Accepted Manuscript

Intraocular Foreign Bodies: A Review

Dean Loporchio, MD, Lekha Mukkamala, MD, Kavya Gorukanti, MD, Marco Zarbin,
MD, PhD, Paul Langer, MD, Neelakshi Bhagat, MD, MPH

PII: S0039-6257(15)30051-5
DOI: 10.1016/j.survophthal.2016.03.005
Reference: SOP 6631

To appear in: Survey of Ophthalmology

Received Date: 21 October 2015

Revised Date: 6 March 2016
Accepted Date: 10 March 2016

Please cite this article as: Loporchio D, Mukkamala L, Gorukanti K, Zarbin M, Langer P, Bhagat
N, Intraocular Foreign Bodies: A Review, Survey of Ophthalmology (2016), doi: 10.1016/
j.survophthal.2016.03.005.

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 ACCEPTED MANUSCRIPT
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Intraocular Foreign Bodies: A Review

Dean Loporchio MD1, Lekha Mukkamala MD1, Kavya Gorukanti MD1, Marco Zarbin MD, PhD1,
Paul Langer MD1, Neelakshi Bhagat MD, MPH1
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Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University

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Corresponding Author:
Neelakshi Bhagat, MD, MPH
Institute of Ophthalmology and Visual Science

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90 Bergen Street, Suite 6100
Newark, NJ 07103
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bhagatne@njms.rutgers.edu
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Abstract

Intraocular foreign body (IOFB) injuries can result in a wide range of intraocular pathology and
visual outcomes based on the mechanism of injury, type of foreign body, and subsequent complications.
We have reviewed the literature to describe the epidemiology and mechanisms of such injuries,

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types of foreign bodies, imaging tools for diagnosis, current trends in management, pre-surgical and
surgical interventions, as well as visual prognosis and potential complications. The purpose of this

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review article is to familiarize clinicians with the recent advances in diagnosis and management of such
injuries.

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Key Words

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Intraocular foreign body; Open globe injury; Ruptured globe, Endophthalmitis; Siderosis bulbi;
Chalicosis; Nail gun injury; Ocular trauma; Penetrating ocular injury, Sympathetic ophthalmia
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I. INTRODUCTION
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Open globe injury (OGI) often can result in serious visual loss and imposes a significant economic
burden on the patient and society. Intraocular foreign bodies (IOFBs) account for 18%-41% of all OGIs. 99,
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138, 141
Most post-traumatic IOFBs (58%-88%) reside in the posterior segment. 99, 141, 15, 120, 136 The extent
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of ocular injury and visual prognosis depends on the IOFB size, the zone of the injury, and the ensuing
complications. 136, 36, 39, 53, 59 For open-globe perforating injuries, the zone is described by the most
posterior defect, as opposed to the “site” of injury (typically entrance site). Here, we review the
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diagnosis, medical and surgical management, and outcomes of IOFB-associated open globe injury.

II. EPIDEMIOLOGY
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Among an estimated 2.4 million eye injuries occurring each year in the United States, between
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20,000 and 68,000 are serious vision-threatening injuries. 98 According to the United States eye injury
database, the places of injury include: home (43%), industrial premises (20%), recreation and sport
(13%), street and highway (15%), school (3%), farm (3%), and public buildings (3%). The causes of injury
include: various blunt objects (34%), various sharp objects (26%), motor vehicle crash (10%), gunshot
(6%), BB and pellet gun (6%), fall (5%), fireworks (5%), hammering on metal (5%), and explosion (3%). 41
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The incidence of IOFBs among open globe injuries ranges from 18% to 41%. 47, 65, 136, 141 Young
males constitute 92-100% of the patients presenting with IOFBs. 25, 53, 55, 74 The average age of a patient
with an IOFB is 29 to 38 years of age with a majority (66%) of the patients between 21 and 40. The most
common place of injury is work (54-72%) followed by home (30%). Most common causes include
hammering (60-80%), usage of power or machine tools (18-25%), and weapon-related injuries (19%). 47,

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53, 55, 65, 136
Approximately 25% of the United States military service members seen by the Walter Reed
Army Medical Center Ophthalmology Service for combat related ocular injury in Afghanistan and Iraq

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since 2003 had intraocular foreign bodies. 28 One series in Turkey showed that 45 of 47 eyes suffering
OGI related to military activities had IOFB. 49 Less common causes of an IOFB-related injury include

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assault, motor vehicle accidents, lawn mower, and firework injuries. 62, 107

a. CHARACTERISTICS OF IOFBs

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Foreign body-related injuries can be penetrating or perforating. Foreign bodies that lie
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intraocularly are penetrating and can enter through the cornea (65%), sclera (25%), or at the limbus
(10%). 107 These foreign bodies are usually seen in the posterior segment in the majority (58-88%) of
cases, with most others in the anterior chamber (10-15%) or the lens (2-8%).53, 55, 128, 141
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A literature review conducted by Kuhn et al has shown that, in penetrating injuries, multiple IOFBs
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can be found in 8-25% of eyes, with an average size of an IOFB of 3.5 mm (Range: 0.5-25 mm).65 The
composition of IOFBs varies from organic material (e.g., insect parts and animal hairs), glass, plastic, or
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metals such as zinc, nickel, aluminum, mercury, iron and copper. 128 By far, most IOFBs are metallic in
nature. 141, 136, 42 Imaging modalities used in diagnosis may differ depending on the composition of the
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IOFB and are described below.

III. PATHOPHYSIOLOGY
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a. Direct Mechanical Damage

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Intraocular foreign bodies can cause direct mechanical damage along their path of entry into the
eye. Their path is not always linear, as they can ricochet and cause additional intraocular damage. For
example, intravitreal IOFBs can come to rest in the vitreous after rebounding off the retina.74 In one
study of 64 eyes with ferrous IOFBs in the posterior segment, there was a 66% probability of the metal
causing one retinal lesion and a 20% probability of causing two or more retinal lesions. 85
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The extent of intraocular damage caused by IOFBs depends on several factors. Wound length can
be used to predict the risk of retinal injury. A shorter wound means that less of the IOFBs energy is
dissipated during penetration and may travel much further inside the eye, allowing it to reach and injure
the retina. Foreign bodies entering the eye through the sclera are more likely to cause intraocular
damage than those entering though the cornea.65 Object shape can also be predictive of intraocular

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damage. Sharp IOFBs cause less damage than blunt ones of the same size. 65 This is presumably due to
the increased transfer of energy to the eye at the time of impact by blunt IOFBs as opposed to sharp

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IOFBs,103 which often enter through a smaller linear laceration. Retained IOFBs can exhibit long-term
toxicity as described below.

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b. Metallosis
i. Siderosis Bulbi

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A retained IOFB containing iron can lead to siderosis bulbi, which can occur in as short as 18 days
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after ocular injury.95 Iron deposition in the eye results in ocular siderosis, which includes iris
heterochromia, pupillary mydriasis, cataract formation, secondary glaucoma, and retinal pigmentary
degeneration. 84, 122, 143 Characteristic ERG changes of siderosis bulbi are an increased “a” wave followed
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by a continual reduction of the “b” wave. 65

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Ocular damage can be caused by the deposition of released iron from the IOFB as ferritin
throughout the cytoplasm of ocular cells especially in the form of siderosomes. 122 Chao and coworkers
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created experimental siderosis by administering an iron particle, FeSO4 in eyes of Wistar rats. This
experimental siderosis system resulted in the disorganization of the retina with loss of photoreceptor
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outer segments and cholinergic amacrine cells. Chao and coworkers suggest that retinal damage occurs
possibly due to oxidative stress combined with excessive glutamate release and increased calcium
influx.19
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ii. Chalcosis

An IOFB containing copper can cause another vision-threatening disease called chalcosis. The
pathogenesis of chalcosis is not clear, but one possible mechanism may be free radical attack. 112 In the
presence of copper, reactive free hydroxyl radicals can be generated from hydrogen peroxide, 112 which
is a product generated from the reaction between superoxide dismutase and superoxide free radicals.
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Some clinical signs of chalcosis include Kayser-Fleischer ring (green-blue perilimbal ring in the cornea
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at the level of Descemet’s membrane), tiny refractile copper particles in the anterior chamber or iris,
and formation of a sunflower cataract. 74

A copper foreign body can induce mild reversible retinal toxicity and/or a severe inflammatory
reaction, depending on its purity. However, Tokoro and associates have reported a case of a copper

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foreign body located in the lens for over 15 years without causing a severe inflammatory reaction. One
possible explanation could be that the epithelial cells in the lens encapsulated the foreign body, which
might reduce the diffusion of the copper ion. Alternatively the formation of water-insoluble copper

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oxide on the surface of the foreign body may have reduced copper ionization. Even though visual acuity
was restored in this case, the authors warn that pure copper in the anterior chamber or the vitreous

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cavity could have caused serious toxic effects.125 Copper-containing IOFBs should be removed, if
possible. Even after a copper IOFB is removed, the presence of retained copper powder can continue to

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cause ocular damage.3
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IV. ASSESSMENT OF INJURY
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a. History

An essential step in the pre-operative management of IOFBs is to collect a detailed history. The
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history should emphasize mechanism of injury,137 the setting in which the injury occurred (e.g., at work),
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the date and time of injury, whether safety glasses or other eye protection was used at the time of
injury, when the patient last had anything to eat or drink, whether the patient has allergies to any
medications, and events and interventions since time of injury. 107 In addition, one should inquire as to
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the eye’s baseline visual acuity before the injury occurred. Knowledge of the mechanism of injury might
aid in identifying the nature of the IOFB (e.g., metallic vs. vegetable) and/or its location.74 If the history
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is reliable, the patient’s perspective on the potential nature of the IOFB (metal from hammering or glass
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from a windshield) may be useful.

Patients sometimes do not experience pain or changes in visual acuity 65 and are unaware that
objects might have entered their eyes.74 The clinician should be suspicious of a potential IOFB(s) if the
patient’s history is suggestive of a possible IOFB or if the patient is engaged in high risk activities such as
the use of powered tools, projectile weapons (e.g., guns or BB guns), motor vehicle accidents,
explosions, any high impact trauma in which eyeglass lenses are fragmented, and any metal on metal
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impacts that can cause small objects to penetrate the globe.74 It is also important to keep in mind that
more than one IOFB may be present.86

b. Ocular Examination

After obtaining a history, a complete ocular examination including an external inspection of the

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injury and surrounding areas for obvious foreign bodies and lacerations, followed by visual acuity
assessment, pupillary evaluation, external slit–lamp and fundus examinations should be performed

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depending on the severity of the injury.107 If a globe rupture is present or suspected, special care should
be taken since pressure on the globe may cause expulsion of ocular contents. Therefore, applanation

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tonometry, gonioscopy, and scleral depression generally are not suggested until the entry wound has
been closed.55

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Apart from signs of a ruptured globe [e.g., low intraocular pressure (IOP), shallow anterior
chamber, irregular pupillary contour (e.g., tear drop shape)], some clinical signs of a possible IOFB
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include focal lens opacities, iris transillumination defect, iris heterochromia, and small self-sealing
wounds.107 Other signs of occult globe penetration include the following: subconjunctival hemorrhage,
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chemosis (particularly hemorrhagic chemosis), positive Seidel test, and restriction of extraocular
movements.128 In some cases, IOFBs can reside in locations that one cannot visualize clinically (e.g., in
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the anterior chamber angle, on the pars plicata) but which one can visualize with carefully performed
ultrasound biomicroscopy, as noted below.33, 52 Another indication of an occult IOFB may be an eye with
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endophthalmitis that seems to be resistant to antibiotic therapy.15 Repeat computed tomography (CT)
scan [or magnetic resonance imaging (MRI) if deemed safe] or ultrasound biomicroscopy (UBM) may be
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performed to assess this possibility.

c. Ocular Imaging
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Ocular imaging is a vital tool for management of IOFBs. Historically, ultrasonography, B-scan, X-ray
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imaging,1, 27 CT,40, 54, 60 and MRI75 have been the adjunct imaging tools used in detection of IOFBs. The
appropriate diagnostic tool for visualization and localization depends on the suspected composition and
location of the IOFB.

i. Plain Film Radiographs

Plain X-rays may be used as a screening modality to detect and localize foreign bodies in the eye or
orbital area; 110 however, IOFBs that are not radio-opaque can be missed by this method. 81 Plain X-rays
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sometimes reveal the presence of multiple IOFBs more readily than computed tomography (CT) scans,
as CT scan cuts may miss small IOFBs.

ii. Computed Tomography (CT)

Computed tomography of the orbits without contrast is the preferred method used in cases of

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globe rupture to examine the orbital and facial bones, the retrobulbar space, and the bilateral globes
themselves.135, 137 Scanning in two planes (sagittal and coronal) with thin cuts (1.0-1.5 mm) through the

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orbit is required.74 This CT modality is preferred because it is highly sensitive, can locate single or
multiple IOFBs, requires little patient cooperation, and does not lead to globe manipulation.55, 107 The

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minimum detectable size of IOFB on CT depends on its composition: steel and copper: 0.06 mm3;
aluminum and auto window glass: 1.5-1.8 mm3; and wood: if small, probably cannot be visualized
(unless coated with lead-containing paint).121 The amount of attenuation with or without surrounding

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artifact as well as Hounsfield units can be used to differentiate various types of foreign bodies.87
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There are two categories of CT imaging used in diagnosis of IOFBs: conventional CT and
helical/spiral CT. Conventional CTs are more commonly used due to more widespread availability in
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medical centers. Lakits et al have shown that helical CT with multiplanar reconstruction enables
accurate assessment of intraocular metallic, stone, and glass foreign bodies. 67 Some benefits of using
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helical CT over conventional CT include decreased examination time, less radiation exposure, better
multiplanar reconstruction ability, and reduced motion artifacts.67, 68, 69, 104 Using helical CT’s multiplanar
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reconstruction ability, one can obtain useful sagittal and coronal views without supplementary scanning.
This feature is especially beneficial to elderly patients and patients with neck injuries, who cannot be
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positioned for conventional CT coronal view. Helical CT has also been shown to be more sensitive than
axial CT, MRI, and sonography in detecting glass IOFBs.45
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Some limitations of using CT scans include the possibility of missing certain ceramic, plastic,74
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wooden, and metallic foreign bodies if too wide cuts are utilized or if the eye moves during the
procedure.12

iii. Ultrasonography

When an IOFB cannot be visualized directly or with a CT scan (e.g., glass, plastic), ultrasonography
can be used. It allows real-time imaging, high resolution (0.01-0.1 mm), multiple, rapid cross-sections
and is less expensive than other imaging modalities.74 However, it must be performed extremely
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carefully in select eyes with OGI, as the examination poses a risk of extruding globe contents due to
pressure of the probe. CT scan or MRI (depending on suspected composition of the IOFB) may be
performed as an adjunct to B-scan ultrasonography. With CT scanning, it can be difficult to determine
whether a metallic IOFB located near the sclera is intra- or extraocular due to reflection artifact.
Ultrasound imaging permits more accurate assessment of the IOFB location in this respect and is also

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used for assessment of the extent of related intraocular tissue damage.83 Using ultrasonography, one
can obtain multiple views of the same object and can see the object from various angles. This

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information can help in localization, size determination, and composition of an IOFB.139

Ultrasound biomicroscopy, an imaging technique that uses high frequency (50Mhz) sound waves,

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can be used to detect small, nonmetallic and anteriorly located foreign bodies in the angle or around
ciliary body, ciliary processes, and retrolental space.34 With UBM, one can image the anterior segment

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to a 5 mm depth. UBM imaging of the anterior segment affords an axial resolution of 30 µm, lateral
resolution of 60 µm and a depth of field of 0.85 mm. It is preferred to conventional B-scan for IOFBs in
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the anterior segment, which is limited to resolutions of 150 µm, 450 µm and 9.6 mm, respectively. 94, 111

As noted above, ultrasonography can disrupt the normal anatomy of the eye and the probe should
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be used very gently.139 Another disadvantage of using ultrasonography is that it requires sophisticated
machinery and skilled operator to distinguish artifacts from IOFBs.139 Wood and vegetable matter may
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be only intermediately reflective and can resemble blood or vitritis when imaged with ultrasonography.
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Sharp borders may suggest an IOFB. Finally, an air bubble in the vitreous can resemble an IOFB with
ultrasonography.
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iv. Magnetic Resonance Imaging (MRI)

MRI is utilized only when the presence of a metallic IOFB is ruled out. There are some metals, such
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as platinum, titanium, and tantalum that are MRI-compatible.11, 79, 123, 124, 142 Magnetic forces can cause
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movements of ferromagnetic foreign bodies leading to further intraocular damage including hyphema.72
To exclude the presence of a metallic IOFB, a detailed occupational and surgical history and an X-ray or
CT of the orbits should be performed before the MRI.130 Brunberg et al recommend using orbital plain
films as a prerequisite for MR imaging whenever a patient has a history of known IOFB or if the patient is
engaged in high risk occupational activities such as welding and metal working.90 However, in one
report, 1.0T MRI with 3mm cuts was able to detect tiny ferromagnetic IOFBs that were missed by CT
(also with 3mm cuts), plain film x-ray, and B-scan, without causing damage to ocular tissues. Therefore
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it was suggested that 1.0 T MRI may be useful to detect tiny (<0.5mm) ferromagnetic bodies that may
otherwise be missed.140 One series found that MRI was superior to CT in detecting and accurately
identifying the type of IOFB, based on an algorithm, and advocated the use of MRI once CT has been
used to exclude metallic foreign body.88, 89

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The multitude of diagnostic imaging techniques available for detection of IOFBs affords varying
levels of specificity for foreign bodies of various compositions. It is generally accepted that CT, especially
helical is the most reliable method, regardless of the location of IOFB and is recommended as the first-

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line diagnostic modality. 99, 51, 76, 102 Type of IOFB-specific imaging modalities will be discussed below.

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v. Special cases
1. Wood

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Wood IOFB injuries are typically encountered in an outdoor setting such as landscaping or
gardening. These IOFBs may resemble air on CT or MRI, appearing hypodense on CT and hypointense on
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T2-weighted MRI. However, the geometric shape of the IOFB (oblong/elongated) may aid in the
diagnosis and distinguish it from air.51 CT scanning is the preferred imaging modality, as it can be used
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when the nature of the IOFB is unknown, i.e., regardless of whether the IOFB is metallic or nonmetallic.
51, 82, 126
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In cases where CT scans are not definitive or appear negative despite high clinical suspicion of an
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IOFB, MRI and ultrasound imaging may be appropriate adjuncts to aid in ruling out an IOFB. 42, 33, 75, 51, 126,
2, 16, 46, 108, 117
On ultrasonography, organic IOFBs may appear (highly) reflective and hyperechoic in
comparison to surrounding tissue, with an anechoic shadow behind them.33
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2. Glass
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Glass IOFBs constitute a smaller percentage of retained IOFBs, ranging from 2.8%-17.6% in several
series.99, 141, 136, 42 The most common scenario leading to glass IOFBs is a motor vehicle accident. 44 Spiral
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CT with multiplanar reconstruction is an effective and preferred method for glass IOFB localization.99, 68
Various types of glass IOFBs will produce different attenuation signals when viewed on CT, with green
beer bottle glass being more easily detectable than spectacle glass, presumably due to green beer bottle
attenuation signal of 550 H, which is much higher than their reported spectacle glass samples (80 H) and
typical soft tissue upper limits (300 H).45, 17 Although lead is commonly found in different types of glass,
the authors did not note its influence in this study.
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Glass foreign bodies will appear as hyperechoic structures on ultrasonography and as hypointense
structures on T2-weighted MRI. High resolution scanning is available with MRI (as small as 3 mm
sections),78 however, glass IOFB identification may be difficult due to artifact. 66

3. Metallic

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The majority of retained IOFBs are metallic, which comprise 55%-91% of total IOFBs. 141, 136, 42 CT
scanning is the preferred primary imaging modality and is able to detect metal IOFBs with a threshold of

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0.07 mm3. 96 As noted above, the exact threshold depends on the composition of the metallic IOFB.135
Metallic IOFBs will appear on B-scan as echo-dense signals with marked shadowing posterior to the

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foreign body. They may be surrounded by fibrous tissue, depending on time of diagnosis and have also
been associated with “comet tail artifacts.” 71 Though MR imaging is contraindicated, certain materials
can be relatively safe. Platinum microcoils,79, 123, 124 tantalum clips (used in scleral buckles),11 and

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zirconium materials142 have been shown to be MRI-compatible. However, metallic IOFBs associated with
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OGI are likely to be impure compounds comprising ferromagnetic particles (iron, copper) that
contraindicate MRI use.
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V. MANAGEMENT
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a. Pre-Surgical Measures
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At the time of transport for evaluation and after examination until surgery, the injured eye should
be protected with a rigid shield. If a Fox shield is not available, another rigid device (e.g., inverted
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Styrofoam cup) can be used. The patient should be started on intravenous antibiotics emergently
(described below) if an OGI is suspected. IOFBs pose a significant threat of infection. If an IOFB is
suspected, it is important to ensure coverage for pathogens that are typically encountered in this
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setting, e.g., Bacillus, Clostridium, and coagulase-negative Staphylococci species 15,29. Cultures should be
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obtained and the patient’s tetanus status should be determined and enhanced if necessary 107.
Appropriate immunization should be achieved according to guidelines published by the Centers for
Disease Control and Prevention, and regularly updated by the Morbidity and Mortality Weekly Report
(the most up-to-date information can be accessed at
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a5.htm 119 for children from 0-18 years of age,
and http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a4.htm57 for adults greater than 19 years
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old). If needed, anti-nausea medication may be used to prevent vomiting which could potentially lead
to expulsion of intraocular contents 74.

b. Surgery
i. Delayed vs. Immediate Surgery for IOFB Removal

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The timing of IOFB removal depends on several factors, including the patient’s overall health status
(e.g., presence of life threatening injuries, ability to tolerate surgery), the nature of the injury (heat-

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sterilized missiles are probably less likely to induce infectious endophthalmitis whereas farm injuries
with contaminated IOFBs are more likely to cause endophthalmitis), and the composition of the IOFB

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(e.g., pure copper IOFBs induce an intense inflammatory response whereas glass IOFBs tend to be inert
and better tolerated). Globe repair with immediate IOFB removal is almost always recommended in
patients with clinical signs of endophthalmitis except in cases of a simultaneous life-threatening injury

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that would prevent ophthalmic surgery. If ophthalmologists who are experienced in the required
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surgery are not available, it may be better to delay IOFB removal and temporize with primary globe
closure and administration of intravitreal and systemic antibiotics.137 The patient can then be referred
expeditiously to the specialist for definitive treatment of FB removal.
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Yeh et al listed the potential advantages of immediate IOFB removal, which include a decrease in
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risk of endophthalmitis, a decrease in the rate of proliferative vitreoretinopathy (PVR) and a single
procedure for the patient. 137 According to the literature review conducted by Yeh et al, the average
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incidence of endophthalmitis with IOFBs during the past 30 years is 6.65% (range 0% - 16.5%, mean
13%). Some studies have shown that removal of IOFBs within 24 hours reduces the risk of
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endophthalmitis.53, 20 Chaudhry and coworkers reported that a crucial predictive factor for developing
endophthalmitis was delayed repair (>24 hours) of the globe and IOFB removal. Among the 589 eyes
that sustained ocular trauma with retained IOFB in their study, 44 eyes (7.5%) developed
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endophthalmitis. Of these 44 eyes, eleven (25%) had immediate IOFB removal and repair within 24
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hours after trauma compared to 33 eyes (75%) that underwent same procedures 24 hours or more after
the trauma.20 Similar results were reported by Jonas and associates who also found that patients who
had immediate removal of IOFBs within 24 hours had a lower rate of endophthalmitis (28.6%) compared
to those (71.4%) whose surgery was delayed for more than one day. 53 Incidences of infectious
endophthalmitis with IOFBs have been reported in numerous studies and are summarized in Table 1.
Additionally, the timing of removal is also described in Table 2.
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However, some investigators found that the timing of IOFB removal surgery is not a significant
factor in the development of post-traumatic endophthalmitis. Colyer and associates have reported that
delayed IOFB removal does not necessarily lead to post-traumatic endophthalmitis. 28 Their study
consisted of 79 eyes with a variety of retained IOFBs (e.g., metal, stone) in 70 US soldiers who sustained
ocular injury during Operation Iraqi Freedom and Enduring Freedom. The average patient age was 27

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years, with average postoperative follow up of 331 days. The average IOFB size was 3.7 mm, and the
mean time to IOFB removal was 38 days (range 2 – 661 days). There were no cases of endophthalmitis,

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siderosis bulbi, or sympathetic ophthalmia. Timing of pars plana vitrectomy (PPV) and IOFB removal
were not correlated with visual outcome. The authors attribute these results to 1) primary globe closure

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performed within hours of injury and 2) broad-spectrum antibiotics administered promptly. Almost all
patients received antibiotic treatment, with 86% receiving systemic (oral or IV) antibiotics in addition to
topical medications. Only three patients were given intravitreal antibiotics (vancomycin and

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ceftazidime), solely based on surgeon preference, not signs of endophthalmitis. 28 Also, the high-speed
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metallic objects most likely were self-sterilized with friction-generated heat. Non-metallic IOFBs such as
stone, however, may not have been so sterilized.
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Potential advantages to delayed IOFB removal include improved control of inflammation caused by
initial open globe injury, the ability to assess intraocular structures further, and the possible
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development of spontaneous posterior vitreous detachment (PVD) which might make excision of the
posterior hyaloid easier.28 Delaying the surgery will also allow adequate time to assemble appropriately
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skilled operation room personnel and necessary surgical equipment.137 Although there are some
advantages of delaying IOFB removal, there is a high risk of endophthalmitis with leaving a potentially
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contaminated FB in the eye.

ii. Instruments for IOFB Removal

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External electromagnets (EEM), forceps, and rare earth intraocular magnets (IOM) are three basic
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types of instruments used to extract intraocular foreign bodies. Intraocular forceps require dexterity and
can be used for nonmagnetic IOFBs in the anterior chamber and lens as well as posterior segment IOFBs
and large IOFBs.

Rare earth intraocular magnets may permit easier instrument engagement of the IOFB than
forceps, but unless the IOFB is relatively small, it is often difficult to remove the IOFB from the eye with
the magnet alone, as the IOFB can become engaged with the sclera or cornea during extraction.
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Although the external electromagnet has a strong pulling force,65 it is not recommended since its usage
can lead to vitreous hemorrhage and other iatrogenic damage,85 particularly if the IOFB is located within
30 degrees of the macular center. Typically, this device is used with an external surgical approach. The
sclera overlying the IOFB or the pars plana 180 degrees away from the IOFB is incised, exposing choroid.
The choroid is diathermized and incised, exposing vitreous base (if the incision is over the pars plana) or

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the retina adjacent to the IOFB. The electromagnet is then brought into position over the incision and
activated attracting the IOFB to its tip. It is not unusual for the IOFB to become engaged with choroidal

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and scleral tissue, thus requiring the use of forceps for IOFB removal from the eye once the IOFB is
brought into position at the sclerotomy site. Mester and Kuhn compared the use of an external magnet

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versus PPV with forceps extraction and reported that eyes undergoing IOFB removal with forceps and
PPV had better anatomical and functional outcomes. Complications such as proliferative
vitreoretinopathy (PVR), retinal detachment, phthisis, enucleation, and evisceration were higher in the

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cohort that underwent extraction using external electromagnet. Postoperative visual acuity was also
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higher in the PPV with forceps group compared to the external electromagnet group.85

iii. Removal of Anterior Chamber IOFB

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Removal of IOFBs through the entry wound is generally not recommended due to the potential for
additional damage during removal, 107 but possible exceptions include a very large foreign body or a
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gaping corneal wound.74 IOFBs in the anterior chamber usually do not require a pars plana vitrectomy132
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and often can be removed through a secondary limbal incision.107

Before trying to grasp the IOFB directly, saline solution or a viscoelastic should be used to dislodge
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the foreign body.74 If this method does not work, a limbal incision 90 or 180 degrees away from the
foreign body should be made, 86 and the foreign body can be removed with an intraocular rare earth
magnet or forceps. Viscoelastics should be used to maintain chamber depth and protect the
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endothelium and lens integrity. 86 It may be useful to induce miosis to protect the lens during IOFB
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extraction (one should examine the fundus, however, before leaving the operating room, to be sure
there is no peripheral retinal damage or additional IOFBs). If the IOFB is located in the anterior chamber
angle and thus is difficult to visualize directly through the operating microscope, one can use gonioscopy
to visualize the IOFB while accessing the IOFB through a paracentesis and excising it using either forceps
or a rare earth magnet under direct visualization.74 Sometimes magnetic IOFBs can be removed by
touching a magnet to a knife tip following incision or a blunt iris (steel) spatula.58 This maneuver will
magnetize the surgical instrument.
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For objects embedded in the ciliary body, access to the IOFB may require a scleral flap created near
the limbus or a trephine flap over the pars plana of the ciliary body. If the original (entrance) wound has
not sealed and is large enough, it may be possible to remove the IOFB through it without need for a
secondary incision; smaller or sealed wounds necessitate an incision.

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IOFBs located in the iris may require an iridotomy/iridectomy to remove the iris and fixed particle.
For particles on the posterior iris surface, the approach will depend on whether the crystalline lens is
present and/or damaged. If the lens is to be removed or if the patient is aphakic or pseudophakic, then

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forceps or a rare earth magnet may be used for IOFB extraction via a limbal incision.58 If the patient is
phakic and the lens is not damaged, then flexible iris retractors may be used to assist in exposing the

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posterior iris surface so that the IOFB can be identified and removed. After the IOFB is successful
removed, the surgeon should proceed with reconstructing the anterior segment as necessary.86

iv. Removal of Intralenticular IOFB

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Intralenticular foreign bodies are not encountered often and comprise 5-10% of all IOFBs.128, 84, 8, 100
They can be metallic or nonmetallic (cilia, glass, stone, vegetable matter and coal). Typically, for objects
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that embed themselves in the lens and are inert (non-metallic, non-organic), immediate removal may
not be warranted. Damage to the lens abrogates capsular integrity, which may lead to the formation of
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a visually significant cataract. 8, 48 Complications such as glaucoma and severe intraocular inflammation
may result from the escape of lenticular proteins and particles.84 Other complications such as uveitis,
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endophthalmitis, and intralenticular metallosis have also been reported.8 However, there are some
cases in which there are no severe ocular complications associated with a retained intralenticular
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foreign body for an extended period of time.18, 35 If a clinician decides to treat the patient conservatively
with deferred removal and the IOFB is metallic, the patient should be closely monitored with serial
electroretinograms for any signs of complications. Ferrous IOFBs should be extracted if signs of siderosis
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bulbi occur.18
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Surgeons should base the timing and necessity of intralenticular foreign body removal on the
characteristics of the IOFB and the associated ocular trauma. 8 Kuhn and coworkers recommend
removing the lens if a cataract is present or is inevitable.65 Because of the accommodation potential in
younger patients, age should be considered as an important factor in deciding on whether to extract the
lens during IOFB removal.18 Some studies suggest that combined primary cataract extraction,
intraocular lens (IOL) implantation, and IOFB removal is safe in certain cases.84, 48, 18, 10, 13, 77 Potential
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advantages of performing these procedures concomitantly include quicker visual rehabilitation and
patient comfort. 137, 77 However, if signs of endophthalmitis are present, we do not recommend placing
an intraocular lens at the time of initial globe repair. 15 Andreoli and associates have reported primary
intraocular lens placement during primary globe repair as a significant risk factor for the development of
endophthalmitis. 6 Techniques to remove lenticular foreign bodies include phacoemulsification,

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intracapsular removal with a cryoprobe, or via extracapsular extraction with a forceps or magnet (for an
extensively damaged lens).58

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v. Removal of Posterior Segment IOFB

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Pars plana vitrectomy (PPV) is the most commonly used technique to remove IOFBs from the
posterior segment. 132 Some advantages of vitrectomy include the ability to visualize the IOFB directly,
remove media opacities (e.g., hemorrhage, cataract), and increase the clearance of mediators of

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inflammation at the time of surgery. 47, 131 Many studies in the literature have shown that vitrectomy is
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an effective method for IOFB removal. 85, 32, 101

Surgeons can obtain an undiluted vitreous sample for gram stain and culture during the beginning
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of the PPV. In cases of suspected endophthalmitis, intravitreal antibiotics, such as vancomycin and
ceftazidime, are administered empirically. Gram stain results can modify antibiotic selection. If fungal
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contamination is not suspected but the gram stain reveals evidence of fungi, then antifungal agents,
e.g., intravitreal and systemic voriconazole, can be added to the regimen. Prophylactic antibiotics may
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not be necessary if there is no evidence of preoperative endophthalmitis or if no organisms are found on

the gram stain. It is important to recognize that positive gram stain and/or culture results do not
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necessarily indicate the presence of infectious endophthalmitis, and these data should be interpreted in
light of the clinical presentation and the prior likelihood of infectious endophthalmitis (e.g., injury
occurring in a rural setting with a contaminated farm implement has a relatively high risk of associated
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infectious endophthalmitis).7
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Prior to removal of posteriorly-located IOFBs, media opacities (hyphema, cataract, vitreous

hemorrhage) should be removed. 132 If the cornea is opaque or too damaged to permit clear
visualization of the posterior pole, then a temporary keratoprosthesis can be used intraoperatively after
the damaged cornea has been excised.114 After surgery, a cornea transplant is done. Alternatively, an
intravitreous endoscope can be used in cases of IOFB with opaque corneas.132
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For most posterior segment IOFBs, a pars plana vitrectomy is used.47, 53, 55 At a minimum, a core
vitrectomy is performed. If the IOFB is suspended in the vitreous gel, then the IOFB should then be
freed by dissecting around its perimeter to remove any adhesions prior to extraction. After an
intravitreal IOFB is removed, the posterior hyaloid face should be excised, particularly if severe
intraocular inflammation is not present. If, however, there are significant areas of retinitis, then hyaloid

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face excision may result in the creation of retinal breaks. In this setting, one may defer hyaloid excision
with the plan to excise the hyaloid at a planned secondary vitrectomy, by which point spontaneous

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posterior vitreous detachment most likely will have occurred. If retinal impact sites are present and the
IOFB is embedded in the retina/choroid, one should attempt to excise the posterior hyaloid and vitreous

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in these locations to eliminate vitreous attachments that could result in peripheral retinal break
formation during IOFB extraction, and to reduce the chance for postoperative epiretinal membrane
formation with attendant risk of postoperative retinal detachment. Sometimes the IOFB is intimately

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associated with the posterior cortical vitreous and, particularly if the IOFB is relatively small, excision of
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the posterior hyaloid face may facilitate delivery of the IOFB off of the retinal surface.

If a retinal detachment is present, infusion of a heavier- than- water liquid (e.g., perfluorodecalin)
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can partially or fully reattach the retina, which may render IOFB extraction safer and more efficient.
After IOFB removal and posterior hyaloid face excision, the heavier-than-water liquid is exchanged with
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fluid (to insure complete removal), and then a fluid-air exchange is done to reattach the retina. The use
of gas or oil tamponade depends on several issues including: the need/ability of the patient to position
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face down consistently, the number and location of retinal breaks (inferior retinal breaks probably are
better tamponaded with gas rather than oil due to silicone oil’s low specific gravity), and the patient’s
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need for rapid visual rehabilitation.

The extraction strategy for the IOFB is based on its size and composition.132 Metallic and
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ferromagnetic IOFBs less than 0.1 mm in size can be removed using an intraocular rare earth magnet.
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Small, nonferrous IOFBs (as well as magnetic IOFBs) can be extracted by just utilizing the vitreous cutter
if the IOFB is suspended in the vitreous cavity. 137 IOFBs whose size ranges from 1-3 mm can be
removed with active compression forceps (e.g., de Juan) or basket forceps regardless of composition.
For larger IOFBs (3.0-5.0 mm) and for glass IOFBs, the clinician might consider using diamond-coated
forceps, which makes extraction easier by preventing slippage of IOFB,132, 10 or large foreign body
forceps, which open with active compression and close passively.
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If the foreign body’s total volume is greater than 4.0 x 4.0 x 4.0 mm3, the clinician should consider
making a T-shaped sclerotomy for IOFB extraction. Smaller foreign bodies can be removed at the
sclerotomy site.137 Alternatively, the IOFB can be removed through the original corneal or scleral entry
site if it can be extracted without additional trauma to the tissue. This maneuver may require reopening
the sutured entry site. Alternatively, it may be necessary to create a new extraction locus or to enlarge

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a sclerotomy in order extract the IOFB as mentioned above.

After the IOFB is extracted, the surgeon should perform a complete retinal examination with scleral

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depression to check for retinal tears, retinal detachment, and/or choroidal detachment. Retinal tears
are treated with laser photocoagulation or, if blood precludes good laser uptake, retinal cryopexy is

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required. If retinal detachment is present, PPV with gas or oil tamponade is performed. Depending on
the anatomy and anticipated likelihood of PVR development, an encircling scleral buckle also may be

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placed to offset peripheral vitreo-retinal traction.
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VI. POST-OPERATIVE CARE AND COMPLICATIONS
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The postoperative examinations are focused on complications such as endophthalmitis,

postoperative retinal detachment, and PVR. Consideration should be given to the use of post-operative
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topical antibiotics such as gatifloxacin and moxifloxacin137 which have been shown to be more potent
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than second and third generation fluoroquinolones against gram-positive bacteria. 80

a. Endophthalmitis
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Post-traumatic endophthalmitis is an important albeit infrequent complication of OGI. A detailed

treatment of this subject is beyond the scope of this review but has been reviewed elsewhere.15 Nobe
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and coworkers studied 50 cases of exogenous endophthalmitis and found that patients with
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postoperative endophthalmitis had better visual outcomes than those with post-traumatic
endophthalmitis.93 Delay in diagnosis and initiation of treatment, increased prevalence of virulent
organisms, and injury-associated tissue damage all contribute to the poor visual prognosis associated
with post-traumatic endophthalmitis.30 Post-traumatic endophthalmitis has been reported to develop in
2.1% to 17% of patients (mean 6.8%) with OGI.6, 15, 31, 61 Among 10,309 cases of serious ocular injury
reported to the United States Eye Injury Registry in 2002, 136 cases (3.4%) developed post-traumatic
endophthalmitis.30, 31
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i. Risk Factors

The presence of an IOFB increases the risk of developing post-traumatic endophthalmitis.6, 9, 30, 53 116
IOFBs can serve as a vehicle for infectious organisms.9, 15 The rate of infectious endophthamlitis related
to IOFB ranges from 0-48.1% in various studies, 9, 15, 28, 53, 74, 136 with a higher rate in patients with retained

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IOFB composed of organic materials.

Andreoli and coworkers analyzed 558 cases of OGI with at least 30 days of follow-up. Patients were

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treated using a standardized treatment protocol that included intravenous vancomycin and ceftazidime
upon admission, which was discontinued after 48 hours. After surgery, topical antibiotics,

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corticosteroids, and cycloplegics were administered. Endophthalmitis developed in 5 cases (0.9%). The
authors attribute this low rate of endophthalmitis to the presence of a competent eye trauma service
equipped with a standardized protocol and the administration of intravenous antibiotics for 48 hours.

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The presence of an IOFB (P = .03) and primary intraocular lens placement (P = .05) were statistically
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significant risk factors for the development of endophthalmitis. Delay in surgical repair, delay in
presentation, prolapse of uveal tissue, and vitrectomy were not significant risk factors for
endophthalmitis.6
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As noted elsewhere (Table 2), delayed IOFB removal may be a risk factor for endophthalmitis, but
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this conclusion is uncertain due to confounding variables such as the timing of primary wound closure,
the timing of antibiotic administration, and the nature of the IOFB (e.g., heat-sterilized missiles).
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Other risk factors for the development of post-traumatic endophthalmitis include contaminated
wound, 39 lens capsule breach, 39 intraocular lens implantation,6 and contaminated and rural injury
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setting. 30

ii. Diagnosis
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The diagnosis of post-traumatic endophthalmitis can be delayed due to the presence of masking
signs from ocular trauma. Some early symptoms of post-traumatic endophthalmitis include pain out of
proportion to clinical findings or increasing pain after injury stabilization, progressive visual loss after the
initial injury, hypopyon, and vitritis. Other less specific signs include lid edema, conjunctival erythema
and edema, corneal edema, fibrous pupillary membrane formation, and loss of the red reflex. 64 An
injury involving soil contamination or an IOFB composed of vegetable matter such as wood should raise
concern about fungal or polymicrobial infection.64 Some clinical signs of a fungal infection include
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delayed onset of inflammation after injury and the presence of aggregates of inflammatory cells and/or
fungi described as “fluff balls” or “string of pearls” in the vitreous or anterior chamber.15 The clinician
should assume that endophthalmitis is present in all open globe injuries until proven otherwise.30
Samples for cultures and stains should be obtained if signs and symptoms indicate the possibility of
endophthalmitis.15

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iii. Microbiology

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The majority of the organisms that cause post-traumatic endophthalmitis are gram-positive, but
gram negative and fungal organisms can also occur.137 The most frequent gram-positive microorganisms

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cultured include Coagulase-negative Staphylococcus, which includes Staphylococcus epidermis,
Streptococcus species, Bacillus species, and Staphylococcus aureus.21 Bacillus species is associated with
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post-traumatic endophthalmitis in the presence of an IOFB relatively frequently.

iv. Management
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Factors such as the nature of the trauma, the setting, the presence of an IOFB, and the types of
organisms involved all play a role in deciding the course of treatment for post-traumatic
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endophthalmitis. 15, 14, 64, 91 If signs of endophthalmitis are present, we recommend immediate
institution of intravenous antibiotics, prompt culture of the wound, and timely surgery to repair the
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globe and remove the IOFB if present.15, 137 If there will be an unavoidable delay in surgery (e.g., medical
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stabilization of the patient), then an in-office vitreous biopsy can be undertaken combined with in-office
administration of intravitreal antibiotics. Regarding the choice of antibiotics, we recommend initially
using intravitreal vancomycin hydrochloride (1 mg/0.1 mL normal saline) and ceftazidime (2.25 mg/0.1
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mL normal saline).15, 55 Topical antibiotics are generally considered as an appropriate adjuvant to

intravitreal and systemic antibiotic use once the wound is closed. A combination of topical vancomycin
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(50 mg/ml) every hour, ceftazidime (50-100 mg/ml) every hour and topical cycloplegics +/-steroids are
administered at the onset of treatment.4 If a patient is allergic to penicillins, clindamycin can be used for
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coverage against gram-positive organisms 109 and amikacin for gram-negative organisms.15 Systemic
fluoroquinolones such as levofloxacin (3rd generation), moxifloxacin and gatifloxacin (4th generation) can
also be employed. For treatment of post-traumatic fungal endophthalmitis, we recommend using
intravitreal and systemic voriconazole because it covers most commonly encountered fungal organisms
and does not have the same retinal toxicity profile as amphotericin B.15, 50
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Some clinicians administer antibiotics, such as third and fourth generation fluoroquinolones
[moxifloxacin (400 mg) and levofloxacin (500 mg)], preoperatively and for 7 to 10 days following surgery
as prophylaxis against post-traumatic endophthalmitis. 137 The decision to use prophylactic antibiotics in
the absence of signs or symptoms of endophthalmitis has been controversial. 15 The benefits of
prophylactic systemic antibiotics have not been confirmed in randomized large-scale studies. 15, 39 The

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preferred route of administration15 and the ideal antibiotic regimen 39 have not been established
through randomized clinical trials. In cases of an open globe injury with an IOFB, we recommend using a

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2 to 5 day course of intravenous vancomycin and ceftazidime followed by a 7 to 10 day course of oral
ciprofloxacin or levofloxacin. 15, 55 Use of intravitreal antibiotic prophylaxis also remains controversial.

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Evidence demonstrating a benefit of using prophylactic intravitreal antibiotics for OGIs without an IOFB
is scarce,15 and more research is needed in this area. Soheilian and coworkers have shown that
intraocular injections of gentamicin and clindamycin may prevent acute post-traumatic endophthalmitis

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in eyes with a retained IOFB.116 Essex et al recommend consideration of prophylactic intravitreal
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antibiotics if at least two of the following three risk factors are present: 1) delay in primary repair of ≥ 24
hours, 2) dirty wound, or 3) lens breach.39 Administration of intravitreal antibiotics should be performed
with extreme care in an eye with a small vitreous cavity, such as may be present in the setting of trauma
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with a large suprachoroidal hemorrhage.39 If used, a reduction in antibiotic dose in proportion to the
reduction of the volume of the vitreous should be considered.
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b. Post-Operative Retinal Detachment

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Preoperative and postoperative retinal detachment is a serious complication of injury associated

with IOFBs.38 Removal of an IOFB in the presence of a detached retina is associated with an increased
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risk of iatrogenic retinal breaks, which in turn can lead to increased risk of postoperative retinal
detachment.64 The rate of postoperative retinal detachment ranges from 6 to 40%.131, 23, 26, 133 Many
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studies have reported that postoperative retinal detachment is associated with a poor visual prognosis
23, 26, 47, 131
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although the visual prognosis is even worse in the setting of a preoperative retinal
detachment. El-Asrar and coworkers have shown that the presence of endophthalmitis and IOFB size
greater than 4 mm are associated with increased risk of developing retinal detachment post-
vitrectomy.38

c. Proliferative Vitreoretinopathy (PVR)

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Proliferative vitreoretinopathy, which involves growth and contraction of membranous scar tissue
on the epi- and/or subretinal surface, is a serious complication and serves as an obstacle to successful
retinal reattachment surgery.118 Many studies have shown that PVR is associated with poor visual
outcome.120, 133 Some risk factors associated with the development of PVR include the size of the IOFB,
and size and number of retinal tears.

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d. Sympathetic Ophthalmia (SO)

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Sympathetic ophthalmia (SO) is an immune-mediated (largely T-cell driven) reaction to ocular
antigens (e.g., S antigen) exposed to the immune surveillance system following ocular injury.

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Inflammation in the injured (“exciting”) eye due to SO can be difficult to recognize due to the
concomitant presence of inflammation secondary to the initial injury and/or surgical repair.
Sympathetic ophthalmia can be recognized in the uninjured (“sympathizing”) eye by the presence of

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mild pain, lacrimation, photophobia, blurred vision or paresis of accommodation. 92 Clinical findings
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may also include granulomatous uveitis (e.g., mutton-fat keratic precipitates, choroidal thickening,
vasculitis, choroiditis, Dalen-Fuchs spots). Fortunately, the incidence of SO is low and occurs in 0.28-
1.9% of eyes with penetrating ocular trauma.97 Sympathetic ophthalmia typically is managed with
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immunosuppressive therapy, such as systemic corticosteroids and steroid-sparing agents.

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e. Anterior Segment Complications

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Many complications of OGI involve the anterior segment. Following OGI, with or without retained
IOFB, complications such as cataract, hyphema, and mechanical damage to the cornea are common.
The reported incidence of hyphema, corneal damage, traumatic cataract, and lens damage (including
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capsule rupture, luxation and subluxation) are: 7-32%, 67-68%, 50-73% and 32-66%, respectively.141, 120,
42, 85, 24, 56
These injuries are repaired using standard techniques, but occasionally special approaches
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(e.g., capsular tension ring to provide capsular support during lens extraction in the setting of zonule
disruption) are needed.70
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f. Metallosis

Metallic IOFBs are rarely pure65 and can consist of iron, copper, zinc or nickel.128 The chronic
damage caused by these IOFBs depends on the amount of the harmful component.65 This was described
in detail in the earlier section.
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VII. PROGNOSIS

A literature search for the prognostic factors for OGIs with a retained IOFB demonstrates that many
variables can be responsible for the final visual acuity. Mass of the IOFB is a prognostic factor. In a case-
series of 69 patients with IOFBs, Woodcock and coworkers reported that increased IOFB mass was

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associated with posterior segment injury, retinal impact, presenting and final best-corrected visual
acuity of ≤ 20/200, increasing complications, and retinal detachment.136 Many reports have shown that
the size of the IOFB can also play a role in postoperative visual acuity.120, 53, 23 Due to its higher kinetic

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energy, a larger IOFB is more likely to cause serious damage and have a poor prognosis.131 Szijarto and
associates have reported that larger IOFBs (mean length 5.7mm) are associated with worse visual

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prognosis120 while Chiquet et al have found that IOFBs with diameter <3 mm have a relatively better
chance of good visual outcome.23 Other studies have also reported that posterior segment IOFBs lead to

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a poor visual prognosis.141, 20, 37
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Presenting visual acuity is also an important prognostic factor for final visual outcome. 141, 120, 136, 53,
20, 47, 131, 37, 5, 22, 73, 134
Initial visual acuity to a certain extent can be representative of the severity of ocular
damage after trauma.141 Many studies have shown that better presenting visual acuity (20/200 or
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better) is associated with a better visual outcome.20, 23, 37, 5 Ehlers et al demonstrated that presenting
visual acuity of > 20/200 was associated with final visual acuity of ≥ 20/50 (P=0.001) while Williams et al
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found that visual acuities of ≥ 20/40 at presentation were associated with final VA of > 20/40.37, 134
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Other factors that have been reported in the literature that are predictive of poor visual outcome
include presentation with hyphema,133 vitreous hemorrhage,47, 133 uveal prolapse, 133, 37 no PPV for
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posterior IOFB,20 PVR,120, 133 hammering metal on metal as a mechanism of injury,47 culture of a non-
virulent organism,73 younger age,37 increased wound length, 141, 37 wound larger than the IOFB in largest
length,141 the presence of retinal detachment,131, 23, 133 presence of afferent pupillary defect47, 133 and the
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presence of endophthalmitis.141, 120, 39 However, Chiquet et al have reported that presentation with
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hyphema and vitreous hemorrhage did not affect prognosis.23 Soheilian et al noted that the nature of
IOFB may affect its ease of removal. They found that, because non-magnetic metallic and non-metallic
IOFBs had to be removed with intraocular forceps as opposed to a magnet, extraction through pars
plana incisions was potentially associated with higher rates of retinal break formation and subsequent
retinal detachment. This higher rate was particularly notable with glass IOFBs. 115
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Additional factors that have been reported to portend a good visual prognosis include the
following: normal lens at presentation,37 absence of lens injury,131 decreased wound length,37, 73 anterior
segment IOFB,37 older age,37 use of PPV rather than magnets for posterior located IOFB,85, 20 lack of
retinal detachment, 131, 73 and absence of endophthalmitis.73 Location and mechanism of injury are
important factors that influence a patient’s final best-corrected visual acuity. Injury limited to the

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anterior segment was found to be predictive of better final visual acuity than injury to the posterior
segment.37 Woodcock et al found that posterior segment IOFBs were associated with worse outcomes

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(best-corrected visual acuity ≤ 20/200) than anterior segment IOFBs (best-corrected visual acuity ≥
20/40 and > 20/200) at various time-points. Favorable visual outcomes were seen in eyes in which the

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IOFB did not damage the lens. 136, 59, 37 In one study, there was no statistically significant association
between corneal perforation and poor visual outcome.136 However, wound length did contribute to
worse visual outcomes. 37

VIII. RECENT ADVANCES

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Advancements in the management have improved the prognosis of OGIs with an IOFB. 65
Nonetheless, the literature on prognostic factors can be confusing and sometimes is contradictory. To
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improve our ability to gauge visual prognosis after an OGI, Kuhn and coworkers developed the Ocular
Trauma Score (OTS) System utilizing data from 2500 injuries from the United States and Hungarian Eye
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Injury Registries. Using the OTS system (Table 3),63 the clinician assigns a numerical value to each of the
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following variables: initial visual acuity, rupture, endophthalmitis, perforating injury, retinal detachment,
and afferent pupillary defect. These variables are not difficult to assess during the initial eye exam or
during surgery. The sum from the numerical values can then be used to predict the expected visual
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acuity. A low total sum indicates poor visual acuity prognosis. 63 Many studies have shown that the OTS
can be used to determine reliable prognostic information in OGIs, 43, 105, 127 including childhood OGIs, 129
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eyes with siderosis bulbi from retained IOFB 143 and in deadly weapon-related OGIs.113
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IX. CONCLUSION

A significant proportion of OGIs include IOFBs, with the majority of IOFBs occurring in the
workplace. Initial management of patients with OGIs and retained IOFBs as well as management of their
sequelae pose a challenge regarding initial diagnosis, classification, and recognition and management of
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late complications. Using a standardized system of classification63 and appropriate diagnostic imaging,
coupled with a thorough history and physical exam, a physician is able to accurately assess the extent of
initial damage, identify the type and location of IOFB(s), and initiate proper care.
If an IOFB is suspected, we recommend that prophylactic intravenous antibiotics be administered
empirically. The use of intravitreal antibiotics remains controversial. Modifications to the empiric

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antibiotic regimen are needed on the basis of culture results if endophthalmitis is noted.
Expedited surgical repair to remove the IOFB and repair the open globe is warranted. The

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appropriate surgical technique for IOFB removal depends on the location and composition of the IOFB.
Regular follow-up is necessary as serious complications, such as retinal detachment, may develop. One

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of the single best predictive factors for visual outcome is the injured eye’s presenting visual acuity. 136, 37,
22, 134

With the information presented here, the reader may gain a more unified understanding of the

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nature, diagnosis, management, and outcomes of commonly encountered IOFBs associated with OGI.
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Although much is known about IOFB injury, the visual potential is guarded. Posterior IOFBs have been
found to have poorer prognosis than anterior IOFBs. Further investigative studies may help better
characterize specific injuries and improve management. As surgical techniques become more refined,
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common post-operative complications such as retinal detachments and PVR may become less frequent.
Increased sophistication of imaging modalities may also help identify foreign bodies more accurately
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and aid in surgical planning. Although most agree to administer systemic antibiotic treatment, the
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specific route and duration, as well as the use of intravitreal antibiotics remain controversial. Further
studies are needed to elucidate the role of antibiotics. Continued improvement in management
strategies and surgical techniques will hopefully lead to more favorable outcomes for patients suffering
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OGI with IOFB.

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Literature Search
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A literature search was performed on the PubMed database from July 2012 to October 2015.
Search terms included “open-globe injury,” “intraocular foreign body,” “penetrating ocular injury,”
“perforating ocular injury,” “post-traumatic endophthalmitis,” “metallic foreign body,” “wood foreign
body,” “organic foreign body,” “glass foreign body,” “ocular trauma,” “intraocular foreign body
imaging,” “intraocular foreign body removal,” “intraocular foreign body management,” “anterior
segment foreign body,” “posterior segment foreign body,” “intraocular foreign body prognosis,” “retinal
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detachment,” “proliferative vitreoretinopathy,” “choroidal rupture,” “vitreous hemorrhage” and

“sympathetic ophthalmia.” Inclusion criteria were any relevant articles published until October 2015,
with preference given to articles published in the last 20 years.

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Disclosures
The financial disclosures for each author are listed below:

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Dean Loporchio: None

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Lekha Mukkamala: None

Kavya Gorukanti: None

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Marco Zarbin: Consultant for the following companies: Helios KK, Novartis, Pfizer, Calhoun
Vision, Imagen Biotech, Roche, Genentech
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Paul Langer: None

Neelakshi Bhagat: None

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Acknowledgements
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The authors report no acknowledgements for this manuscript. No funding was received for this project.
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Table 1. Incidence of Infectious Endophthalmitis with IOFBs.

Study Endophthalmitis, Percent

# of cases (total # of patients)
Armstrong et al, 1988 5 (95) 5.3

Behrens-Baumann & Praetorius, 1989 14 (297) 4.7

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Brinton et al, 1984 11 (103) 11

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Chaudhry et al, 2008 44 (589) 7.5

El-Asar et al, 2000 13 (96) 14

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Jonas et al, 2000 7 (130) 5.4

Kazokoglu & Saatci, 1990 13 (27) 48

Khan et al, 1987

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Szijarto et al, 2007 4 (28) 14

Thompson et al, 1993 34 (492) 6.9

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Williams et al, 1988 14 (105) 13

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Zhang et al, 2011 232 (1421) 17

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Table 2. Traumatic Endophthalmitis Prophylaxis: Timing of IOFB Removal.

Incidence Endophthalmitis Incidence Endophthalmitis

Study P-Value
IOFB Removal ≤ 24 hrs. IOFB Removal > 24 hrs.

Colyer et al, 2008 0/0 (0%) 0/79 (0%) NS

PT
Chaudhry et al, 2008 11/? (589 total) 33/? (589 total) <0.05

Ehlers et al, 2008 4/96 (4.2%) 4/96 (4.2%) NS

RI
Essex et al, 2004 4/38 (11%) 5/31 (16%) 0.72

SC
Ferrari et al, 2001 0/17 0/12 NS

Greven et al, 2000 0/39 0/20 NS

U
Jonas & Budde, 1999 1/43 (2.3%) AN 3/19 (16%) =0.046

Schmidseder et al, 1998 10/57 (18%) 8/15 (53%) =0.004

Thompson et al, 1993 10/287 (3.5%) 22/164 (13%) <0.0001

M

Woodcock et al, 2006 3/28 (11%) [≤48 hrs.] 1/41 (2.4%) [>48 hrs.] NS

Zhang et al, 2011 26/209 (12%) 206/1175 (18%) =0.07

D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
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Table 3. Calculating the Ocular Trauma Score (OTS): variables and raw points

Variable Raw Points

PT
Initial Vision

No Light Perception 60

RI
Light Perception/Hand Motion 70

1/200-19/200 80

SC
20/200-20/50 90

≥ 20/40 100

Rupture -23
U
AN
Endophthalmitis -17

Perforating Injury -14

M

Retinal Detachment -11

D

Afferent pupillary defect -10

TE
C EP
AC