Clinical and Experimental Ophthalmology 2005; 33: 659–664

Letters to the Editor

Photographic Essays

Intralenticular foreign body: a D-Day reminder

ABSTRACT

Intralenticular foreign bodies are not uncommon after penetratingeye injuries. This is an observational case report where a patientwas found to have an embedded lenticular foreign body for morethan 60 years. Following such a long period of time the patient hasnot experienced any significant cataract formation or compromisedocular function due to the foreign body.

Key words: cataract, intralenticular foreign body, penetrating

eye injury.

INTRODUCTION

The frequency of intralenticular foreign bodies after penetratingeye injuries is about 5–10%. A large percentage of intraocularforeign bodies (86%) were found to be metallic in origin.1 Conser-vative management of intralenticular foreign bodies is an accept-able option unless ocular complications such as intraocularinflammation, cataract formation or siderosis bulbi develop.2

Cazabon and Dabbs reported a case of a patient who was found tohave a retained intralenticular foreign body for 40 years with noocular complications.3 As far as we are aware we are reporting thelongest case of a retained intralenticular foreign body with noassociated problems.

CASE REPORT

An 87-year-old man was referred to our Ophthalmology Depart-ment because of progressive deterioration of the visual acuity inboth eyes over the past 9–12 months. The patient had a past ocularhistory of a penetrating traumatic injury to the left eye 60 yearsago, that occurred on D-Day (June 1944, Normandy, World WarII) during a grenade explosion. Surgical repair, which involvedsuturing of the corneal laceration and a broad iridectomy for pro-lapsing iris, was performed at that time. On presentation visualacuities were counting fingers and 6/60 in the right and left eyerespectively. Anterior segment showed no obvious abnormalitiesexcept for a broad iridectomy in the left eye (Fig. 1). Funduscopyshowed macular scarring in both eyes, compatible with dry age-related macular degeneration and confirmed with fluoresceinangiography. This was the main cause for his decreased visualacuity. Both lenses were clear and an incidental intralenticular for-eign body superonasally was detected in the left eye. The foreignbody seemed embedded in the anterior lens cortex. The surround-ing lenticular area was absolutely clear and there was no obvioussign of anterior capsular breach (Fig. 2).

Figure 1. Left eye showing previously repaired corneal lacera-tion, a broad iridectomy and a small superonasal intralenticularforeign body.

Figure 2. Magnified view of the intralenticular foreign body andsurrounding clear lens within the area of excised iris.

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DISCUSSION

To our knowledge this case illustrates the longest-lasting intralen-ticular foreign body ever reported in the ophthalmic literature. Nocortical, nuclear or subcapsular lens opacification was detected. Ithas been reported that the anterior capsule has a healing capacityif there is a small breach, epithelial proliferation rapidly restores itscontinuity, limiting the free passage of ions and fluid that mayprogress to the development of cataract.4 This might explain theclear lens in our case. We are not sure of the exact nature of theintralenticular foreign body. One of the main worries in cases ofintraocular metallic foreign bodies is siderosis bulbi. Although theforeign body looks metallic, there was no obvious sign of siderosistoxicity in this case. Due to the long-standing history of the intral-enticular foreign body and the absence of any associated sequelae,radiography, ultrasound and electrodiagnostic tests were deemedunjustified to try and find out the nature of the foreign body at thisstage. Some authors have reported that intraocular foreign bodiesmay become encapsulated or loose their magnetic properties withtime.5 This could explain the benign natural history of this long-lasting intralenticular foreign body. Conservative management, asin this case, shows to be a valid option unless the ocular functionis compromised, in which case, cataract surgery and intraocular lensimplant may be indicated.2,6 In addition, we would like to recom-mend caution when subjecting such patients to magnetic resonanceimaging as this could cause important ocular damage in cases offoreign bodies with magnetic properties.

Felipe E Dhawahir-Scala MRCSEd (Ophth)1 andA Kamal FRCOphth2

1Manchester Royal Eye Hospital, Manchester, and 2University HospitalAintree, Liverpool, UK

REFERENCES

1. Coleman DJ, Lucas BC, Rondeau MJ, Chang S. Managementof intraocular foreign bodies. Ophthalmology 1987; 94: 1647–53.

2. Lee LR, Briner AM. Intralenticular metallic foreign body. AustNZ J Ophthalmol 1996; 24: 361–3.

3. Cazabon S, Dabbs T. Intralenticular metallic foreign body. JCataract Refract Surg 2002; 28: 2233–4.

4. Fegerholm PP, Philipson BT. Human traumatic cataract: aquantitative microradiographic and electron microscopicstudy. Acta J Ophthalmol 1929; 12: 970–7.

5. Casali A. Due casi di siderosis oculare. Ann Ottalmol 1910; 39:572–604.

6. Pieramici DJ, Capone A Jr, Rubsamen PE, Roseman RL. Lenspreservation after intraocular foreign body injuries. Ophthalmol-ogy 1996; 103: 1563–7.

Blackwell Science, LtdOxford, UKCEOClinical and Experimental Ophthalmology1442-64042005 The Royal Australian and New Zealand College of OphthalmologistsDecember 2005336••••Letter to the EditorLetter to the EditorLetter to the Editor

Letter to the EditorPhotographic Essay

Traumatic cataract and intralenticular foreign body

ABSTRACT

Traumatic cataracts resulting from penetrating injuries occur mostfrequently from projectile metallic foreign bodies. The majority of

intraocular foreign bodies cause sight-threatening damage includingtraumatic cataract in up to 25% of the cases. A case of traumaticcataract and retained intralenticular foreign body that was removedsuccessfully with phacoemulsification and foldable intraocular lensimplantation in the capsular bag is described. This case report high-lights the benefit in planning surgical management as a two-stagedprocedure after appropriate investigations.

Key words: intralenticular foreign body, phacoemulsification,

traumatic cataract.

INTRODUCTION

Traumatic cataracts resulting from penetrating injuries occur mostfrequently from projectile metallic foreign bodies.1 The presenceof an intralenticular foreign body is uncommon but has beenreported in the past2 including retention of good vision for severalyears. The majority of intraocular foreign bodies cause sight-threatening damage including traumatic cataract in up to 25% ofthe cases.1 The major complication of retained intraocular foreignbody is the sight-threatening condition of siderosis bulbi. In themajority of cases the preferred management choice is early removalof the retained foreign body especially in view of advances insurgical techniques.3

We report a case of traumatic cataract and retained intralentic-ular foreign body that was removed successfully with phacoemul-sification and foldable intraocular lens implantation in the capsularbag.

CASE REPORT

A 48-year-old man presented with an injury to the right eye whilehammering metal. He sustained the injury at work despite wearingeye protection. On examination his visual acuity was 6/60. He hada red eye with a limbal penetrating injury. Mild anterior uveitis waspresent together with an intralenticular metallic foreign body. Thepatient underwent a primary repair of the corneoscleral wound thatevening. The following morning, B-scan and computerized tomog-raphy scan of the orbit confirmed a solitary foreign body embeddedin the nucleus, the posterior capsule appeared intact and no otherposterior segment abnormalities were noted. Over the next 7 dayshe developed a rapidly progressive traumatic white cataract (Fig. 1).

A surgical approach was planned to remove the foreign bodyand white cataract together with an intraocular lens implant. Cap-sulorhexis was incomplete because of the breach of the anteriorcapsule by the foreign body. The nuclear matter was de-bulked withphacoemulsification, allowing the foreign body to be mobilized andremoved through the 2.8-mm corneal section (Fig. 2). A foldableintraocular lens implant was placed in the capsular bag. Postoper-ative recovery was uneventful and the best-corrected visual acuitywas maintained at 6/6 at final follow up at 12 months.

DISCUSSION

Ocular trauma as a result of high-velocity injuries continues to bea hazard for certain professions. The natural progression of retainedintraocular foreign bodies varies depending on its size and location.In previous reports it has been suggested that small metallic foreignbodies embedded within the crystalline lens or in the posteriorsegment can be treated conservatively.3,4 However, these patients

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require careful follow up in order to monitor for siderosis bulbi.4 Inview of this sight-threatening complication and with the develop-ment of better surgical techniques, we advocate the preferred treat-ment of choice to be early removal of intraocular foreign bodies.

There has been one previous case report of successful manage-ment of an intralenticular metallic foreign body where the patientmaintained good vision for some 40 years after the injury.2 Our casereport highlights the benefit in planning surgical management as atwo-staged procedure after appropriate investigations for thisunusual case. Advent of trypan blue to dye the capsule in thepresence of white lens opacity and further advancement in micro-incision phacoemulsification will further aid in the management ofthese surgically challenging cases.

Anupma Kumar MRCOphth,1 Vinod KumarFRCSEd(Ophth)2,3 and Robert B Dapling FRCS1

1Royal Shrewsbury Hospital, Shrewsbury, 2University Hospital ofWales, Cardiff, and 3Princess of Wales Hospital, Bridgend, UK

REFERENCES

1. Dannenberg AL, Parver LM, Brechner RJ, Khoo L. Penetratingeye injuries in the workplace; the National Eye Trauma SystemRegistry. Arch Ophthalmol 1992; 110: 843–8.

2. Cazabon S, Dabbs TR. Intralenticular metallic foreign body. JCataract Refract Surg 2002; 28: 2233–4.

3. Keeney AH. Intralenticular foreign bodies. Arch Ophthalmol1971; 86: 499–501.

4. Sneed SR, Weingeist TA. Management of siderosis bulbi dueto a retained iron-containing intraocular body. Ophthalmology1990; 97: 375–9.

Figure 1. White cataract debulking with phacoemulsification andintralenticular foreign body.

Figure 2. Removal of foreign body.

Orbital foreign body masquerading as conjunctival melanoma 60 years after injury

ABSTRACT

A 74-year-old man presented with a 6-month history of a pigmentedconjunctival lesion on his left eye. The lesion was initially suspiciousfor conjunctival melanoma. The patient admitted to a remote historyof trauma from a airgun pellet over 60 years ago. Anterior examina-tion revealed a 6 × 6 mm pigmented left conjunctival lesion and B-scan of the lesion was suggestive of a retained orbital foreign body.The lesion was removed through a transcaruncular medial orbitomyand pathology showed a retained orbital foreign body. A newlypigmented conjunctival lesion although initially concerning for mela-noma represented a retained orbital body that surfaced many yearsafter the initial orbital trauma.

Key words: airgun pellet, ocular trauma, orbital foreign body.

INTRODUCTION

Surgical removal of intraorbital foreign bodies is controversial andindications for surgery include optic nerve compromise, extraocularmovement restriction, inflammation or infection.

Herein, we report a case of a man with a 6-month history of apigmented conjunctival lesion which represented a surfacing orbitalforeign body.

CASE REPORT

A 74-year-old white man was referred to the oculoplastic andorbital surgery clinic with a 6-month history of a gradually enlarg-ing pigmented left conjunctival mass (Fig. 1). His past ocular his-tory included a vague history of orbital injury from a airgun pelletover 60 years ago. No surgical interventions were performed at thetime of the injury and he remained asymptomatic until hispresentation.

On examination his best-corrected visual acuity was 6/6 in botheyes. There was a 6 × 6 mm pigmented lesion on the medial aspectof the left eye. The rest of the anterior segment examination wasnormal but fundoscopic examination showed a nasal chorioretinalscar consistent with sclopetaria (Fig. 2). A diagnostic B-scan ultra-

662 Letters to the Editor

sound of the affected lesion demonstrated a ringing effect from aforeign body located inferonasally with respect to the globe(Fig. 3). A transcaruncular medial orbitotomy was performed withcomplete removal of the mass and the mass was sent for histopatho-logical examination (Fig. 4). The specimen was consistent with aretained metallic foreign body.

DISCUSSION

Surgical removal of intraorbital foreign bodies is controversial andindications for surgery include optic nerve compromise, extraocularmovement restriction, inflammation or infection. Without theseindications retained foreign bodies are well tolerated in the orbitwith limited complications and may spontaneously migrate andsurface after the initial injury.1,2

In our case, the appearance of the pigmented lesion 60 yearsafter the initial trauma raised concerns for an acquired melanoma.Conjunctival melanomas are potentially lethal neoplasms often aris-ing from de nova, nevi or primary acquired melanosis on the con-junctiva and previous reports have described occult foreign bodiessimulating a choroidal and conjunctival melanoma.3,4 Although thepigmented lesion appeared suspicious for a conjunctival melanoma,it represented a retained orbital foreign body that surfaced manyyears after the initial orbital trauma.

Christopher D Gelston MD,1 Naresh Mandava MD2 andVikram D Durairaj MD3

Departments of 1Ophthalmology, 2Ophthalmology, Vitreous and RetinaSurgery and 3Ophthalmology, Oculoplastic and Orbital Surgery,

Rocky Mountain Lions Eye Institute, University of Colorado School ofMedicine, Denver, Colorado, USA

Figure 1. Left eye with a pigmented conjunctival lesion suspi-cious for melanoma.

Figure 2. Fundus photograph shows a nasal chorioretinal scarconsistent with presumed sclopetaria.

Figure 3. B-scan ultrasound showing a conjunctival foreign bodyand acoustic shadow suggestive of a foreign body.

Figure 4. A 6 × 6 mm metallic foreign body retrieved during amedial orbitotomy.

Letters to the Editor 663

REFERENCES

1. Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraor-bital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20: 232–6.

2. Duke-Elder S, MacFaul PA. Foreign bodies in the orbit. In:Duke-Elder S, ed. System of Ophthalmology, Vol. 14. St Louis,MO: Mosby, 1972; 655–69.

3. Lebowitz HA, Couch JM, Thompson JT, Shields JA. Occultforeign body simulating a choroidal melanoma with extras-cleral extension. Retina 1998; 8: 141–4.

4. Guy JR, Roa NA. Graphite foreign body of the conjunctivasimulating melanoma. Cornea 1985–86; 4: 263–5.

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Asymptomatic choroidal granulomas in common variable immunodeficiency

ABSTRACT

Common variable immunodeficiency disease represents the mostcommon cause of significant antibody deficiency in adults. It is aheterogeneous group of disorders that can be sporadic or familialwith various modes of inheritance with defects in B-cell function,regulatory T-cells and macrophage function all being reported. Hereina case of asymptomatic bilateral choroidal granulomatous disease ina 27-year-old man with common variable immunodeficiency diseaseis described.

INTRODUCTION

We report a case of asymptomatic bilateral choroidal granuloma-tous disease in a patient with common variable immunodeficiencydisease (CVID). We discuss ocular features of CVID, how our casediffers from previously reported cases and how it may be differen-tiated from other conditions, in particular sarcoidosis.

CASE REPORT

A 27-year-old man was referred by the optician with ‘pigment spots’in the right fundus. He had normal visual acuity and was otherwiseasymptomatic.

Fundal examination revealed multiple, pale, deep choroidallesions in both eyes with no signs of inflammation in anterior orposterior segments (Figs 1,2). Furthermore, there was no clinicalevidence of current ocular or systemic infections and he had nosystemic symptoms. His past ophthalmic history wasunremarkable.

About 8 years previously he had presented with hypogamma-globulinaemia, autoimmune haemolytic anaemia, thrombocytope-nia and recurrent infections and was diagnosed with CVID(granulomatous antibody-deficient variant).

At the time of his consultation in the eye clinic he was beingtreated with 50 mg of oral prednisolone for a second episode ofhaemolytic anaemia. His serum angiotensin-converting enzymewas elevated at 70 (8–55 IU/L) with normal serum calcium andchest X-ray. His immunoglobulin (Ig) levels were reduced (IgA0.1 g/L [0.7–4 g/L], IgM 0.6 [0.4–2.3 g/L] and IgG 10.8 [7–16 g/L][reflecting replacement IgG treatment]).

DISCUSSION

Common variable immunodeficiency disease represents the mostcommon cause of significant antibody deficiency in adults. It is aheterogeneous group of disorders that can be sporadic or familialwith various modes of inheritance with defects in B-cell function,regulatory T-cells and macrophage function all being reported.1

The primary pathology, however, is a defect of Ig production withsubsequent increased susceptibility to infection, autoimmune disor-ders, inflammatory disorders and increased incidence of malig-nancy, particularly lymphoma.2 Non-caseating granulomas occur inabout one-third of patients with deposition in many organs includ-ing the choroid and differentiation from sarcoid in such cases canbe difficult. A sarcoid-like syndrome can be seen in about 8% ofpatients with elevated serum angiotensin-converting enzyme levelsand has been described in the presence of CVID.2

In our patient there were no clinical features suggestive of sar-coidosis and his chest X-ray was normal; however, high-resolutioncomputerized tomography of the chest has proven to be a moresensitive test in such cases.3 In our patient high-resolution comput-

Figure 1. Right eye demonstrating choroidal lesions.

Figure 2. Left eye demonstrating choroidal lesions.

664 Letters to the Editor

erized tomography of the chest demonstrated widespread lym-phadenopathy and parenchymal nodules; however, radiologistswere not able to differentiate CVID from sarcoidosis by comput-erized tomography criteria alone.

Furthermore, the combination of normal calcium levels,haemolytic anaemia, thrombocytopenia and hypogammaglobuli-naemia argue against a primary diagnosis of sarcoid, althoughhypogammaglobulinaemia can be seen in patients with CVID andconcurrent sarcoidosis.4

Immunophenotyping did not reveal lymphoma and performingan infection serology would not have been useful as there is noantibody response in CVID.

Previously reported cases of CVID with ocular involvement areextremely rare. Cohen et al. described bilateral granulomatous ante-rior uveitis, optic nerve oedema and multiple areas of choroidalpallor that was eventually linked to a diagnosis of CVID.2 Ocularresponse to treatment with steroids remains unclear.

In the case mentioned early the anterior uveitis responded wellto topical steroids although the fate of the posterior segmentinflammation was unclear.5 Retinal vasculitis with optic nerve andmacular oedema has also been linked to CVID in a series of threechildren describing a variant autoimmune manifestation of this con-dition. In this report visual acuity improved in only one case treatedwith oral steroids and cyclosporin.6

All the cases reported, however, have been symptomatic andhad other signs of active intraocular inflammation. Our patient didnot report any ocular symptoms nor did he have any evidence ofactive inflammation. This might be due to his previous oral steroidtreatment for CVID-associated complications although previousreports describe a variable response of uveitis to steroids.

The chorioretinal findings were asymptomatic and appearedquiescent. It is possible that the patient had active, asymptomaticinflammation in the past that has now settled.

Such lesions have been noted in other conditions such as carri-ers of X-linked chronic granulomatous disease that is associatedwith recurrent infections secondary to abnormal phagocyticfunction.7

Patients with the granulomatous variant of CVID are often onimmunosuppressive treatment and ocular inflammation may beasymptomatic as in our case. We suggest that a retinal examinationmay be useful as part of the initial assessment of patientswith granulomatous CVID to detect possible posterior segmentinflammation.

Shaharm Kashani MRCOphth,1

Gus Gazzard FRCOphth,1

Stephen Jolles MRCPath2 andGenevieve Larkin FRCOphth1

1King’s College Hospital, Rotherhithe, and2Royal Free Hospital, London, UK

REFERENCES

1. Sewell C, Buckland M, Jolles S. Therapeutic strategies incommon variable immunodeficiency. Drugs 2003; 63: 1359–71.

2. Cohen V, Lee J, Egner W, Whyite M, Rennie I. Bilateral gran-ulomatous uveitis in association with common variable immu-nodeficiency. Br J Ophthalmol 2001; 85: 625.

3. Kaiser P, Lowder C, Sullivan P et al. Chest computerizedtomography in the evaluation of uveitis in elderly women. AmJ Ophthalmol 2002; 133: 499–505.

4. Fasano M, Sullivan K, Sarpong S et al. Sarcoidosis and commonvariable immunodeficiency. Report of 8 cases and review ofliterature. Medicine 1996; 75: 251–6.

5. Gray R, Vodden J, Gomples M. Uveitis in a patient with com-mon variable immunodeficiency. Eye 2003; 17: 99–101.

6. Van Meurs J, Lightman S, de Waard P, Baarsma G. Retinalvasculitis occurring with common variable immunodeficiencysyndrome. Am J Ophthalmol 2000; 129: 269–70.

7. Goldblatt D, Butcher J, Thrasher A, Russell-Eggitt I. Chorioret-inal lesions in patients and carriers of chronic granulomatousdisease. J Pediatr 1999; 134: 780–3.