original clinical study
Combined Cataract Extraction With Pars Plana Vitrectomy
and Metallic Intraocular Foreign Body Removal
Through Sclerocorneal Tunnel Using a Novel
“Magnet Handshake” Technique
Pankaja Dhoble, MS, and Ashish Khodifad, DNB
Purpose: To study the outcomes of combined cataract extraction with
pars plana vitrectomy (PPV) and metallic intraocular foreign body (IOFB)
removal through a sclerocorneal tunnel using the “magnetic handshake”
technique.
Design: A retrospective review.
Methods: Retrospective review of case records of 14 patients from
2010 to 2016 with metallic IOFB and traumatic cataract was performed.
Cataract extraction was combined with PPV. Two intraocular magnets
(IOMs) introduced through 20-gauge vitrectomy port and sclerocorneal
tunnel helped achieve safe delivery of IOFB outside the globe by the
“magnetic handshake” technique.
Results: All patients were males with a mean age of 33.04 years. A
final best corrected visual acuity (BCVA) of 20/60 or better was noted in
10 (71.42%) of 14 patients. Final reattachment with more than 1 surgery
was achieved in 13 (92.85%) patients. Postoperative complications in‑
cluded retinal detachment (RD) and phthisis bulbi in 1 (14.28%) patient
each.
Conclusions: Combined cataract extraction with PPV and metallic
IOFB removal through sclerocorneal tunnel using the “magnet hand‑
shake” technique gives good visual and surgical outcomes.
Key Words: intraocular foreign body removal, “magnet handshake”
technique, traumatic cataract, IOFB
(Asia-Pac J Ophthalmol 2017;6:0–0)
T he incidence of intraocular foreign bodies (IOFBs) in pen‑
etrating eye injuries is 14% to 45%.1‒3 Such injuries are an
important cause of visual loss in young males.1‒3 Various surgi‑
cal techniques to remove IOFBs have been described.4 Pars plana
vitrectomy (PPV) is the current treatment of choice for posterior
segment IOFB.4,5 With the advent of small-gauge vitrectomy,
standard 3-port, 23-gauge6 or 25-gauge7,8 vitrectomy has been
employed for posterior segment IOFB removal.
Small (<1.0 mm) metallic IOFBs are removed with an intra‑
ocular magnet (IOM). Medium-sized IOFBs (1.0–3.0 mm) and
larger IOFBs (3.0‒5.0 mm) are better removed with various avail‑
able intraocular forceps.9
The route by which the IOFB should be removed depends on
From the Retina Services, Aravind Eye Hospital, Pondicherry, India.
Received for publication June 4, 2017; accepted August 25, 2017.
The authors have no funding or conflicts of interest to declare.
Reprints: Pankaja Dhoble, MS, Retina Services, Aravind Eye Hospital, Cuddalore
Road, Thavalakuppam, Pondicherry, 605007, India. E‑mail: pankajadhoble@
yahoo.co.in.
Copyright © 2017 by Asia Pacific Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.22608/APO.2017207
Asia-Pacific Journal of Ophthalmology • Volume 0, Number 0, Month 2017
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
its size and volume.9 Small and medium-sized IOFBs are normally
removed through the sclerotomy.9 However, the wound needs to
be enlarged. This is associated with complications like hypotony,
vitreous incarceration, and retinal detachment.10,11 Large IOFBs
greater than 4.0 × 4.0 × 4.0 mm cannot be removed through the
sclerotomy and need to be removed through the scleral tunnel by
sacrificing the lens.9
The incidence of traumatic cataract in cases of open globe
injury and retained IOFB is 45%.12,13 Despite advances in micro‑
surgical techniques, management of these cases is challenging.
Various studies have shown good results with primary cataract
extraction, IOFB removal, and intraocular lens (IOL) implanta‑
tion.14‒16 Cataract extraction has been performed by lensectomy,17,18
manual small-incision cataract surgery,19 and phacoemulsifica‑
tion. The IOFB has been removed by intraocular forceps through
the scleral tunnel19 or by enlarging the sclerotomy wound.20,21 The
advantages of this combined procedure are better visualization of
the posterior segment during vitrectomy and early visual rehabili‑
tation of the patients.
In this study we describe the outcomes of removing IOFB
through the sclerocorneal tunnel in patients with open globe in‑
jury, traumatic cataract, and metallic IOFB using the modified
“magnet handshake” technique.
materials and methods
A retrospective review of hospital records between 2010 and
2016 was performed. Consent was obtained from the institutional
review board. Fourteen patients with open globe injury, traumatic
cataract, and metallic IOFBs were included. In every case a com‑
plete preoperative eye examination was carried out. The presence
of IOFB was confirmed using B-scan ultrasonography and plain
X-ray of the orbit in cases where cataract prevented the direct
visualization of IOFB. At each follow-up visit, slit-lamp exami‑
nation, indirect ophthalmoscopy, intraocular pressure (IOP) with
applanation tonometry, and best corrected visual acuity (BCVA)
were performed.
Surgical Technique
Corneal wound repair was done in 8 (57.14%) of the 14 pa‑
tients (Fig. 1); 1 patient needed scleral tear suturing. In 5 (35.71%)
other patients the corneal wound was self-sealing. All corneal
wounds were linear and singular.
In all patients a 6-mm triplanar sclerocorneal tunnel was
made. The tunnel was made 2 mm from the limbus in the superior
quadrant. Phacoemulsification or lens aspiration was performed
through the tunnel by an anterior segment surgeon (Fig. 2). Ex‑
cept for 1 patient with scleral tear, both anterior and posterior
capsule rupture, along with traumatic cataract, were present in all
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Dhoble and Khodifad
figure 1. A case of penetrating injury. Primary corneal repair was done.
patients. Care was taken to create good anterior continuous circular
capsulorrhexis (CCC). Vitrectomy cutter was used to smoothen or
enlarge the irregular posterior capsular tear.
Pars plana vitrectomy and IOFB removal was done by a
single retinal surgeon (P.D.) using the “magnet handshake” tech‑
nique (Fig. 3). Standard 3-port PPV with 23-gauge infusion port
and handheld light source was combined with 20-gauge vitrecto‑
my port. Core vitrectomy was combined with 360-degree scleral
indentation and removal of vitreous debris. Posterior vitreous de‑
tachment was induced using active suction in patients when not
present.
Foreign body was identified and freed from surrounding vit‑
reous. An IOM was introduced through the 20-gauge vitrectomy
port. The metallic IOFB was lifted through the posterior capsule
defect to the iris plane. A second IOM was introduced through the
scleral tunnel. The IOFB was transferred from one IOM to an‑
other in a “magnet handshake” manner and delivered outside the
eye through the scleral tunnel. There was no slippage of the me‑
tallic IOFB into the vitreous, though at times clasping of both the
IOMs occurred. However, the magnets could be easily separated
without slippage of the IOFB. Hence, care was taken to touch
only the IOFB and not the second IOM, to prevent the magnets
from clasping together.
Endolaser was applied in patients with retinal tears at the site
figure 3. “Magnet handshake” technique.
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Asia-Pacific Journal of Ophthalmology • Volume 0, Number 0, Month 2017
figure 2. Construction of sclerocorneal tunnel.
of foreign body impact. Silicone oil was used as tamponade in 2
patients with preoperative retinal detachment (RD) and choroidal
detachment (CD). None of the patients underwent 360-degree
silicone buckle.
Endophthalmitis was present in 1 (7.14%) patient preop‑
eratively. This patient was given intravitreal antibiotics intraop‑
eratively after removal of IOFB. None of the patients developed
postoperative endophthalmitis.
Nine patients underwent primary IOL implantation. After re‑
moval of IOFB, 3-piece polymethylmethacrylate (PMMA) IOL
with 6-mm optic was placed in the sulcus over the anterior cap‑
sular rim.
After removal of IOFB, its size was measured using a ruler
(Fig. 4). Postoperatively all patients received tablet ciprofloxacin
500 mg twice daily for 5 days. Topical antibiotics, steroids, and
cycloplegics were given in tapering doses for 4 weeks. Systemic
steroids were given in patients with severe inflammation. Follow-
up duration ranged from 4 to 48 months with a median of 12
months.
There were no intraoperative complications. Early postop‑
erative complications (within 1 month after surgery) included
corneal edema, fibrinous reaction in anterior chamber, and raised
IOP. Late postoperative complications (after 1 month of surgery)
included raised IOP, phthisis bulbi, and RD.
figure 4. Measuring size of IOFB (6 mm).
© 2017 Asia-Pacific Academy of Ophthalmology
Asia-Pacific Journal of Ophthalmology • Volume 0, Number 0, Month 2017 Magnet Handshake Technique for IOFB Removal

Table 1. Summary of Cases

Duration of Presentation Size of IOL

Age After Injury (d) Fundus IOFB (mm) Site of IOFB Implantation Follow-Up (mo) Preop VA Postop VA

44 5 ‒ 1×1 Vitreous Primary 12 20/80 20/20

55 1 RD, CD 4×2 Vitreous Aphakia 6 PL + PL +
28 1 VH 1×1 Vitreous Primary 48 1/60 20/20
37 1 ‒ 9×4 Vitreous Secondary 36 PL + 20/20
38 7 VH 6×3 Vitreous Primary 12 HM + 20/40
17 3 ‒ 4×2 Vitreous Primary 32 20/60 20/20
40 300 Siderosis 5×2 Vitreous Primary 12 20/30 20/60
19 360 Siderosis 3×1 Vitreous Primary 7 20/80 20/20
38 4 ‒ 5×4 Vitreous Primary 10 HM + 20/30
48 5 ‒ 2×2 Vitreous Secondary 4 PL + 20/120
28 7 ‒ 4×1 Retina Secondary 12 HM + 20/200
31 1 ‒ 4×3 Vitreous Primary 4 20/40 20/30
15 1 RD, CD 9×4 Retina Aphakia 24 HM + 3/60
31 9 VH 6×3 Vitreous Primary 4 20/80 20/40

HM indicates hand movement; PL, perception of light; Postop, postoperative; Preop, preoperative; VH, vitreous hemorrhage.

Results and 20/80 in 1 (10%) patient, and counting fingers at 3 m or less

The details of all the cases are summarized in Table 1. All
the patients were males with a mean age of 33.04 ± 11.68 years
(range, 15‒55 years). The elapsed time between injury and IOFB
removal ranged from 1 to 334 days. Twelve (85.71%) out of the
14 cases presented within 10 days of injury. Two cases presented
at 300 and 360 days after trauma. The average time elapsed be‑
tween injury and presentation excluding these 2 cases was 3.75 ±
2.86 days. Follow-up duration ranged from 4 to 48 months, with
a median of 12 months (Table 2).
Entry site was corneal in 13 (92.85%) patients and scleral in
1 patient. The patient with scleral tear did not have a traumatic
cataract. The size of IOFB was 9 mm in this patient. Hence, clear
lens aspiration and removal of IOFB by the “magnet handshake”
technique through the sclerocorneal tunnel was done. At presen‑
tation 6 (42.84%) patients showed uveal prolapse, whereas 3
(21.42%) patients had iris defect (Table 3).
The average size of IOFB in our study was 4.42 ± 2.56 mm
(range, 1 mm to 9 mm). Small IOFBs were present in 2 (14.30%)
patients, medium-sized IOFBs in 2 (14.30%), and 10 (71.42%)
patients had large sized IOFBs (≥3 mm). Out of 10 patients with
large IOFBs, 6 (60%) patients had IOFB of 3 to 5 mm, 2 (20%)
patients had IOFB of 5 to 7 mm, and 2 (20%) patients had IOFB
of 7 to 9 mm (Table 4).
Out of 10 patients with large IOFB, final BCVA of 20/60 or
better was achieved in 7 (70%) patients, BCVA between 20/200
in 2 (20%) patients.
Both our patients with poor visual outcomes had large IOFBs.
Both these patients had RD with CD at the time of presentation.
Silicone oil tamponade was used in these patients. One of these
2 patients developed phthisis bulbi after surgery and did not un‑
dergo further surgical intervention.
The other patient developed postoperative RD after 1 month
due to retinal fibrosis and reopening of old inferior retinal tear.
Surgical reintervention included vitrectomy, endophotocoagula‑
tion, and silicone oil (5000 centistokes) tamponade. Although the
retina was attached at final follow-up, visual improvement was
poor.
Two (14.28%) patients developed increased IOP, which was
controlled by a single topical medication. Siderosis bulbi was
seen in 2 (14.28%) patients, who had duration of IOFB for 9 and
11 months, respectively.
In our study, primary IOL implantation was done in 9
(64.25%) patients. Three (21.45%) patients underwent secondary
IOL implantation in the sulcus, whereas 2 (14.30%) patients were
left aphakic at last follow-up (Table 5).
There were no intraoperative complications. Early postopera‑
tive complications included corneal edema in 3 patients (21.42%),
fibrin membrane in 6 (42.85%), and raised IOP in 4 (28.57%)
Table 3. Anterior Segment Findings

IOFB Entrance
Table 2. Demographic and Clinical Features
Corneal 13 (92.85%)
Scleral 1 (7.15%)
Age in years, mean ± SD (range) 33.04 ± 11.68 (15‒55 y)
Corneoscleral 0 (0.0%)
Sex
Iris
Male 14
Uveal prolapse 6 (42.9%)
Female 0
Iris defect 3 (21.45%)
Interval in days, mean ± SD, (range)* 3.75 ± 2.86 (1‒9 d)
Lens
Follow-up in months, median (range) 12 (4‒48 mo)
Traumatic cataract 13 (92.85%)
*Injury to presentation, excluding 2 cases at 300 and 360 days. Clear lens 1 (7.15%)

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Dhoble and Khodifad Asia-Pacific Journal of Ophthalmology • Volume 0, Number 0, Month 2017

Table 4. Characteristics of Intraocular Foreign Bodies Table 5. Surgical Details

IOFB location Intraocular lens

Vitreous 12 (85.7%) Primary 9 (64.35%)
Retina 2 (14.3%) Secondary 3 (21.45%)
IOFB size Aphakia 2 (14.30%)
Small (≤1 mm) 2 (14.3%) Intraoperative complications Nil
Medium (1‒3 mm) 2 (14.3%) Early postoperative complications (in 1 month after surgery)
Large (≥3 mm) 10 (71.5%) Corneal edema 3 (21.5%)
Large IOFBs Raised IOP 4 (28.60%)
3 to 5 mm 6 (60%) Fibrinous reaction 6 (42.90%)
5 to 7 mm 2 (20%) Late postoperative complications (after 1 month)
7 to 9 mm 2 (20%) Phthisis bulbi 1 (7.15%)
Retinal detachment 1 (7.15%)
Raised IOP 2 (14.30%)
patients. Late postoperative complications included raised IOP in
2 (14.28%) patients, phthisis bulbi in 1 (7.14%) patient, and RD
in 1 (7.14%) patient (Table 5). manner. The second IOM helps in holding and delivering the
Final BCVA of 20/60 or better was noted in 10 (71.42%) IOFB safely outside the tunnel. In this study the average size of
patients; 2 (14.28%) patients had final BCVA 20/200 to 20/80 IOFB was 4.42 mm. Foreign body forceps is usually adequate
and 2 (14.28%) patients had final BCVA less than 20/200 (Table enough to hold IOFBs of the average size of 4‒5 mm. However,
6). Primary anatomical success was achieved in 12 (85.71%) pa‑ our technique can be preferred for this size of IOFB, as it will
tients. Final reattachment with more than 1 surgery was achieved prevent slippage and is safe. This technique may be especially
in 13 (92.85%) patients. useful in cases of large irregular IOFB, of more than 5 mm, as the
forceps may not be adequate enough to hold the IOFB.
In our patients, risk factors determining the final visual
Discussion prognosis were mainly poor presenting visual acuity, large size
In our retrospective case series of traumatic cataract and of IOFB, and preoperative presence of RD and CD. In this se‑
metallic IOFB, we have combined cataract extraction with vit‑ ries, large IOFBs were present in 71.4% of patients. Several
rectomy. Intraocular foreign bodies were removed through the studies have shown poor visual prognosis associated with large
sclerocorneal tunnel using 2 IOMs introduced through the 20- IOFBs.8,14,15 A large IOFB can enter the eye with high velocity and
gauge vitrectomy port and sclerocorneal tunnel. This combined cause severe injury at presentation.11 Another important cause of
procedure not only aided in removing the traumatic cataract but poor visual outcome is the trauma occurring to the ocular struc‑
also helped in removing IOFBs of all size through the sclerocor‑ tures while removing a large IOFB through the enlarged scleroto‑
neal tunnel, without the need to enlarge the sclerotomy wound. my port.25‒27 Although all patients in our study who had poor final
Irregular posterior capsule tear can occur while removing a large BCVA of less than 20/200 had injury with large IOFB, good final
IOFB. Hence, in these cases it is important to create good anterior BCVA of 20/60 or better was achieved in a majority (70%) of
CCC for implantation of an IOL. patients with large IOFB with our technique.
Various studies have described phacoemulsification of trau‑ Preoperatively, RD and CD were present in 2 (14.28%) pa‑
matic cataract and removal of metallic IOFB through the limbal tients who were injured by large IOFB. Postoperatively, 1 of these
route.8,22 Singh et al22 inserted 20-gauge diamond-coated IOFB case developed RD, whereas the other developed phthisis bulbi.
forceps through the limbal wound and metallic IOFB was grasped Both these patients had poor surgical and visual outcomes.
along its longest dimension and removed through the limbal port. In a study conducted by Wani et al,11 preoperative RD was
In a study conducted by Mahapatra et al,19 magnetic IOFBs present in 17.5% patients with IOFB. They found the presence of
were lifted to the pupillary plane using an IOM and then forceps preoperative RD to be a crucial factor for development of post‑
were used to grasp the IOFB and remove it through the sclerocor‑ operative RD and predictor of poor visual outcome.11 Chiquet et
neal tunnel.19 al26 similarly reported poor final visual acuity (VA) of less than
Extraction of long, smooth IOFB by phacoemulsification 20/400 in 75% of patients having RD at presentation. Hence, we
and through small corneal incisions has also been reported.8,18,23 feel an aggressive approach in the presence of these risk factors is
However, removing large irregular IOFB through the corneal needed to improve visual outcome.
wound can result in irregular astigmatism, poor wound healing,
and increased loss of endothelial cells.24
Various studies in the literature also describe phacoemulsi‑ Table 6. Visual Acuity
fication of traumatic cataract and removal of IOFB through the
enlarged sclerotomy wound.6,14,16,21 Yuksel et al,6 in 47.2% of their Preoperative Postoperative
cases, combined 23-gauge vitrectomy, phacoemulsification, and Visual Acuity No. (%) No. (%)
removal of IOFB through the enlarged sclerotomy into a “T” or ≥20/60 3 (21.45%) 10 (71.50%)
“L” shaped wound. 20/200–20/80 3 (21.45%) 2 (14.30%)
We have modified this technique of removing IOFBs through ≤20/200 8 (57.10%) 2 (14.30%)
the sclerocorneal tunnel by using a second magnet in a handshake

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Asia-Pacific Journal of Ophthalmology • Volume 0, Number 0, Month 2017
Various studies have shown good results with primary
IOL implantation with IOFB removal. It provides early visual
rehabilitation and avoids a second intervention.14‒16 We deferred
primary IOL implantation in cases with severe ocular injury at
presentation (eg, RD, CD, inadequate zonular/capsular support)
and in cases where we anticipated a second vitreoretinal surgery.
These patients underwent secondary IOL implantation at a later
date, upon stabilization of their eye condition. However, we feel
IOFB removal with phacoemulsification and primary IOL im‑
plantation is a good option in less severe cases without RD, CD,
and endophthalmitis at presentation.
Final BCVA of 20/60 or better was achieved in 78.57% of our
patients. This success rate is comparable to the other studies that
have performed simultaneous phacoemulsification, PPV, IOFB
extraction through sclerotomy1,14,16 or sclerocorneal tunnel,19,22
and IOL implantation. Anatomical success, defined as attached
retina at last visit, was achieved in 92.85% of the patients.
Mahapatra et al19 reported visual acuity of 20/20 to 20/60
in 13 of the 17 cases (76.47%) who underwent PPV and IOFB
removal through the sclerocorneal tunnel combined with sulcus-
fixated IOL. These results are similar to our current study. Batman
et al1 reported visual acuity of 20/200 or better in 13 of 17 patients
(76%) in their study of combined clear corneal phacoemulsifica‑
tion, PPV, IOFB extraction, and IOL implantation. We also noted
similar visual outcomes in our study. Tyagi et al16 similarly re‑
ported BCVA of better or equal to 20/60 in 80% of their cases
who underwent removal of IOFB with cataract extraction.
The strength of the present study is that PPV and IOFB
removal by the “magnet handshake” technique in all the cases
were conducted by a single vitreoretinal surgeon. The study has
a good mean follow-up duration of 15.7 months. To the best of
our knowledge, this is the first case series describing the “magnet
handshake” technique and its visual outcomes. The limitations of
our study include its retrospective design and modest sample size.
The reason for the small sample size is the low incidence of IOFB
with traumatic cataract.
In conclusion, good visual and anatomical results were
achieved in our patients by combining cataract extraction and
IOFB removal through the sclerocorneal tunnel by the “magnet
handshake” technique. It can be a preferred technique for remov‑
al of large metallic IOFBs associated with traumatic cataract. It
would also be desirable to remove medium-sized IOFB by this
route, as it avoids enlarging the sclerotomy port. We found it
was preferable to remove IOFB through the sclerocorneal tun‑
nel, rather than through the sclerotomy, irrespective of the size
of the IOFB.
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