal edema and endothelial decompensation. You can see this patient has a lot of folds. One tip on these cases is if you want to remove something from the anterior chamber and you don’t want it to fall back in the eye is to not dilate the pupil. Oftentimes we’re dilating the pupil routinely for surgery or examination. Once I see this in the anterior chamber, I do an ultrasound to confirm no retinal detachment. Then I don’t dilate the patient. Normally we do not put dexamethasone implants in patients that are aphakic. But I think this provider did not know about this potential complication. So we use viscoelastic here. And we try to grasp it with the forceps but sometimes soft intraocular foreign bodies are brittle and they actually just break. What we do then is insert the phacoemulsification probe. One tip is not to turn the infusion on. If you turn the infusion on, sometimes the foreign body can move around and potentially migrate posteriorly. So I form the anterior chamber with viscoelastic, then use the phacoemulsification just to aspirate it and not cause a lot of fluctuation and movement in the anterior chamber. And I’m using the Drysdale instrument here to protect the posterior, try to stop it from going posteriorly. And this is a good reason to actually record your surgeries. So at the time, it was hard to tell because of how fast this came in, did it slip posteriorly or did it actually go into the phacomachine? And the good news is we were able to see on the video intraoperatively that it indeed went into the phacoemulsification probe, and then we were essentially done, without having to do a vitrectomy in this case. So the tip here is, keep patients undilated for anterior chamber migration of dexamethasone implants. Use the phacoemulsification for soft and brittle intraocular foreign bodies. The other way you can get this out is actually just to burp it out the wound. It was a little bit more challenging because this was far away, but one tip is you can actually make a slightly larger wound, push viscoelastic on the far side of the foreign body, and migrate it out the wound by putting pressure on the posterior lip of the wound and having it just run out the eye. Okay. Let’s take a look at some of the questions. So one question is, what are some of the factors that tell you about the timing of the intraocular foreign body removal? It’s a good question. We usually try to avoid doing these in the middle of the night. If there’s any signs of endophthalmitis, this is an immediate surgery, the reason being oftentimes the infection can double quite fast. And these are not always very common microbes that are very sensitive. If there’s any signs of infection, those are surgeries we’ll do in the middle of the night or right away. In terms of other procedures, if they’re glass, they may be left. If they’re metal, I usually try to do it within the next day. But they can wait. There are some papers that show high velocity injuries can wait. However you’ll see there was already one case with a retinal detachment, I’ll show you another one with a retinal detachment, that over time I think what happens is if the metal is bouncing around in the eye, it can lead to retinal breaks and detachment. So probably at least within a few days if possible. If the intraocular foreign body is associated with vitreous hemorrhage, what is the interval for operation? I in those cases will often go sooner, the reason being sometimes it’s difficult to assess the retina, even with ultrasound. In younger patients, blood layering on the posterior hyaloid surface can often mimic retinal detachments, or there can be tears you can’t see during your examination. In those cases I will go to surgery a little more quickly. Any role for anti-VEGF? I think there is in vitreous hemorrhage. I know that doesn’t always make sense from a pathophysiological standpoint because it’s usually for neo-vascularization. However some studies show endothelial stabilization. I have a couple of mentors and I personally have also had reasonably good success in terms of just preventing further bleeding or using anti-VEGF to slow down bleeding in these cases. Can you leave plastic IOFBs in the eye? I think you can if they are inert. So what are the main safety and efficacy considerations of dexamethasone? That’s a little outside the scope of this talk, but I would say the main concerns are elevation and intraocular pressure, migration of the anterior chamber. They’re really excellent for cystoid macular edema or posterior noninfectious uveitis as well as macular edema that’s nonresponsive to anti-VEGF treatment. How much time do we have to wait before the corneal edema subsides before doing a transplant? I would give it some time. I’ve had patients at one month and two months with significant corneal decompensation, over time it does slowly clear. So I would wait at least three to six months before going for corneal transplant. We touched on which can be left inside. We talked about endophthalmitis. Can you remove the smaller fragments that can’t be removed by the phaco probe? Actually the phaco probe will get the smaller fragments as well. It will actually get all the fragments, it will eat all of them. With foreign bodies in the cornea, what’s the prognosis? They can be good, but they can tend to harbor fungal or bacterial organisms. I try to inject antibiotics in these cases. I try to make sure we’re not doing any surgery without antibiotics in these cases. What will you do if a glass piece is in the vitreous which is not easy to identify with ophthalmoscopy? You can monitor it and use ultrasound or CT scan. Let’s move on. So another tip is, places where intraocular foreign bodies can hide are actually in the lens itself. So we talked about the iris. If you have a cataract and you’re having trouble identifying the foreign body, think about it being actually in the lens. That’s why we go with phacoemulsification to start and make sure we’re really seeing the lens and the sulcus because those are very common places for foreign bodies to hide. My one tip is, as soon as you see the foreign body, just remove it. You don’t really want to get the rest of the lens, because there could be a defect in the posterior capsule and then the foreign body will fall to the back. You can see here this is an odd shaped foreign body and it may be difficult to grasp and get out once it falls to the back of the eye. In this case I recommend just getting it out as soon as possible. So as soon as we identify it, even if there’s still lens material in the eye, I just enlarged the phaco wound and pulled it out. Even if your phaco wound is leaking a little bit, that’s usually not much of a problem. And we’re able to remove the rest of the lens and complete the case. Some other tips for this case is that try to use the phaco wound if you already have it, if you’ve already made the wound in the eye. Another one is don’t phaco vitreous. As soon as you see vitreous potentially in these cases, switch to the vitrector. If you phacoemulsify, there’s a risk for tear. I make sure I’m only eating lens material and there’s no signs of vitreous. I’ll move on. Another tip where foreign bodies is hide is the actual entry site. Before going and putting in the trocars here, and this is an example of, we talked about earlier, about the ultrasound and the CT scan not always telling you where the foreign body is. It’s hard to tell. They’re very hyperreflective. It looks like it’s close to the wall of the eye, but this could easily be in the sulcus or the angle. But what I do is I at least check the entry site before putting the trocars in. So here we do a little bit of a peritomy and we see a small piece. We use the forceps here to reach right into the scleral wound and take it out. This might be the easiest foreign body removal I’ve done where you just pull it straight out of the sclera, put a couple of sutures there, close the peritomy and place a little viscoelastic because there was a small defect near the cornea. And then call it a day. Here we have another discussion question. So should you remove the capsule if there is an anterior and posterior capsule defect? If you have a defect in the anterior and posterior capsule, would you remove it? We talked a little bit about this earlier but we’ll show a case about it. And then I see a question about tetanus. Yes, so usually we would update tetanus vaccines if a patient has a metallic foreign body. Again, a good question, because we have a split answer. Most people are saying yes. But here’s the counterpoint, sometimes it’s a no. So here we have a very large foreign body. This is a staple. You can see that you know right away there’s going to be a capsule, a defect, given the size of this. If you look at the CT scan, even more so. You can see it’s already in the mid-vitreous. So you know there’s an anterior capsule defect and a posterior capsule defect. Another point is that oftentimes, if it’s this far into the vitreous cavity, there is likely a retinal strike site. I know there are questions about should these be done anterior segment surgery, posterior segment surgery. I usually favor, if there’s violation of the posterior capsule, it’s very important to have a vitrectomy because it’s likely there will be a posterior strike site. One tip about removing these is to try not to manipulate it. This is going to cause a very strange shape in the cornea. You can see it’s a square. And these are hard to close. So what you want to do is try to remove it using two hands with minimal manipulation and twisting. So we’re just lifting it straight out the eye. Close the corneal defect. Then what we proceed to do is, there say large posterior capsule defect. As soon as we went in there, there was lens material that dropped so we didn’t do the phacoemulsification. However we did a capsule rhexis and were able to keep the sulcus interact. Same story, we lifted the vitreous off the posterior hyaloid. And you can see there is a strike site there which we lasered. And I think here is a good picture, you can see the sulcus is still fully intact here. We removed the foreign body, closed the cornea. We waited a few months, removed the sutures, got lens calculations, came back, and placed a sulcus lens very easily, and the patient was 20/30 uncorrected. I lost my Q&A here. Let me just pause for a second and find it again. I’m going to stop sharing for one second. Oh, here you go, Q&A. Okay. So the tips in this case, I would say preserve the sulcus if possible. If you really think it’s viable for a secondary lens, that’s always the easiest secondary lens. Vitrectomy at the time of IOFB removal, I usually do advocate for this. I think even if they’re protruding out the cornea, if the vitreous cavity has been violated, they’re at high risk for retinal detachment, even when I removed that staple, the vitreous was coming forward which means there’s traction. I usually don’t place the intraocular lens at the same time as the surgery. Let’s see some of the questions. What are the side effects of using viscoelastic substance in the eye? They’re very minimal, usually just high pressure postoperatively. I don’t usually notice much of a problem. In what situations would preserving both anterior and posterior capsule would be beneficial during IOFB removal? Usually I just pick one of the two. However, sometimes if you have a defect in the anterior and a defect in the posterior that are not matching, over time what can happen is the capsule fuses and you can get strengthening of the capsule three months later. So if you feel like the anterior capsule alone is not enough to hold a sulcus IOL and there’s still a defect in the posterior but the posterior is not enough to hold a sulcus IOL, sometimes you can add them together and have enough support for a sulcus IOL. In those cases I’ll wait, the capsule will fuse, and it usually strengthens over time. The next question is, if you have good sulcus support, would you insert a three piece in the first surgery? I usually don’t, unless you’re worried about cost to the patient or followup, the reason being is that the corneal calculations and the IOL calculations will be incorrect due to the astigmatism induced by the sutures and the wound, especially because some of these cases, they can have good vision potential, as you saw on this eye. You do want an accurate lens calculation if possible. So I would wait to place the IOL. The question is, is it safe to place the sulcus, what if the IOL drops? Actually I find that you’re better off giving it a shot. And I have often been pleasantly surprised that the sulcus can be stronger than we think. Sometimes I have in some of these cases said I’m not really sure if the sulcus is very strong, I put the lens in, then been surprised that it does hold. What’s the downside? If it does fall, you pick out the lens, take it out and leave it alone. After vitrectomy, what implant do we use to sustain the globe? We usually don’t use any tamponade. I’ll usually just use air, unless there’s a detachment. Where to tuck the haptics in a sulcus IOL? I usually place this right on top of the capsule and underneath the iris. So in the case of X-rays not available, which view to catch the IOFB? We usually — the best view is usually the axial view. And we ask specifically the radiologist on CT scan for thin axial cuts. Sometimes the regular axial cuts are two millimeters apart, meaning if the IOFB is only one millimeter, we miss it. We ask for thin cuts which can be one millimeter or less. I write in the order to the radiologist where we think the IOFB will be in the eye. They don’t have to do thin cuts in the orbit or brain, but we say, at least in the eye, give me one cut every millimeter or so. Is it necessary to do a vitrectomy in these cases? I think it is. The risk of open globe detachments are very high, especially if there’s vitreous violation. It’s almost 50% in zone 3 cases. And when they do detach, they usually have a poor prognosis. I usually do recommend vitrectomy if possible. And here is a good example why. That’s a good lead into this case here. So this is a large glass intraocular foreign body. One tip is if you have a very large foreign body, I like to place the infusion first. We don’t know how big of a wound this is going to cause. And if you take the foreign body out and the eye gets very soft, it can be more difficult to place an infusion line at that point. So what I would do is at least place an infusion before you remove the foreign body to see how big the wound actually may be. And you can see in this case how large the actual glass piece was and how big the scleral defect would be. Then we do the peritomy. I close the globe with Vicryl suture. I prefer Vicryl because it resolves with no tear. It doesn’t usually need nylon sutures on the sclera. So then we have vitreous hemorrhage. The question is, again, do you have to do this? Many would say no. This is the reason why, there’s always going to be vitreous traction here. There’s lots of vitreous hemorrhage. We, again, see actually now there is a retinal detachment. So it’s very hard to capture this on ultrasound, pre-op you don’t want to push too hard on the eye and do aggressive ultrasound but I find many of these cases are actually detached at the time of the intraocular foreign body. We’re having a hard time lifting the hyaloid here. Again, I use the flex loop on the macula to initiate the vitreous detachment. And once the vitreous is clear, we can see a superior nasal retinal detachment. This patient also had some blepharon formation later which we used amniotic membrane transplant on. There is some retinal blood but you don’t need to create an extra retinopathy, it will resorb, especially if it’s in the macula it won’t lead to vision loss. In this case we do a fluid air exchange, laser the area of where the strike site was and we place oil. This patient did well, their retina never came off and they ended up with good vision after cataract removal later. And again, you can see the subretinal blood is there but not causing a problem. Two months later, all resolved. Request good photoreceptor layer on the OCT. The tip here is place the infusion first for large intraocular foreign body. I do advocate for vitrectomy at the time of intraocular foreign body, especially vitreous hemorrhage, because you may be missing a detachment that’s already there. And this detachment was macula on, so we were able to save the patient from going macula off and losing vision. Again, the flex loop for the posterior hyaloid. And no need to remove subretinal blood. Let’s go back to the questions. Some doctors place one piece in the IOL in the sulcus. Usually I try to avoid that. However if this is all you have available, I think the rates are actually quite low. If needed, you could always remove it later. So I have actually seen many patients who have had a lens migrate to the sulcus that’s a one-piece and do just fine for many years. So if that’s only what you have available in your country and it’s a matter of either that or the patient being aphakic, it’s not an unreasonable option. How long do you wait to get the capsule fibrosis before a secondary lens? I usually wait three months. I still think there’s a little more fibrosis that occurs between three months and six months, so if you can wait six months, that’s ideal. What are the chances of persistent IOP spike after removing the IOFB? It’s actually quite rare, oftentimes it’s due to something else like steroid response from the steroid drops or oil emulsification if you use silicone oil. But I don’t often find primarily because of the intraocular foreign body you get high pressure. Do you recommend having multiple calculations on hand before the surgery? For the secondary lens, yes. I wouldn’t have it at the time of IOFB removal, because I don’t like to place the lens at that time. However, yes, if you’re going to go place a secondary lens, maybe you weren’t even the one who did the first surgery, you don’t know how much capsule is there already. So yes, in that case I would get a lens calculation for a sulcus lens as well as a sulcus lens that I may use intrascleral fixation or answer a lens which I prefer the AOS360. So I would get all three calculations. In this case what was the patient’s IOP? So the IOP was okay in this patient. What’s the ideal gauge for vitrectomy in cases of intraocular foreign body removal? I usually like 23 gauge. I use 23 gauge for effectively all my surgeries. There’s a couple of reasons for this. I future all the sclerotomies either way. I don’t find that smaller gauge is that helpful for me. I may prefer a smaller gauge in diabetic traction detachments to undermine the membranes. However the benefits of 23 gauge, especially in young patients, it’s better for vitreous removal. The vitreous is usually more thick. Number 2, if you’re going to use oil, the oil insertion and removal is much faster with 23 gauge. Number 3, there’s more faster lens material removal with 23 gauge vitrectomy. Oftentimes these are soft lenses and you don’t need the fragmatome. If you can avoid the extra wound and remove the lens with the 23 gauge, that is preferable. Also the instruments are more stiff. So if you need to do work in the anterior chamber, you can still use the pars plana and use the instruments to the anterior chamber for things like iridotomies. Sometimes I find the 25 gauge is more flexible and will bend before getting to the anterior chamber. How is the vision after this injury? In all these cases, as long as the retina doesn’t come off, the vision can be pretty good. Do I always put oil for — I usually do, yes, again only if I’m concerned about followup for the patient. Some of these patients will get posterior vitreal retinopathy. So I usually try for oil. If it’s superior, like we saw in one of the cases, I will try for gas if possible. What is the systemic therapy? I usually don’t use systemic antibiotics. What’s the risk of PVR if you do not get a PVD? It’s hard to answer that. I’ve had other patients where I usually try to induce a PVD in every patient, however I’ve had patients that I’ve seen in followup where other people have done the IFP removal and the vitreous is still attached and we can see that on the OCT and the patient’s done fine. I think it’s hard to know. I would say if the retina is detached, you definitely want to get the vitreous off as much as possible. If the retina is attached, I’m not sure it’s necessary. So this case I do not have a video of, but I wanted to just show there’s another great instrument. This is the nitinol loop. One tricky IOFB are the ones that are square shared or cuboidal shaped where they don’t have an area you can grasp with the forceps well. If they’re glass, they’re not metallic and you can’t use the magnet. I think the nitinol loop is a really good option for this. Dr. Vavvas, another doctor at our hospital, has a YouTube page with a great video if you want to check it out. Okay. So this is another case here. So this is a case kind of demonstrating that the PFO can be helpful. And again, back to tip number 1, don’t miss the intraocular foreign body. This patient was drilling one year prior, went to an outside emergency room, was told he had a corneal abrasion, again, small translumination defect in the iris peripheral. Then he presented to us because he lost vision one year later with a retinal detachment. When we looked in the eye we saw a foreign body, placed the scleral buckle, detachment is there. We tried to remove the sclerotic material, it’s quite adherent, suggesting chronicity. We used diathermy to surround it and used two hands to dissect it off and removed the foreign body in that manner without causing a large retinal defect. So the key is to use PFO first. The reason being, is that you can get retinal incarceration. If you make a sclerotomy and you have an infusion on, the retina can fly out the sclerotomy, and then you may have to do a retinectomy. The difficulty of using PFO is it will cause bubbles and can make the view difficult. As long as you can complete the case, then that’s the better option. Here you can see, even though the view is a little bit hazy, and it’s a little bit tricky to get it off, we do eventually get the foreign material out of the eye with the PFO keeping everything intact, again, sparing the lens, using the chandelier. Another tip here is, I usually like to use the temporal wound to remove IOFBs. And so in this case, I normally operate with the trocars at 9 and 3 or close to that. But in this case, what I’ll do is I’ll move the infusion a little more inferior, move that temporal trocar more superior, and give myself plenty of wound to make a nice temporal sclerotomy for good access. The reason I do that temporal and maybe not superior is that if you have an assistant, it’s nice to have someone else to be able to gape the wound. So I think in this case we have the assistant holding the wound open, which allows for better access. I usually will also increase the pressure to 60 on the infusion, which increases the flow out of the eye and prevents the foreign body from getting caught in the wound or falling backwards. Let’s go to the questions. Is there a high risk of sympathetic ophthalmia and how do you follow the other eye? There is a risk in any open globe surgery. I don’t think it’s higher in intraocular foreign bodies, but we don’t know that for sure. We do follow the other eye. But I think it’s quite rare, sympathetic ophthalmia. I think it’s more related to exposure of uveal tissue. Oftentimes, the foreign bodies, they have smaller wounds. I think it’s not very common. Do they feel something inside their eye if it’s in there? Usually not. That’s why sometimes they present very late. This patient had an intraocular foreign body in their eye for one year without noticing a problem. And I think this question is in Spanish, I think it’s basically do they use gas C3F8. I usually will use C3F8 if there is a retinal tear or detachment. I would say I lean towards gas even if there’s a small defect, even if there’s not a big problem, if it’s a strike site. If you’re removing the vitreous, sometimes you’re removing what’s actually tamponading the break. So once you remove the vitreous, there’s actually more potential for small holes and tears to become mobile and have fluid go under. So I’m pretty conservative, if there’s any concern at all, I will use gas and C3F8. So what was the vision of the patient on presentation? So this patient was actually poor vision count fingers. It did not improve all that much, I believe it got to 2400, but it was a chronic detachment so it did not improve very much. Do I do a direct PFC to silicone oil exchange? I don’t think it’s necessary in these cases, partially because there’s not a giant tear and there’s a low risk of slippage. I do sometimes do this in giant retinal tears. But even then, I try to avoid it. Part of the reason is that oftentimes you can’t get all the PFO out, and that can lead to a mix of silicone and PFO which can sink to the bottom of the eye and be very difficult to remove when you go back in. I usually try to avoid direct PFO to silicone oil exchange. The one tip would be to go very slowly because oftentimes the pressure goes very high. So any tips to remove the foreign body embedded in optic disk? I actually have to say I have not encountered this prior, so I wouldn’t know for sure. I would say just as gently as possible and to minimize damage. We talked a little bit about this, about what about a foreign body which is behind the eye in the orbit? I usually refer to oculoplastics, but oftentimes they don’t need to be removed, and it’s a discussion with the patient. They can never get MRIs if it’s metallic because the MRI would cause the foreign body to extrude. It’s not ideal to have a foreign body in the orbit and never be able to get a brain MRI, let’s say you had a stroke or something like this. We usually try to advocate removing it but it’s not 100% necessary. Okay. I believe this is the last case. I saved the big one for last. So one tip right off the bat is I always close the corneal wound first. And if there’s a large intraocular foreign body, I will always try to make a new wound. The reason being is that the corneal wound where the wound went in is usually very small. And it’s irregularly shaped. It’s best to just close that wound and make a new one even if you’re making two large wounds, the eye usually does fine. So you can see we closed the corneal wound here to give stability to the eye. We make a small scleral tunnel. We’re attempting to remove the foreign body. But it’s quite large. We can see it there just barely. There’s a lot of blood in the eye. We extend the wound even further. We then now use the magnet. So the magnet can be very good for metallic foreign bodies that are large, that are hard to grasp. Again, trying to grasp it. Maybe there’s some lens material in the eye so we extend the wound, remove some of the lens material. Again, try to use the magnet. It’s very clear this is a very large foreign body. More vitrectomy, more lens material removal. Extend even further, now we have almost a four to five clock wound. At this point we have no choice, this is too large a foreign body to leave in the eye, there’s likely to be retinal damage. If there’s any hope of saving this eye, we have to get it out. And then here we go, we depress, put the infusion up, use the magnet, again, using the assistant to help gape the wound open, and teasing the foreign body out slowly with the high infusion pressure. And you can see how large this really is. I think it measured over 14, 15 millimeters there. Close again with Vicryl. So I previously said I really like to do vitrectomies at the time. In this case I would have considered it. I think the problem here is we have a poor view because of the cornea. We also have two really large wounds in the eye. So I think at this point we’re trying to minimize manipulation. We’ve already been in the surgery for a couple of hours. But with that said, what you want to do is then go back very soon. So within a week later, we see that there is an ultrasound with a retinal detachment and a lot of blood. And so if you don’t come back in this eye soon, it will go into a funnel detachment and be a very poor prognosis, which it already was, but we thought there may be a chance to save the vision in this eye. So we use infusion. You can see the blood is extremely thick, dense hemorrhage, almost unable to be cut with a vitrec for, again, why I use a 23 gauge, sometimes they navigate these membranes better. The view is tricky. We slowly persist. I usually recommend doing a vitrectomy superiorly first, that way if you make a retinal break it can be covered by gas or oil. So we try to avoid inferior breaks or breaks in the macula. We see inferior retinal detachment with three retinal holes. The goal here, again, is not to do too much but to just relieve the vitreous, flatten the retina, get some laser over the retinal break, we leave the subretinal blood alone. We perform laser around the tears. And again, you see the macula has not come off this time. So there is a potential for vision, even though it’s a poor prognosis, there’s a high risk of retinal redetachment, but there’s still a chance at this point. Postoperatively, day one, the retina is nicely attached, the blood is gone. This patient I’ve seen for four years, he’s actually doing quite well, the retina is still attached. He has had some corneal decompensation, he’s getting a corneal transplant, but we’ve removed the oil and he’s still doing quite well. Okay. Let’s go to the questions. So was that case done with a bandaged contact lens? The answer is yes, we did use a bandage contact lens. Do you need general anesthesia for that case? Yes, because there’s quite a lot of manipulation. And where do you prefer using a magnet instead of forceps? It’s a good question. I think it’s really dependent on the size of the foreign body. If you feel like it’s something that’s difficult to grasp, if it’s not flat in one of the planes, that’s usually a good one to use the magnet. Even then, the magnet is actually quite strong, so I find that the magnet is surprisingly good in the majority of cases. Unless you really think you can grab it well. The downside of using the magnet is it’s much larger than the forceps. So you need a bigger wound. And I think because you don’t have a good hold of it, it can fall off as you bring it outside the eye. So I prefer the forceps, if you think you can grab it. If you can’t grab it, definitely go with the magnet. But the magnet is actually quite strong. So in the case of an eye blast injury, what do you do for the small piece of metal? It’s very difficult. There’s many — usually in these blast cases, there’s many pieces, and you’re not likely to remove them all. So what I try to do is get the big ones out. But if you have some small ones scattered all over the eye and you’re risking more damage by trying to remove them, I think you’re better off leaving them alone and monitoring for siderosis with the ERG. You may get some depression over time. But retinal detachment is really the downside. So what’s the final vision in this last case? Right now he’s 2200 vision but he’s aphakic and he’s got corneal decompensation. Again, the macula has never come off, so in theory he has some reasonable vision potential with a corneal transplant and a contact lens. And why do I prefer using laser? So laser is less inflammatory than I believe what you may be asking the alternative being cryotherapy. In that case I would use laser. Is scleral buckle recommended in IOFB cases with no evidence of retinal detachments? Usually I don’t think so, many times you can get away without buckle. However, it’s not a bad thought, because sometimes these cases can get retinal detachment. But I would say it’s maybe a little bit overkill to put a buckle on without retinal detachment. Do you recommend pulling the foreign body blindly that might be catching some tissue along the way? So that’s one of the advantages of using the corneal wound. So if you really think it’s very large and it could catch some tissue, some retina, some other things like this, that’s why using a corneal wound is always a little bit better, because you get good visualization, and you’re less likely to damage the structures and cause say cyclodialysis, damage to the iris. If you’re worried about a large foreign body that you’re worried what damage it’s going to cause on removal, I would remove the lens and take it out a corneal or limbal wound. We talked about PDV and the timing before. How do you prevent endothelial damage or other damage? That’s where the viscoelastic can be helpful. So before I remove any foreign body from the cornea, I’ll usually fill the anterior chamber with viscoelastic. In terms of the blast injuries intracorneal, I think you can leave it, if there’s metallic foreign bodies sometimes within the stroma. The downside is they do epithelialize sometimes over time, and that can lead to pain. So the patient may be coming back repeatedly with pain in the eye. But if they are difficult to remove, you can leave them. We do have evidence for that, we see a lot of metallic corneal foreign bodies that we remove and they get a rust ring. Usually over time they do just fine with that. Okay. I think we’ve answered most of the questions here. Just to wrap this up with the final tips, especially in these large intraocular foreign bodies, if you’re not doing a vitrectomy, there usually will be a retinal detachment postoperatively. Make sure you ultrasound the patient within the first week. Okay. Here’s the final slide. This is my Instagram account. Please follow. I post interesting cases, both pediatric and adult retina. Also I have a YouTube channel, if you could please subscribe to this channel. This is where I post many of these surgery cases as well as other interesting retinal cases and instructive videos on things like lens exchange. Okay. I think that we can wrap it up there. Andy, do we have anything else? >> Awesome, thank you so much, Dr. Patel. >> DR. NIMESH PATEL: Thank you all for coming. I hope it was informative. I’m pleased to see how many people came, I think we saw upwards of 3 and 400 people on the webinar. It’s very impressive to see that there’s so many people interested in these topics and this presentation.